항Proliferating Cell Nuclear Antigen 항체 양성의 류마티스관절염 환자 1예
Anti-Proliferating Cell Nuclear Antigen Antibodies Detected in Rheumatoid Arthritis: A Case Report
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류마티스관절염(rheumatoid arthritis, RA)은 관절의 부종, 통증, 윤활관절의 파괴를 특징으로 하는 만성염증질환으로 관련된 자가항체로는 류마티스인자, 항cyclic citrullinated peptide (CCP) 항체 등이 있다. Proliferating cell nuclear antigen (PCNA)에 대한 항체는 주로 전신홍반루푸스(systemic lupus erythematosus, SLE) 환자에서 발견되는데 특히 고역가의 항체는 전신홍반루프스 환자와 연관성이 높은 것으로 알려져 있다. 전신홍반루프스 환자가 아닌 다른 자가면역질환에서도 PCNA에 대한 항체가 발견되기도 하는데, Vermeersch 등과 Mahler 등은 PCNA에 대한 항체가 양성인 두 명의 류마티스관절염 환자를 각각 보고하였으나 모두 낮은 역가를 보였다. 본원에서 시행한 AIT 검사를 통해 한 명의 류마티스관절염 환자에서 고역가의 PCNA에 대한 항체가 발견되어 보고하는 바이다. 56세 여자환자로 다른 기저질환, 약물복용력은 없었으며 약 6개월 전부터 아침강직을 동반한 다발성 관절통을 주소로 외래를 통해서 입원하였다. 적혈구침강속도는 102 mm/hr 였고 C-반응성단백은 0.8 mg/dL (정상범위 0-0.8 mg/dL)였다. 류마티스인자는 77 IU/mL로 양성, 항CCP 항체검사는 음성이었다. AIT 검사에서 균일형(1:320), PCNA형(>1:2,560)이 관찰되었다. PCNA에 대한 항체는 이중면역확산법을 통해 다시 한번 확인되었다. 항 DNA검사는 양성이었다(1:160). 수부 X선 검사에서 손목, 중수지 관절, 근위 손가락사이 관절의 연부 조직에 부종이 관찰되었다. 2010년 ACR/EULAR classification criteria for RA에서 8점에 해당되어 류마티스관절염으로 진단되었다. 이는 류마티스관절염 환자에서 발견된 고역가의 PCNA에 대한 항체를 보고한 최초의 증례로 향후에 PCNA에 대한 항체의 임상적 유용성을 평가할 때 도움을 줄 수 있을 것으로 생각된다
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease that results in a chronic inflammatory disorder, which principally attacks the small joints. Several autoantibodies, such as rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibody, are known to be associated with RA. Anti-proliferating cell nuclear antigen (PCNA) antibodies are mainly observed in patients with systemic lupus erythematosus (SLE). Indeed, a high titer of these antibodies is considered highly suggestive of SLE; however, anti-PCNA antibodies also appear in other autoimmune diseases. Two previous reports described RA patients with low titers of anti-PCNA antibodies, respectively. In this report, we describe a case of an RA patient exhibiting a high titer (>1:2,560) of anti-PCNA antibodies. The 56-yr-old female patient, with no underlying disease or medication history, presented with multiple joint pain and morning stiffness that had begun 6 months prior. The erythrocyte sedimentation rate (ESR) and RF were elevated (102 mm/hr and 77 IU/mL, respectively), and C-reactive protein (CRP) was 0.8 mg/dL. While the test for anti-CCP antibodies was negative, an anti-PCNA pattern (>1:2,560) and a homogeneous pattern (1:320) were detected by autoimmune target (AIT) test. The presence of anti-PCNA antibodies was subsequently confirmed using the double immunodiffusion method. The anti-dsDNA test was also positive (1:160). X-ray imaging showed soft tissue swelling of multiple joints of both hands and wrists. According to the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria, the patient was classified as having RA. This is the first case to describe high titers anti-PCNA antibodies associated with RA.
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