Characteristics Of TCM Syndromes Of Rheumatoid Arthritis Associated Interstitial Lung Disease And Analysis Of Intestinal And Coated Tongue Flora

Objective:To observe the distribution characteristics of TCM syndromes of rheumatoid arthritis associated interstitial lung disease(RA-ILD)and analyze its correlation with laboratory indexes,disease activity,pulmonary function test and imaging features.To explore the distribution of intestinal flora and tongue coating flora in patients with RA-ILD and the differences with rheumatoid arthritis(RA)and connective tissue disease associated interstitial lung disease(CTD-ILD).Method:Study 1:80 patients with RA-ILD in the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine were selected.The symptoms,signs,tests and examinations of the patients were investigated by using the self-made information collection table of the four diagnoses of traditional Chinese medicine.The symptoms,tongue and pulse with a frequency of more than 5%were analyzed by cluster analysis,and the correlations of syndrome factors and syndrome types with RA disease activity,laboratory indexes,related indexes of pulmonary function test,chest high-resolution computed tomography(HRCT)characteristics were analyzed.Study 2:10 patients with RA-ILD,10 patients with RA and 10 patients with CTD-ILD(non-RA)were selected from the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine.Fecal and tongue coating samples were sequenced by 16sDNA.The flora abundance,alpha diversity,beta diversity and LDA Effect Size analysis were carried out.Result:Study 1:(1)A total of 80 RA-ILD patients were included,64 females and 16 males,with an average age of 65.34 ± 9.06years.The main symptoms of RA-ILD disease are cold and heat(46.25%)and deficiency and excess(66.25%).Deficiency syndrome is mainly qi deficiency(72.5%),yin deficiency(40.0%),blood deficiency(30.0%)and yang deficiency(22.5%).The disease mainly involved lung(73.75%),kidney(55.00%)and spleen(48.75%).The main pathological factors were dampness(58.75%),phlegm(45.00%)and blood stasis(31.25%).After cluster analysis,four syndrome types were obtained,including 14 cases of yin deficiency and lung dryness with phlegm-dampness syndrome(17.50%),12 cases of lung and kidney deficiency with qi and blood deficiency syndrome(15.00%),39 cases of phlegm and blood stasis syndrome with spleen-yang deficiency syndrome(48.75%),and 15 cases of rheumatism syndrome with lung-kidney qi-yin deficiency syndrome(18.75%).(2)Patients with high disease activity(RA)have a higher proportion of stasis syndrome than those with moderate disease activity(P=0.028).The forced vital capacity(FVC)of patients with phlegm syndrome was lower than that of patients without phlegm syndrome(P=0.03).The platelet count of patients with blood stasis syndrome was higher than that of patients without blood stasis syndrome(P=0.04).The proportion of wet syndrome in patients with ground-glass opacity on HRCT was higher than that in patients without ground-glass opacity(P=0.02).The proportion of stasis syndrome in patients with subpleural arc shadow on HRCT was higher than that without subpleural arc shadow(P=0.02).The positive rate of anti-keratin antibody in patients with deficiency of lung and kidney and deficiency of both qi and blood was higher than that in patients with yin deficiency and lung dryness and phlegm-dampness syndrome(P=0.009).The proportion of patients with yin deficiency and lung dryness combined with phlegm-dampness syndrome was higher than that with phlegm and blood stasis syndrome and spleen-yang deficiency syndrome(P=0.003).The proportion of severe ventilatory dysfunction in syndrome of deficiency of lung and kidney and deficiency of both qi and blood was higher than that of syndrome of stagnation of phlegm and blood stasis and deficiency of spleen-yang(P=0.028).(3)There was a positive correlation between RA disease activity(DAS28,CDAI,SDAI)and imaging stage(DAS28:r=0.224,P=0.046;CDAI:r=0.256,P=0.022;SDAI:r=0.256,P=0.023).The degree of cough was positively correlated with the grade of diffusion dysfunction(r=0.23,P=0.04)and imaging staging(r=0.442,P=0.001).The degree of wheezing was positively correlated with the severity of ventilatory dysfunction and diffusion dysfunction.There was a negative correlation between CEA and diffusion capacity(r=-0.454,P=0.000)and forced vital capacity(r=-0.284,P=0.011).There was a positive correlation between the grade of diffusion dysfunction and the imaging stage(r=0.33,P=0.003).Study 2:12 patients with RA-ILD,10 patients with RA and 10 patients with CTD-ILD(non-RA)were included(In order to avoid sample shedding,2 additional cases were included).(1)In terms of intestinal flora,the main genera in RA-ILD group were Bacteroides,Faecalibacterium,Bifidobacterium,Escherichia-Shigella,Prevotella.Alpha diversity index of Shannon index and Chaol index indicated that intestinal flora richness and diversity of CTDILD were significantly lower than those in RA group,but there was no significant difference between RA-ILD group and RA group or RA-ILD group and CTD-ILD group.There was no significant difference in Simpson index among the three groups.Beta diversity index analysis showed that Beta diversity index in RA-ILD group was higher than that in RA group(P<0.01).Adonis analysis and Anosim analysis showed that there was significant difference between RAILD group and CTD-ILD group,but there was no significant difference between RA group and RA-ILD group.Species analysis showed that the relative abundance of Barnesiella in RA-ILD group was lower than that in RA group.Compared with CTD-ILD group,the relative abundance of Faecalibacterium,Subdoligranulum,Alistipes,Holdemanella,UCG-002,Coprococcus,UCG-005,Lachnospira and CAG-56 was higher in RA-ILD group(P<0.05).LEfSe analysis showed that Streptococcus and Eubacterium_coprostanoligenes_group were significantly different in RA-ILD group.Streptococcus was also significantly different in UIP group.(2)In terms of tongue coating flora,there was no significant difference in Alpha diversity index among the three groups.Beta diversity index in RA-ILD group was higher than that in RA group(P<0.01).Species analysis showed that Fusobacterium in RA-ILD group was significantly lower than that in RA group,while Campylobacter and Peptostreptococcus in RAILD group were significantly higher than those in RA group(P<0.05).The abundance of Peptostreptococcus and Neisseria in RA-ILD group was significantly higher than that in CTDILD group(P<0.05).LEfSe analysis showed that Neisseria were significantly different species in RA-ILD group(P<0.05).There was a significant difference in the distribution of microflora between RA-ILD thin fur group and greasy fur group.Compared with the thin coating group,the genera of Prevotella,TM7x and Atopobium were significantly increased in the greasy coating group(P<0.05).Conclusion:(1)Patients with RA-ILD can be classified into four syndrome types,including yin deficiency and lung dryness with phlegm-dampness syndrome,lung and kidney deficiency with both qi and blood deficiency syndrome,phlegm and blood stasis syndrome with spleen yang deficiency syndrome,wind-dampness obstruction with lung-kidney qi-yin deficiency syndrome.There is a correlation between TCM syndromes and disease activity,aboratory indexes,pulmonary function test,maging and in patients with RA-ILD,which is helpful to provide objective basis for TCM syndrome differentiation.(2)The distribution of microflora in intestinal flora of RA-ILD,RA and CTD-ILD was different.The distribution of some microflora in tongue coating was different between groups.There was significant difference between RA-ILD thin fur and thick greasy fur.Streptococcus may be a biomarker of RA-ILD and a biomarker of UIP in RA-ILD.