Rheumatoid arthritis is an autoimmune pathology that is characterized by the development of the inflammatory process in the tissues of the joints and cartilage. According to statistics, 1% of the total population suffers from this disease, which is approximately 58 million people. Women are more susceptible to this pathology: 4 women per 1 sick man.
This is a truly dangerous disease that has a chronic course with a tendency to gradually worsen the patient's condition. Untimely and incorrect therapy of the disease leads to disability.
Main reasons
To understand how to differentiate rheumatoid arthritis from other pathologies of the joints, and to know how to cure the disease, it is necessary to find out the features of the etiology, pathogenesis, clinic and diagnosis of rheumatoid arthritis.
The term "etiology" means finding out the causes of the disease. Pathogenesis is a phased development of a disease, which determines its clinical manifestations, methods of diagnosis and treatment.
The reason for the development of the named disease is not completely clear. The most common are two theories of its origin: hereditary and infectious. In favor of the first of them, there are cases of the development of the disease in several generations of the same family. This is due to a genetic predisposition to arthritis in the presence of a special gene of the HLA group.
Infectious theory, however, is confirmed by cases of the development of pathology in people who have had hepatitis B, measles, rubella, herpes, and mumps. The role of tubercle bacilli in joint damage is being actively debated.
Researchers separately identify groups of people who are most prone to rheumatoid arthritis:
- women over the age of 45;
- patients with a burdened family history: the presence of rheumatoid arthritis in close relatives;
- often sick.
The main links of pathogenesis
Rheumatoid arthritis is an autoimmune pathology. This means that its development is associated with increased activity of the immune system and impaired immune response. The body produces antibodies against its own cells, which act as antigens. In this case, the cells of the joints and cartilage suffer. The antibody settles on their surface and causes inflammation.
Another mechanism is immunocomplex. The formation of autoantibodies against their own immunoglobulins. These antibodies contribute to the formation of rheumatoid factor. Knowledge of this indicator is very important for the differential diagnosis of rheumatoid arthritis, as it is specific for autoimmune diseases. With pathologies such as gout or osteoarthrosis, rheumatoid factor does not form.
Rheumatoid factor together with immunoglobulin makes up immune complexes that affect joints, cartilage, and bones.
Classification
Depending on the etiology, pathogenesis, clinic, diagnosis and treatment of rheumatoid arthritis, it is divided into separate groups. So, the clinical manifestations and the number of affected joints determine the following types of pathology:
- monoarthritis - damage to one joint;
- oligoarthritis - inflammation of two or three joints;
- polyarthritis is an extensive inflammation of more than three joints.
Depending on the characteristics of pathogenesis and diagnostic criteria, there are:
- seronegative arthritis - rheumatoid factor is not determined;
- seropositive arthritis - a rheumatoid factor is present, and it can be detected in the joint fluid.
Separately distinguish specific groups of the disease, which also need to carry out differential. diagnosis of rheumatoid arthritis. These include juvenile rheumatoid arthritis (it affects children under 16 years old), Still and Felty's syndrome (severe forms of the disease with damage to internal organs).
In the article, we presented a photo of the symptoms, diagnosis and treatment of rheumatoid arthritis.
Clinical manifestations
In the differential diagnosis of rheumatoid arthritis, specific clinical manifestations of joint damage are taken into account. These include:
- The onset of inflammation in the small joints of the hands and feet, wrists, elbows and knees.
- Symmetry of the inflammatory process, that is, simultaneous damage to the joints on two arms or legs.
- Inflammation is accompanied by severe pain.
- A symptom specific to rheumatoid arthritis is morning stiffness, which is manifested by difficulties in starting movements in damaged joints.
- Redness of the skin around the joints during an active inflammatory process.
- With a worsening of the course of the disease and the development of polyarthritis, large joints begin to be affected.
Also, when diagnosing rheumatoid arthritis, it is important to consider which joints are damaged. The most characteristic inflammation of the 2nd and 3rd metacarpophalangeal joint, proximal interphalangeal, elbow and knee, wrist and ankle. That is, if the distal interphalangeal, 1st metacarpophalangeal, proximal interphalangeal joint of the 5th finger is affected, rheumatoid arthritis must be excluded.
Among the symptoms, there is a violation of the general condition of the patient, fever, decreased appetite, weight loss.
Specific changes on the skin are characteristic - subcutaneous nodules. The size is not more than 2 cm in diameter, they either appear or disappear. Their most frequent localization is the back surface of the hands, but can also appear on the back of the head, on the skin of the forearm, and sometimes on the surface of internal organs (heart or lungs).
Symptoms, diagnosis and treatment of rheumatoid arthritis of the fingers are directly related.
Diagnostic criteria
As can be seen from the section above, the described disease causes a lot of different symptoms, and not all patients have them all. Therefore, to simplify the diagnosis, certain criteria for the diagnosis of rheumatoid arthritis are highlighted:
- Morning stiffness for at least one hour, which bothers the patient for more than 1.5 months.
- Inflammation of three or more joints.
- Damage to the joints of the hand.
- Symmetrical defeat.
- The presence of rheumatoid nodules on the skin.
- Positive rheumatoid factor.
- Joint bone changes on x-ray.
The doctor has the right to confirm the presence of rheumatoid arthritis when the patient has 4 or more criteria from the list above.
Additional diagnostic methods
When making a diagnosis, not only the symptoms of the disease are taken into account, but also the data of additional examination methods. The following tests are used to diagnose rheumatoid arthritis:
- general and biochemical blood analysis;
- determination of rheumatoid factor in the blood and joint fluid;
- radiography of the affected areas;
- ultrasound examination of the abdominal cavity;
- joint puncture;
- biopsy of skin nodules.
Changes in the general blood count are not strictly specific for rheumatoid arthritis. They are also present in other autoimmune inflammatory processes. It is characterized by an increase in the erythrocyte sedimentation rate (ESR), an increase in the number of leukocytes (leukocytosis), and a decrease in the concentration of platelets and red blood cells is possible.
In biochemical analysis for the diagnosis of rheumatoid arthritis, an increase in the level of C-reactive protein and gamma globulin is observed. These changes are also not specific.
Rheumatoid factor is determined both in the blood and in the joint fluid. Depending on its presence, the type of rheumatoid arthritis is determined. If arthritis is seropositive, the severity and activity of the process is recognized by the number of rheumatoid factors. If the rheumatoid factor is not defined, in the diagnosis of seronegative rheumatoid arthritis, special attention is paid to other diagnostic criteria.
X-ray stages of the disease
X-ray helps to establish the neglect of the pathological process. Therefore, it is important in the diagnosis of rheumatoid arthritis.
The following stages of pathology are distinguished:
- Softening and destruction of the marginal sections of the bone (pineal glands).
- Reducing the distance between the articular surfaces, narrowing the joint space. The patient develops single ulcerations on the bones (usury).
- The gap narrows even more, a large number of patterns are characteristic, subluxations of the joints are observed, the shape of the hand changes, it deviates towards the ulnar bone of the forearm.
- The changes in the 3rd stage are joined by complete immobility in the joints (ankylosis).
X-ray examination is especially important in the diagnosis of seronegative rheumatoid arthritis, since in the absence of a rheumatoid factor, it is the x-ray that is the main criterion for the severity of the disease.
Features of the early diagnosis of rheumatoid arthritis
The named disease has a progressive course with the development of irreversible changes in the joints, so it is so important to identify it and begin treatment as soon as possible. The diagnostic criteria that we submitted in the corresponding section are quite informative, but have a significant drawback - with their help it is possible to make a diagnosis only at later stages. Therefore, in America and Europe, indicators have been developed that can identify the disease at the very beginning. There are four main groups:
- The number and size of the affected joints (1 to 10, small or large).
- The presence or absence of rheumatoid factor.
- ESR and C-reactive protein levels (normal or elevated).
- Duration of symptoms (more or less than 6 weeks).
Each category is awarded a certain number of points:
- The defeat of 1 large joint - 0 points, 2-10 large joints gives 1 point, 4-10 small - 3 points, more than 10 small - 5 points.
- A negative RF gives 0 points, a low level of 2 points, a high level of 3 points.
- Normal C-reactive protein and ESR - 0 points, increasing the level - 1 point.
- If symptoms last less than 6 weeks - 0 points, and longer than 6 weeks - 1 point.
All of these points are cumulative. And if the total is more than 6, the doctor can confirm the diagnosis. This is the reason for the appointment of appropriate therapy, since there is a direct dependence of the treatment on the symptoms and diagnosis of rheumatoid arthritis of the fingers or other joints.
Features of Juvenile Rheumatoid Arthritis
Symptoms and diagnosis of juvenile rheumatoid arthritis (JuRA) have their own characteristics. So, with the named pathology, certain groups of joints are affected:
- lower spine;
- joints between the temporal bone and the lower jaw.
Unlike adults, larger joints are more often inflamed in children. The course of the disease can be acute and chronic. In the first case, the child’s condition is serious, the temperature rises to 38-39 ° C, an allergic rash appears on the skin. The joints become inflamed sharply, this is accompanied by severe pain. The process is bilateral in nature.
In a chronic course, large joints are damaged first, on the one hand, inflammation is sluggish, without significant pain. If infants are sick, this leads to the fact that the child can not sit or walk.
Another difference between this disease and adult rheumatoid arthritis is damage to the lymphatic system with an increase in lymph nodes. In severe forms (Still's syndrome), the autoimmune process affects the heart with the development of myocarditis, and the liver and spleen increase. These changes can be seen with ultrasound.
Changes in blood tests in children are more pronounced. High leukocytosis due to neutrophils is characteristic, the level of ESR is significantly increased. These changes can be judged on the activity of the process.
What diseases should be used for differential diagnosis?
Joint damage is characteristic of many diseases. It can be autoimmune, as in rheumatoid arthritis, or infectious, as in reactive. It can also occur with metabolic changes in the joint (with osteoarthritis) or may be associated with the formation of uric acid crystals (with gout).
Thus, differential diagnosis of rheumatoid arthritis of the fingers should be carried out with such diseases:
- purulent, or reactive, arthritis;
- tuberculous arthritis;
- rheumatoid arthritis;
- systemic lupus erythematosus ;
- psoriatic arthritis;
- osteoarthrosis;
- gout;
- Ankylosing spondylitis.
Features of infectious and tuberculous arthritis
Purulent arthritis is characterized by an acute onset with a significant increase in body temperature, redness and heat of the skin around the joint. Only one of them is affected, as a rule. A previous infection will help to tell the correct diagnosis.
In a blood test, high leukocytosis with a large number of neutrophils is determined. But if the symptoms and blood picture still do not allow to make a final diagnosis, joint puncture with the study of joint fluid will help in the differential diagnosis with rheumatoid arthritis. With arthritis of an infectious nature, bacteria and neutrophils are determined in it, and with rheumatoid arthritis, a rheumatoid factor is present.
Damage to the joints with tubercle bacillus occurs gradually and is asymptomatic for a long time. On the x-ray, bone destruction is visible, but at the same time, it is not characteristic of the formation of patterns, subluxations and ankylosis.
Differences between rheumatic and rheumatoid arthritis
The defeat of small joints and the formation of subcutaneous nodules with rheumatism leads to difficulties in the differential diagnosis of rheumatoid arthritis and rheumatic. Despite the similarity of names, these are two different pathologies.
Joint inflammation in rheumatism - rheumatoid arthritis - is accompanied by damage to the heart muscle and nerve tissue. As a result, specific conditions such as myocarditis and chorea develop.
Joint syndrome with rheumatism also has distinctive features:
- inflammation of large joints;
- asymmetry of inflammation;
- the "volatility" of the involvement of the joints, that is, the defeat of one is quickly replaced by the defeat of the other.
Joint inflammation with rheumatism is not as progressive as with rheumatoid arthritis. It does not lead to dislocations and ankylosis, and after recovery there are no residual effects.
Differences in Rheumatoid Arthritis and Gout
In the differential diagnosis of rheumatoid arthritis and gouty plays a large role in the nature and localization of the inflammatory process.
With gout, the small joints of the foot are affected first and foremost, inflammation of the joints of the thumb is especially characteristic. Inflammation is manifested by a sharp attack of pain, redness of the skin on the affected area, inability to move a finger. Most often, an attack can be triggered by something: taking alcohol, stress, hypothermia, colds.
Specific formations appear on the skin - tofus. They arise due to the accumulation of crystals of uric acid, which is detected by a biochemical blood test and joint puncture. Characteristic localization - auricles, fingers, elbow joints.
Differences of rheumatoid arthritis and osteoarthrosis
Special attention should be paid to the differential diagnosis of rheumatoid arthritis and osteoarthritis. Osteoarthrosis is a common pathology in the elderly. With it, the joints are not damaged by autoimmune inflammation, as with rheumatoid arthritis. There is a metabolic disorder in the cartilage tissue and the destruction of collagen fibers, which as a result leads to the formation of cracks on the articular surfaces of the bones.
With osteoarthritis, the joints that are most exposed to the load are affected. These are primarily the knee and hip joints. At the same time, with movements, the patient can hear a characteristic crunch. Unlike rheumatoid arthritis, pain with osteoarthritis occurs at the end of the day after prolonged physical exertion. Sometimes acute pain occurs when the joint is blocked.
A specific radiological symptom in osteoarthritis is an overgrowth of bone tissue in the sides (osteophytes). There is also a decrease in the distance between the articular surfaces of the bones.
The development of inflammation is not characteristic of metabolic changes in cartilage, and therefore characteristic changes in general and biochemical blood tests do not occur (increase in the level of leukocytes, ESR, C-reactive protein, gamma globulins).
Rheumatoid arthritis treatment
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Nonsteroidal anti-inflammatory drugs and corticosteroids also have a similar effect. They reduce the formation of biologically active substances produced during the inflammatory process. Thus, inflammation and swelling of the joints is reduced.
Corticosteroids have a stronger effect, but at the same time cause more side effects. Therefore, they are prescribed rarely and in short courses, only with severe inflammation.
The most popular NSAIDs include: "Iboprofen", "Diclofenac", "Nimesulide." Among the corticosteroids, Dixamethasone and Prednisolone are most often used.
Antimalarial drugs (Plaquenil, Delagil) also reduce inflammation. They are used only as an adjunct to immunosuppressive drugs.
With the help of monoclonal antibodies, modern therapy for rheumatoid arthritis is carried out. They affect specific links in the pathogenesis of the disease, while not inhibiting all immunity. The main disadvantage of this group of drugs is the high cost. Therefore, biological therapy is sought after the ineffectiveness of drugs from the main groups.
Possible complications
Rheumatoid arthritis can affect not only joints, but also internal organs. When the process is running, the following complications develop:
- anemia;
- autoimmune inflammation of the lungs and pleura (pneumonitis and pleurisy);
- vascular inflammation (vasculitis);
- inflammation of the heart muscle and the membrane surrounding the heart (myocarditis and pericarditis);
- inflammation of the glands.
Correct differential diagnosis of rheumatoid arthritis and timely prescribed treatment will help to avoid the development of these complications, as well as further deterioration of the course of the disease.