Joint problems often begin with age: pain occurs, the degree of mobility decreases. Most people who have these symptoms consider them to be rheumatism, but arthralgia - pain in the elbow, shoulder, ankle, knee joints - are only a manifestation of the disease, and in most cases are caused by other pathologies or simply age-related changes. Rheumatism is directly related to a previous streptococcal infection and is a complication of tonsillitis, pharyngitis, scarlet fever, acute otitis media and other diseases caused by type A streptococcus. Next, we consider the etiology, pathogenesis and classification of rheumatism, treatment principles and prognosis.
General information about the disease
Rheumatism, or rheumatic fever, is characterized by a chronic course and a tendency to relapse. The disease, which usually occurs as a complication of tonsillitis or pharyngitis caused by group A streptococcus, affects large joints and the heart. In severe cases, rheumatism leads to the development of heart defects that threaten the patient's life. The classification of rheumatism is wide, that is, the disease manifests itself in many forms and stages. In any case (even if the joint pains have disappeared or become less intense), the pathology requires complex and ongoing treatment under the supervision of a rheumatologist and cardiologist.
Causes and risk factors for rheumatism
The causes of the disease have long been unknown. Currently, the theory of the autoimmune nature of rheumatism is widespread. In most cases, the disease occurs after infection of the body with streptococcus, which can cause the common cold or SARS. The likelihood of developing rheumatism is influenced by a low immune response, hypothermia, chronic overfatigue, a genetic predisposition, malnutrition. More often, the disease appears in women or girls 7-15 years old. A risk factor is the presence of systemic diseases in close relatives or the content of a particular protein in the body.
The mechanism of the development of the disease
The development of rheumatism is preceded by infection with group A streptococcus. In the vast majority of patients (about 97%) who have had pharyngitis, scarlet fever, maternal fever, acute otitis media, scarlet fever, tonsillitis, erysipelas, a stable immune system response is formed. In individuals, immunity is not produced, and with repeated infection, a complex autoimmune reaction develops. The body produces antibodies that form immune complexes. In places of their localization, inflammation of the connective tissue develops. The pathological reaction is fixed, which contributes to the progressive course of rheumatism.
Classification of rheumatism
For a long time, the classification proposed by A. I. Nesterov in 1964 was used in domestic medical practice, which provided for the identification of manifestations, the degree of activity of the disease, phase, course options and complications. At present, mild and moderate severity has begun to be observed more often, the disease has acquired a lighter character, severe circulatory failure, severe carditis and visceritis rarely develop, the percentage of formation of heart muscle defects has decreased, the complexity of rheumatic defects has decreased.
In this regard, there was a need for the formation of a modern classification of rheumatism. A working classification that takes into account the particular characteristics of the disease at present was proposed by the congress of rheumatologists of Russia in 2003. According to the WHO, the classification of rheumatism divides clinical forms (acute and repeated rheumatic fever), clinical manifestations (the most common and additional), the outcome of the disease and the degree of circulatory disorders . When formulating a diagnosis, it is recommended that you indicate the following information if possible:
- type of rheumatic heart disease;
- number of reliable fever attacks;
- severity of primary and age-related carditis;
- evidence of streptococcal infection prior to the development of rheumatism;
- increased streptococcus antibody titers.
By phase and activity of the disease
Many experts in practice continue to use the developments of A. I. Nesterov, classifying rheumatism primarily in the phase of the disease. Active and inactive forms of the disease are distinguished. Active is usually a rheumatic attack, which is often the result of a streptococcal infection, as an early complication after acute tonsillitis or tonsillitis. Attacks more often happen with children 5-13 years old, less often occur in adulthood.
In the active phase in the classification of rheumatism according to Nesterov, three degrees of the disease are distinguished, depending on the severity of the pathological process. At a minimal degree, the symptoms are mild, a low level of rheumatism indicators is determined in the blood, and the temperature increase is insignificant. The patient feels relatively normal. Moderate pathological activity is characterized by small changes in blood circulation, an increase in the level of leukocytes and ESR. The degree of rheumatism activity is inherent in the primary attack with severe symptoms. In the clinical picture, pronounced rheumatic heart disease, hyperthermia and an acute form of joint damage are noted. Laboratory studies and analyzes in this case record high rheumatic results.
Rheumatism in the inactive phase is a remission. Symptoms of the disease in this case do not appear for a year or more. The patient's condition is characterized as satisfactory, there are no cases of fever, joint pain, cardiac abnormalities, the results of blood tests are within normal limits. In the absence of relapse within five years, the patient's chances of a favorable outcome of the disease significantly increase.
Reactive rheumatism appears after infectious diseases of a viral or bacterial nature. Pathology usually develops against the background of painful lesions of the knee or ankle joints, followed by the possible retraction of other joints into the process. Depending on the characteristics of an individual organism and immune defense, long periods of illness are possible with the transition of rheumatism to a chronic form.
Variants of the course of the disease
There are five types of rheumatism depending on the variant of the course of the disease:
- latent;
- acute;
- subacute;
- protracted;
- recurrent.
Acute rheumatism is characterized by suddenness and sharp severity of the clinical picture, a high degree of activity of the process, quick and effective treatment. In a subacute course, the duration of the disease is from three to six months, the symptoms are less pronounced, the effectiveness of the treatment is less, the activity of the process is moderate.
A protracted version of rheumatism occurs with sluggish dynamics, a prolonged rheumatic attack, and low activity of the process. With a latent course, the absence of instrumental and clinical-laboratory data is characteristic, the disease is diagnosed by an already formed heart defect. A continuously recurring variant of development is determined by severe exacerbations and incomplete remissions, a progressive lesion of the internal organs.
Clinical and anatomical lesions
When classifying rheumatism, the first (1) to establish clinical manifestations, the state of blood circulation and the general clinical and anatomical characteristics of the involvement of the heart or other body systems. In medical practice, a disease is isolated with the development of heart disease or without it (lesions with involvement of the heart), rheumatic lesions of the lungs, kidneys, neurorheumatism (the involvement of other systems is assessed).
In the WHO classification of rheumatism, clinical manifestations are divided into primary and secondary. The main ones are arthritis (a common inflammatory joint disease), chorea (involuntary movements that cannot be controlled by the patient), carditis (inflammatory heart disease), subcutaneous rheumatic nodules (systemic inflammation of the connective tissues), ring-shaped erythema (damage to the dermis, manifested by various rashes) . Additional include arthralgia (joint pain, which can be either transient or permanent), serositis (inflammation of the serous membrane, for example, pleura, peritoneum, or pericardium) and abdominal pain syndrome.
Symptoms of Rheumatism
The clinical picture depends on the degree of activity and severity of the process, the involvement of various systems and organs. Typical symptoms are directly related to a streptococcal infection (pharyngitis, scarlet fever, tonsillitis), and develops one to two weeks after the disease. The process begins with a slight or severe increase in body temperature, headaches, sweating, weakness and fatigue. Early signs are joint pain. Swelling and limited movement of the affected joints are noted. In the classification of rheumatism, the clinical picture is the first to be established.
One to three weeks after the initial manifestations, rheumatic carditis develops. This condition is accompanied by pain in the heart, rapid heart rate, shortness of breath at rest, malaise, fatigue and lethargy. Damage to the endocardium and myocardium, sometimes the pericardium is involved in the inflammatory process, myocarditis may develop in isolation. Myocardium is involved in the pathological process with rheumatism in all cases. In severe cases, asthma or pulmonary edema, circulatory failure are possible.
The central nervous system can be affected, a sign of which is chorea - involuntary muscle twitching, muscle weakness, emotional instability. Dermatological manifestations and rheumatic nodules are relatively rare (in 7-10% of patients). In severe cases of the disease, damage to the abdominal cavity, kidneys, lungs and other organs is noted. Rheumatic damage to the lungs occurs in the form of pleurisy or pneumonia, with kidney damage, a clinical picture of nephritis occurs, with damage to the abdominal cavity, abdominal pain, vomiting, and digestive upset can be noted. Such conditions are currently rarely diagnosed.
Complications
The classification of rheumatism takes into account the presence of complications. This is determined by the severity, recurrent nature of the course of the disease. Adhesions may develop, mitral valve insufficiency, mitral stenosis, aortic insufficiency, myocardiosclerosis and other heart defects (with the involvement of the valves, the treatment and prognosis are determined by the type of rheumatic valve rheumatism), thromboembolic complications, that is, cerebral ischemia, kidney, retinal, and spleen infarction are possible . Deadly complications are decompensated heart defects and thromboembolism of the great vessels.
Diagnosis of rheumatism
The objective diagnostic criteria are the symptoms of rheumatism and confirmation of a previous streptococcal infection. In the classification of rheumatism, the presence and severity of manifestations are the first to be established: carditis, chorea, polyarthritis, subcutaneous nodules and annular erythema. Small clinical symptoms (joint pain, fever), laboratory (increased ESR and white blood cell count, the presence of C-reactive protein) and instrumental (prolongation of the PQ interval on the ECG, decreased myocardial ability, change in the structure of heart tissue, enlargement of the heart) are distinguished. Infection is confirmed by an increase in antibody titers in OAK, recent scarlet fever.
Disease treatment tactics
Treatment of the active phase of rheumatism should be carried out in a hospital under the supervision of a cardiologist and a rheumatologist. Remediation of potential foci of infection (including caries, tonsillitis, sinusitis), including antibacterial and instrumental treatment, drug therapy, is indicated. To combat inflammation, non-steroidal anti-inflammatory drugs (Meloxicam, Lornoxicam, Diclofenac, Nimesulide, Ibuprofen, Indomethacin, Ketorolac) and glucocorticosteroids (Dexamethasone, Prednisolone, "). Antibiotics (Ampicillin, Bicillin, Penicillin, Erythromycin) allow you to cope with the main causative agent of the disease.
To attenuate the immune response, immunosuppressants (Hydroxychloroquine, Azathioprine, Chloroquine, Chlorobutin) are used, and the work of the heart is supported by cardiac glycosides (Digoxin). Potassium preparations can be used to neutralize the negative effects of glucocorticosteroids, sedatives. The duration of the course of drug therapy is at least two weeks. In remission, treatment is carried out in sanatoriums, and for the prevention of seizures during the off-season, a month-long preventive course is carried out.
Prevention and prognosis of rheumatism
The prognosis is determined by the type of rheumatism. In adults, timely detection of pathology and treatment virtually eliminates a threat to life. The severity of the prognosis is determined by heart damage. Adverse continuously progressive course. With the early onset of the disease and the late start of treatment for any type of rheumatism in children (the classification is the same as for adults), the likelihood of heart muscle defects is increased. In a primary attack in people over twenty-five years, the course of rheumatism is favorable, and clinical symptoms usually do not develop.
The main types of rheumatism prevention are primary and secondary (relapse prevention). Primary prevention measures include earlier detection and resolution of infection. It is also important to improve the social and hygienic living conditions, hardening. Secondary prevention is carried out under the supervision of a private doctor or regional cardiologist, rheumatologist. It is important to take the necessary antimicrobial and anti-inflammatory drugs in the autumn-winter period.