Many of us have often seen old people with twisted fingers and swollen joints on our hands. It is difficult for such people to perform even very simple actions - to fasten a button, hold a spoon with soup, dial a phone number. These signs of rheumatoid arthritis do not occur immediately, but after years from the onset of the disease. The disease affects not only the joints of the hands, but also the legs. If the disease affects the knees, it is very difficult for a person to move even with a cane. For him, it becomes a problem to sit down the stairs. These signs of rheumatoid arthritis also indicate a late stage of the disease. Not everyone knows that you can even die from him. Rheumatoid arthritis in the world kills about 50,000 people each year. Consider what causes this ailment, what signs it has, how it should be treated.
general information
People have known rheumatoid arthritis for more than a thousand years. The characteristic signs of this disease are found on the remains of people who lived 4,500 years BC. Nowadays, it is spread all over the planet. Rheumatoid arthritis affects people of all nationalities and ethnic groups. It is especially common in South America and Russia. What is the reason, scientists have not yet figured out. But it is already known that women are exposed to this disease about 3-5 times more often than men.
Rheumatoid arthritis is considered by some to be an ailment of the elderly, because in older people it is diagnosed more often by about 5 times than in young people. Basically, the first signs of rheumatoid arthritis are observed in people aged 40-50 years.
The disease rarely develops rapidly. Usually it proceeds slowly, the joints are destroyed gradually. In parallel with pathological changes in the musculoskeletal system, the functioning of many body systems deteriorates, which, without quality treatment, can lead to death.
Causes
Many people are confident that the development of rheumatoid arthritis (especially on the hands) is affected by professional activities, for example, work in which it takes a long time to perform manipulations in cold water. This opinion is based on the fact that such workers most often have rheumatoid arthritis symptoms on their hands. The causes of the ailment, unfortunately, have not yet been accurately established by physicians. Adverse working conditions only contribute to its appearance. However, rheumatoid arthritis does not apply to diseases arising from hypothermia.
There is a version that it is associated with bacterial or viral infections, but in practice it is not confirmed.
Many scientists suggest that the basis of its appearance is a violation of the immune system. In a healthy person, suddenly the lymphocytes, designed to protect against all kinds of infections, begin to consider their own completely healthy cells located in the synovial fluid of the joints as foreign agents. This triggers the immune defense mechanism.
This is today the main version explaining the causes of rheumatoid arthritis. Symptoms of the disease do not appear immediately. For a while, the cells try to work in the previous mode, but the running mechanism cannot be stopped. You can only slow down its activity. This is the main task of doctors prescribing a course of therapy for patients with rheumatoid arthritis.
Risk factors
The start for the development of the disease can be a variety of conditions and situations. Doctors divided them into three groups:
1. Heredity. It determines the genetic predisposition of a person to autoimmune reactions. It is known that the first visual signs of rheumatoid arthritis are observed in carriers of antigens of the MHC II group, i.e., HLA DR4 and HLA DR1. In the future, an x-ray, as a rule, confirms the presence of a destructive process in the joints in such patients.
2. Infections. This group includes viruses:
- Hepatitis B.
- Tinea versicolor.
- Epstein - Barr.
- Herpes simplex.
- Paramyxoviruses (cause measles, mumps, respiratory-sencitial infections).
- Cytomegalovirus.
- Retroviruses.
All of them affect the development of rheumatic ailments, acting as a complication of the underlying disease.
3. Other factors that may become triggers:
- Hypothermia.
- Intoxication.
- Stress.
- Some foods and medicines.
- Hyperinsolation (a condition similar to heat stroke).
- Regular overwork.
- Other factors leading to a malfunction in the functioning of the immune system.
Scientists have found that prolonged breastfeeding (over a year) significantly reduces the risk of rheumatoid arthritis.
Joint structure
The first symptoms of rheumatoid arthritis appear mainly in a few months (in some people, years) after the onset of the disease.
To understand how the pathological process in the joint develops all this time, you need to remember its structure. If you do not go into details, we can say that the joint is a movable joint of two bones, the heads of which are covered with the synovial membrane, cartilage and synovial capsule. Between them there is a small gap filled with articular fluid. Its role is to lubricate the cartilage and the shell of the joint during movement, as well as nourish the cartilage.
Synovial fluid is a complex substance that includes many different components. Up to 40% of its composition falls on synovitis. These are specific cells that perform important functions.
There are two types of synovocytes - A and B. Cells of type A are macrophage-like. Their role is to absorb unnecessary components in the synovial fluid. Cells B are fibroblast-like. They release a number of substances into the synovial fluid that lubricate articular surfaces and nourish cartilage.
Pathogenesis
Presumably, when a malfunction in the functioning of the immune system occurs, the synovocytes receive an erroneous command. Cells B cease to secrete beneficial substances and acquire the functions of magrophages. Cells A begin to produce cytokines in the synovial fluid, triggering further reactions in cells B. These synovocytes secrete interleukin 1 and tumor necrosis factors, which leads to the activation of T-helpers.
The next step in the development of the disease is the accumulation of T-helpers in the synovial membrane and simultaneously in the synovial fluid, where they begin to very actively release interferons - proteins that must be produced during the invasion of the virus.
That is, the cells behave as if an infection had entered the joint.
At this stage, the first symptoms of rheumatoid arthritis may already appear in the form of pain during movement, a slight swelling of the joint.
The disease continues to progress. Macrophages and monocytes activated by T-helpers secrete a number of pro-inflammatory cytokines, including IL-8, into the synovial fluid. It causes an increased concentration of neutrophils, which are called by phagocytosis to destroy foreign microorganisms (viruses, bacteria).
Especially dangerous is the cytokine IL-1, which is a mediator of inflammation.
At this stage, brighter signs of rheumatoid arthritis appear in women and men, such as fever, significant joint pain.
Tumor necrosis factor contributes to the appearance of adhesion molecules, which entails exudation and weight loss of the patient.
Subsequently, cytokine I 16 activates B-lymphocytes. In patients in the synovial fluid and in the blood, the concentration of IgG and IgM increases.
As a result of all these complex reactions and interactions, a pannus is formed in the joint. This is a tissue with signs of tumor-like growth. It is introduced into the cartilage and in the surface of the bones of the joints, where it forms erosion.
These deformities correspond to 3 stages of rheumatoid arthritis. The x-ray sign of this condition is clearly visible on x-rays.
IgG, which is part of the immune complex formed in the blood, interacts with rheumatoid factors. As a result, complement is activated in patients and the microvasculature is damaged. This is the cause of visceral (manifested in many organs) signs of rheumatoid arthritis.
Classification
There are several types and forms of rheumatoid arthritis, which are based on clinical indicators, laboratory and hardware studies.
According to clinical manifestations, four stages are distinguished:
- Very early (before the onset of the first symptoms, six months or less from the onset of the disease).
- Early (the period of onset of symptoms from six months to a year).
- Expanded (signs become noticeable a year after the onset of the pathological process).
- Late (after 2 years and later, the first signs of the disease begin to appear).
According to the activity of progression of symptoms, 4 degrees of the disease are distinguished. In this case, the so-called DAS 28 calculator is used. For calculations, the number of swollen and painful joints, the activity of the development of pathology and the functionality of the patients are taken into account. As a result, digits are obtained in the range from zero to some values. These results determine the degree of rheumatoid arthritis in a patient:
- 0 - remission (according to the DAS 28 calculator, the value is below 2.6).
- 1 - low (value from 2.6 to 3.2).
- 2 - average (calculation result from 3.2 to 5.1).
- 3 - high (above 5.1).
By immunological characterization:
- Rheumatoid factor is determined by gray-positive or seronegative.
- Anti-CCP distinguish between gray-positive and gray-negative.
According to the functionality of the limbs, rheumatoid arthritis is divided into four classes:
- I - the patient retained professional and unprofessional activities. Of course, he serves himself.
- II - only unprofessional activity is saved. The patient can serve himself.
- III - all types of activity are violated, but the patient is still able to serve himself.
- IV - any activities are violated. The patient cannot serve himself.
Symptomatology
For unknown reasons, it is from the small joints of the fingers in the vast majority of cases that rheumatoid arthritis begins. The first sign may be pain and swelling of the affected joint, which is caused by swelling of the synovial bags. In some people, redness and fever are observed on the skin at the site of the lesion. Many patients develop articular syndrome, which means stiffness in the morning of the limb in which the joint is affected . Stiffness can last up to half an hour. The duration of this condition depends on how actively the destructive process proceeds.
In most patients, at the onset of the disease, body temperature may increase, there are symptoms of intoxication, fatigue, irritability are observed.
An important sign of rheumatoid arthritis is that the inflammation on two limbs proceeds symmetrically. If, for example, the joint on the index finger of the right hand is affected, then very soon a similar process will develop in the joint of the index finger of the left hand. The reason for this phenomenon has not yet been determined.
As a rule, the development of a destructive process proceeds monotonously, slowly. After treatment, residual effects are observed.
Only in some patients rheumatoid arthritis manifests acute or subacute, which means the rapid development of symptoms.
In many people, a painful reaction in the joints to changes in weather conditions (rain, cold snap, etc.) is also one of the signs of rheumatoid arthritis. Symptoms of the disease are not only deformation of the joints, but also disorders in many body systems:
- In the cardiovascular. Pericarditis, atherosclerosis, vasculitis, granulomatous lesions of the heart valves may develop. This is manifested by pain in the heart, shortness of breath, dry cough, weight loss, general weakness, damage to the larynx, organs of vision, hearing.
- In the respiratory system. Pleurisy often develops, characterized by chest pain during breathing, bending, and coughing.
- On the skin, a mesh lido, rheumatic nodules may appear.
- The nervous system also suffers if a person has rheumatoid arthritis. What signs indicate this? The patient complains of tingling in the affected limb, numbness, loss of skin sensitivity, difficulty in flexion / extension. In some cases, inflammation of the spinal cord (cervical myelitis) may develop.
- Urinary system. Patients with rheumatoid arthritis often develop nephritis, amyloidosis, NSAIDs-nephropathy. These complications are manifested by edema, dysuria, lower back pain. Protein is found in urine, and in plasma its values become abnormally low.
- A blood test of patients reveals that the hemoglobin index is greatly reduced, and platelet count is significantly increased, which creates a risk of blockage of blood vessels. In addition, a low content of neutrophilic granulocytes is observed in the blood, which provokes the frequent occurrence of tonsillitis, gingivitis, stomatitis, pneumonia, intermuscular phlegmon and other dangerous diseases.
Signs of rheumatoid arthritis in women and men are almost identical. The difference in the manifestation of the disease in representatives of both sexes may be due to the biological nature. So, ladies are more likely to experience increased fatigue, mood changes. In addition, some have problems with menstruation (they become more plentiful). In men, the disease can affect the decrease in physical and sexual activity.
Women are more concerned about the aesthetic problems of finger deformation. Some of this state of affairs can lead to a nervous breakdown. Men (until it hurts a lot) due to joint deformations are not very upset.
Juvenile rheumatoid arthritis
It was noted above that this disease is observed in the vast majority of cases in the adult population. However, rheumatoid arthritis can develop in adolescence and even in childhood. In this case, it is called juvenile.
The causes of the disease in children are the same as in adults. The main symptoms are similar too. It:
- Temperature rise.
- Symptoms of intoxication.
- Swelling of the joints.
- Difficulty in performing the movements.
- Weight loss.
- Symmetry of joint damage (one of the main signs).
However, in young patients, a slightly different genetic picture is observed. So, they very rarely have HLA Dw 4 and HLA DRw 4 leukocyte antigens, but often HLA TMo, HLA Dw 7 and 8 antigens are detected. This gives scientists the right to suggest nosological independence of the disease.
In most cases , rheumatoid arthritis in children is acute and subacute. However, children rarely complain of stiffness in the limbs in the morning and joint pain, even if they are swollen. The most characteristic of young patients is increased fatigue, fever, poor appetite, and weight loss.
Finger joints are rarely observed in children, but the cervical spine and temporomandibular joints are more often affected .
The consequences of this ailment in children are stunted growth and physical development, a change in the phalanges of the fingers (shortening or lengthening), underdevelopment of the lower jaw and other parts of the skeleton located near the affected joints.
Diagnostics
Rheumatoid arthritis is diagnosed based on external symptoms and signs. Based on 11 criteria proposed by the American Rheumatological Association:
1. Stiffness in the morning.
2. Swelling of the joint.
3. Soreness during movement (noted in at least one joint).
4. Symmetry of deformations.
5. Soreness in other joints that appears after some time.
6. Radiological signs.
7. Subcutaneous nodules.
8. Rheumatoid factors in serum.
9. Changes in the joint fluid inherent in rheumatoid arthritis.
10. Changes in the synovial membrane.
11. Rheumatoid nodules.
Probable rheumatoid arthritis is diagnosed if the patient has 3 symptoms.
Certain - if 5.
Classic - if 7 or more.
Also perform analyzes:
- Blood.
- Synovial fluid (take a puncture).
- Fragments of the synovial membrane (by biopsy).
- Do an x-ray.
According to radiological signs, rheumatoid arthritis is diagnosed in 4 stages:
- First one. Signs of osteoporosis are detected (the transparency of the bones at the ends is clearly visible in the pictures). However, this symptom is not specific, since such changes are inherent in many diseases of bones and joints.
- The second one. Narrowing the gap between the bones is added to the sign of osteoporosis.
- The third. The images show bone erosion. This radiological symptom of the 3rd stage of rheumatoid arthritis is specific to this disease and indicates that the disease has been developing for a long time.
- Fourth. Ankylosis (this is the immobility of the joints resulting from bone fusion).
Treatment
If there are signs of rheumatoid arthritis, treatment is prescribed according to several schemes, which depends on the degree of manifestation of the disease and the activity of its development. The classic scheme includes:
- Nonsteroidal anti-inflammatory drugs (Indomethacin, Butadion, Ibuprofen, Naproxen, Voltaren tablets). These drugs act quickly. Within two to three weeks, patients notice significant improvements.
- Injections into the joint (Depomedrol, Kenalog). Drugs have a prolonged effect.
- Corticosteroids (Prednisolone). They are prescribed only for the period until the patient manifests pain too clearly.
- Basic anti-rheumatic drugs (Levamisole, D-penicillin, gold salts). They are prescribed if there are no improvements after a course of anti-inflammatory drugs.
- If a positive effect has been achieved, continue to take anti-inflammatory drugs for a long time (sometimes years).
- Cytostatic immunosuppressants (Azathioprine, Cyclophosphamide, Chlorbutin). They are assigned last. At the same time, at least 1 time per week perform a general blood test. In some cases, plasmapheresis is performed (blood sampling, cleaning and returning it to the bloodstream).
The dosage of all drugs is prescribed by the doctor individually for each patient.
Physiotherapeutic procedures have a great help in the treatment of:
- Exercise therapy.
- Massage.
- Paraffin baths.
- Electrophoresis
- UHF
- Inductothermy.
- Radon baths.
- Phonophoresis.
- Microwave therapy.
In case of joint inflammation, painkillers and Voltaren, Deep Relief and others gels are used.
Popular methods are widely used: compresses, rubbing with alcohol tinctures from acacia, lilac, horse chestnut and other plants. Also shown are baths with sea salt, chamomile, nettle. With their help, you can improve the condition of the skin around the inflamed joint, relieve pain.
At the 4th stage, surgical correction of the joints is performed.
Prevention
Rheumatoid arthritis is believed to shorten a person’s life by 3-12 years. Since this disease is autoimmune in nature, there are no preventative measures that would prevent its occurrence with a 100% guarantee. However, there are a number of measures that help strengthen bones, which helps to resist the development of osteoporosis. This is the restoration of calcium balance in the body, an increase in the absorption of calcium in the intestine and a decrease in its excretion from the body. A large role in this case is played by a diet that includes foods rich in calcium and vitamin D (milk, walnuts, cottage cheese, cheese and others).
To support the effect achieved during treatment, patients are shown sanatorium treatment, where they undergo a course of supporting physiotherapeutic procedures.
Since there is a version that rheumatoid arthritis is provoked by the introduction of bacteria and viruses into the body, it is very useful to avoid infectious diseases as a prophylaxis. If they happen, you must follow all the doctor's recommendations so that there are no complications.