Joint rheumatism: symptoms and causes, how to treat rheumatism?
- What is rheumatism?
- Etiology of rheumatism
- Causes of rheumatism
- Symptoms of rheumatism
- Signs of rheumatism
- Diagnosis of rheumatism
- Forms of rheumatism and its classification
- Complications of rheumatism
- How is rheumatism treated? Drugs
- Disability with rheumatism
- Prevention of rheumatism
What is rheumatism?
Rheumatism is a systemic inflammatory disease that is localized mainly in the lining of the heart. At risk are people with a hereditary predisposition to this disease and age from 7 to 15 years. Rheumatism usually affects adolescents and young people, less often elderly and debilitated patients.
Rheumatic heart disease is one of the leading causes of death (approximately 50,000 people die from this disease in the United States each year). Often this disease begins precisely in the cold season, especially in northern latitudes. Rheumatism does not belong to epidemic ailments, although the streptococcal infection preceding it can take on the character of an epidemic. For this reason, rheumatism can begin immediately in a group of people - for example, in schools, orphanages, hospitals, military camps, in poor families and in close living conditions.
Bacteriological and serological studies have shown that rheumatism is a special allergic reaction to infection with one of the beta-hemolytic group A streptococci.
Within a month, 2.5% of those who have had streptococcal infection begin to suffer from acute rheumatism. Often such diseases as tonsillitis, scarlet fever, childbirth fever, acute inflammation of the middle ear and erysipelas precede the development of rheumatism. The body does not develop immunity to infection, and an autoimmune attack begins in response to reinfection.
Etiology of rheumatism
Rheumatism is a complex pathological process of impaired synthesis of connective tissue, affecting mainly the musculoskeletal system and the heart.
Despite the fact that in modern research and practice, rheumatism is determined in several ways, the essence of the pathological process is the same.
The development of rheumatic pathology is based on disturbances in the functioning of connective tissue cells and destruction of the intercellular substance. The main change lies in the destruction of collagen fibers that form the tissues of the joints and heart. For this reason, the heart (primarily the valves), blood vessels and the musculoskeletal system (joints and cartilage) are most affected.
The etiology of rheumatism today is represented by three theories:
- Complex theory. It proceeds from the multiplicity of reasons for the formation of rheumatism, including an allergic reaction and bacterial damage (by organisms of the genus streptococci);
- Infectious theory. It proceeds from the fact that the main cause of the development of rheumatism is the streptococcus bacteria;
Bacterial immunological theory. Its essence lies in the fact that a microorganism is a trigger of a disease, which entails an immune response and, as a result, the destruction of connective tissue substances.
According to a comprehensive theory, rheumatism is a polyetiological process that includes several aspects. Unlike the bacterial-immunological theory, here we are talking about a microorganism as an independent cause, and not a trigger.
This concept is based on the idea of the development of the disease as a result of the penetration of streptococcal infection into the tissues of the body and the dislocation of bacteria in the heart and joints (they are carried with the blood stream).
However, a necessary condition is repeated contact with the pathogen, which leads to an increase in the body's sensitivity. As a result, the body becomes less resistant to the effects of a particular strain of streptococcus, and the immune response is not able to completely suppress the development of infection.
The concentration of antibodies, however, is high enough to have a destructive effect on cellular structures and the intercellular substance of the organism itself. The substances produced by streptococcus have the same effect.
Both bacteria and antibodies are equally detrimental to the body, provoking rheumatism. In support of the theory, often when examining samples (analyzes) handed over by patients with rheumatism, streptococcus is found.
It comes from the only cause of the disease - bacterial damage. In the fluid taken from patients with rheumatism from the pleural cavity or pericardium, specific disease-causing particles are found, which confirms the theory.
Bacterial immunological theory
Gives immunity a leading role in the mechanism of disease development. The reason is that a high concentration of antibodies to streptococcus is found in the blood of patients, but the samples for streptococcus itself also remain positive. Consequently, the body's immune response acts in this case as a destructive factor.
Within the framework of this theory, the microorganism does not have a significant effect on a person and is only a trigger.
Thus, all theories point to the complex nature of the disease, which is based on infection and the immune response.
Causes of rheumatism
The main causes of rheumatism are three:
- Postponed streptococcal infections (tonsillitis, etc.);
- Immune (allergic) reaction;
- Genetic predisposition.
As it was said, only streptococci (group A streptococcus, beta-hemolytic) affect the formation of the disease and only with repeated interaction, as a result of which the body's protective ability decreases.
Since there are serological subgroups within the group of microorganisms, it is important to say that the interaction should be carried out with streptococcus of the same subgroup. This explains why rheumatism does not develop after any cold illness.
The risk of developing rheumatism is also higher with a single contact, if the patient does not receive the necessary treatment. The disease becomes chronic, and a bacterial focus grows in the patient, capable of provoking rheumatism and other serious complications at any time.
A severe allergic reaction can be caused by both the streptococcus itself and the substances secreted by it (toxins and enzyme proteins). Since the pathogen spreads throughout the body with the blood flow, the immune response can be systemic, but it is most pronounced by lesions of the heart and joints.
According to research, bacteria are responsible for the development of acute rheumatism involving the joints (this is the classic form of the disease).
However, chronic rheumatism is not associated with streptococcal lesions, since the test results show that neither antibodies to streptococcus nor streptococcus itself are detected. There is also no effectiveness of preventive measures against recurrence of rheumatism. These arguments support an unexplored allergic or autoimmune process.
The disease is not transmitted genetically, but a predisposition to the disease is inherited. This is due, first of all, to the similarity of the immune systems of the parents and the child, and since rheumatism is predominantly an immune disease, the mechanism of its development and causes are similar to other allergic pathologies (Hashimoto's thyroiditis, bronchial asthma, etc.).
Elena Malysheva will tell you about the main cause of rheumatism:
Be sure to watch the video to the end to understand the cause of rheumatism!
Symptoms of rheumatism
Rheumatism is not an isolated disease. Often it "coexists" with other pathologies for the reason that the harmful substances secreted by streptococcus and immunity antibodies damage many organs and systems, and all these manifestations can be considered as forms of rheumatism.
The first symptoms of rheumatism do not allow diagnosing the disease. They appear 2-3 weeks after a repeated upper respiratory tract infection (pharyngitis, laryngitis, tonsillitis) with an established streptococcal lesion. The picture looks like a relapse of a cold. Symptoms of acute rheumatism include fever, sometimes up to 40 ° C, increased heart rate, chills, increased sweating, loss of strength, swollen and painful joints. The largest and most actively used joints are affected first.
Further, the inflammation spreads to other joints, often symmetrically. The joints are very swollen, reddened, hot to the touch, pain is felt with pressure and with movement. Usually, the inflammatory process does not lead to stable changes in the joints. The pulse is frequent, arrhythmic, there is chest pain, dilatation (expansion) of the heart, sometimes a pericardial friction noise is heard - this indicates heart damage.
Common symptoms of rheumatism:
- Hyperthermia. The body temperature rises to menacing levels (38.0-40.0 ° C). The symptom is associated with the development of an acute immune response against pathogens;
- Lethargy. As the patients describe, the body becomes “wadded”, you constantly want to sleep;
- Headache. Localized in the forehead.
Specific symptoms of rheumatism:
- Joint pain. First of all, large joints (knee, elbow) are affected, pulling pains, dull and prolonged. Rheumatism is characterized by the rapid development of the process, and the same rapid disappearance of inflammation and pain in the joints with the restoration of their functions;
Pain in the chest. Pain in the region of the heart, dull or aching. The symptom does not appear immediately, but after a day or several days;
- Vascular disorders. Vascular fragility, nosebleeds and more;
- Annular eruptions. They appear in no more than 4-10% of all cases. They look like a pink rash that forms rounded curves with jagged edges. Does not disturb the patient in any way;
- Rheumatic nodes. Formed on the affected joints. They look like subcutaneous formations from 5 mm to 2-3 cm in diameter, dense and immobile, but painless. They appear extremely rarely and persist for about 2 months from the beginning of the course of the disease.
Specific symptoms appear only after 1-3 days. Occasionally, there are symptoms of damage to the abdominal organs (pain in the right hypochondrium, etc.), which indicates a severe course of the disease and requires immediate hospitalization).
Rheumatism in children is milder or chronic, without any special symptoms. General malaise, rapid pulse and joint pain are noted, pain is not felt when moving (the so-called "pain of growth"). If there are no signs of heart damage, then the disease rarely ends in death, although with the development of carditis, the average life expectancy of patients in the future is significantly reduced.
Signs of rheumatism
Other signs of rheumatism include:
- Secondary. The disease is formed as a result of the development of a chronic focus of unique streptococci beta-hemolytics. Therefore, the manifestations of the disease do not appear immediately, but after a certain period (several weeks);
- Polyethiological. The disease is caused by both antibodies of lymphocytes and toxins, as well as enzymatic substances of streptococcus;
- A tendency to recurrent course. After the first course of rheumatism in an acute form, the disease, even with successful treatment, turns into a chronic form with frequent relapses;
- Monopathology. For rheumatism, regardless of its etiology, a specific single complex of symptoms is characteristic, indicating damage to the heart, blood vessels, cartilage and joints. The heart suffers the most, as its tissues are destroyed by antibodies. The mechanism of defeat is also the same;
- Many concomitant pathologies. Some doctors call concomitant diseases forms of rheumatism. This is not entirely accurate, moreover, they do not appear in all patients and not always. Among them are chorea (nervous disease), erythema nodosum and others;
- Self-elimination of symptoms. Symptoms of acute rheumatism go away on their own and as quickly as they arose (with the exception of cases of severe course, when acute heart failure is observed);
- Unpredictability. Symptoms subside after some time, but it is impossible to accurately predict it. Even during the course of treatment, relapses occur. Relapse rates also vary. The disease can "subside" for a long time, and then reappear, or it can make itself felt every month. The duration of relapse cannot be predicted accurately;
- Swiftness. The first specific symptoms develop rapidly and all at once;
- Complexity of diagnosis. Rheumatism has manifestations similar to other diseases. Since bright symptoms, indicating pathology, can be found very often, rheumatism is easy to "blink". For example, with joint damage, with rheumatoid arthritis, but this is a completely different disease that has nothing to do with rheumatism.
Diagnosis of rheumatism
With 100% accuracy, none of the diagnostic procedures will indicate the presence of rheumatism. Only by evaluating the data obtained in a complex, an experienced specialist can conclude that the disease exists. That is why the diagnosis of this disease is difficult.
Diagnostic measures include a number of laboratory and instrumental studies:
- Ultrasound diagnostics;
- Cardiography (ECG);
- Blood tests.
Cardiac ultrasound (also known as echocardiography) evaluates the condition of the valves as well as their ability to contract. As rheumatism develops, changes in the activity of the heart increase. Thanks to echocardiography, it is possible to identify defects in the early stages and take the necessary actions in time.
The study makes it possible to clarify the degree of nutritional status of the heart muscle. The ECG detects the slightest violations of cardiac activity and displays them graphically using a special sensor. It is most effective to conduct a series of cardiographic studies within a few days, because rheumatism is a permanent disorder, and the changes in the work of the heart are best seen in dynamics.
Changes in the work of the heart muscle are found in the vast majority of patients with rheumatism (up to 90%).
To diagnose rheumatism, venous blood is taken. The following indicators should alert the doctor:
- Leukocytosis - increased content of leukocytes;
- Protein disorders of blood composition;
- The presence of antibodies to streptococci;
- Detection of antibodies to streptococcal enzyme substances (ASL-O);
- Identification of specific C-reactive protein;
- Decrease in hemoglobin index;
- Increased ESR.
Also, during the initial examination, the doctor may detect symptoms of polyarthritis (swelling of the joints, redness, joints that are hot to the touch). In combination, these diagnostic manipulations make it possible to establish the diagnosis of rheumatism with high accuracy.
To make a diagnosis, it is important that one of the following sets of symptoms occurs:
- Disruption of the heart (carditis) and the release of antibodies against streptococcus from the patient's blood;
- Violation of the heart and the presence of two laboratory parameters indicating rheumatism;
- Violation of the heart and pronounced external manifestations (swelling of the joints, etc.);
- Two specific signs in the anamnesis (inflammation of the joints, heart dysfunction, chorea minor, skin rashes, rheumatic nodes) and one nonspecific (cardiac arrhythmias, hyperthermia, changes in laboratory tests of the type mentioned above, etc.);
- One specific feature and three non-specific ones.
Forms of rheumatism and its classification
The main classification adopted by rheumatology doctors includes two types of rheumatism.
Rheumatism in the acute phase most often manifests itself in young people under 20 years of age. The causative agent is streptococcus. The relationship of the disease with previous infections of the upper respiratory tract is the late manifestation of symptoms (14-21 days).
Acute rheumatism develops rapidly. At first, symptoms of general intoxication appear, as with a cold, which does not immediately determine the disease, then after a day or two specific symptoms appear (polyarthritis, carditis, skin rashes and very rarely nodules). The acute phase lasts, on average, up to 3 months. A longer course (up to six months) is also possible. The most dangerous in acute rheumatism is heart damage (carditis). in 1/4 of all cases, it contributes to the formation of heart disease.
The chronic form is characterized by a frequent recurrent course, even during therapy. Exacerbations occur at any time of the year. Especially often during cold seasons (autumn, winter). Patients living in damp or cold apartments are subject to the same effect. Exacerbations - several times a year. The majority of patients (about 85%) are persons under 40 years of age.
Joints and heart are affected. The course of the disease is severe and significantly reduces the quality of life. The patient experiences constant pain in the joints and heart. After the acute phase (relapse) has passed, the sluggish course can last for several months, or even years.
Classification of rheumatism
Rheumatism is divided into forms according to the criterion of the affected system or organ:
- Cardiac form of rheumatism. Otherwise - rheumatic heart disease. In this case, the muscle structures of the heart are affected. It can bother the patient with severe pain, or it can barely appear. But destructive processes will still go on. In the first stages, the course is almost imperceptible and is detected only with the help of an ECG. At the later stages of formation, it causes severe damage to the heart and acute heart failure against the background of a decrease in the nutrition of the muscles of the organ and, as a result, a decline in contractility. It manifests itself as disturbances in the heart rhythm (tachycardia) and is detected by ultrasound (echocardiography);
- Articular form of rheumatism. It can exist as an independent clinical manifestation of rheumatism, or in combination with heart damage. With this form of the disease, large joints are affected. At a later stage, small joints are also involved in the process. In rheumatism, under the influence of lymphocyte antibodies and streptococcal enzymes, the articular bag and the cartilage itself are destroyed. Therefore, the diagnosis is not a problem: the joint looks very swollen and red. The patient cannot move the affected limbs because of severe pain. The acute phase of the articular form is characterized by an increase in body temperature up to 38-39 ° C;
- Damage to the nervous system. The neurological form is somewhat less common. With this form of the disease, the cells-neurons of the cerebral cortex, which are responsible for motor activity, are damaged. Their involuntary stimulation with active substances leads to the fact that the patient has spontaneous uncontrolled muscle movements. This is manifested by twitching of the limbs and grimaces. The form is extremely unpleasant, since it complicates a person's social life and interferes with self-service in everyday life. Symptoms last 2 to 4 weeks. There are no manifestations in sleep;
- Pulmonary form. It manifests itself in combination with damage to the joints and heart, but is extremely rare (about 1-3% of the total number of clinical cases). Develops in the form of pleurisy or bronchitis;
- Skin form. It manifests itself as skin rashes, or rheumatic nodules. It occurs in no more than 5% of cases;
- Ophthalmic form. It is diagnosed only in combination with the "classic" symptoms of rheumatism. It consists in damage to the retina (retinitis), or other structures of the eye (iritis, iridocyclitis, etc.). May cause complete or partial loss of vision.
Complications of rheumatism
Complications of the transferred rheumatism include:
- Chronic recurrent course. The disease can become chronic;
- Development of heart defects. The formation of defects occurs in 25% of cases of the acute phase of pathology. The defect affects the main muscle structures of the heart and leads to a decrease in the quality of the organ;
- Chronic heart failure. The heart, being affected by rheumatism, ceases to cope with its functions. Diffuse changes, decreased cardiac contractility and rhythm disturbances may occur;
- Thromboembolic and ischemic disorders. As a result, foci of ruptures or blockages (strokes) of blood vessels, including the retina of the eye, renal arteries, etc.;
- Inflammation of the membranes of the heart. It is infectious in nature and can pose an immediate danger to the patient's life.
How is rheumatism treated? Preparations for rheumatism
Rheumatism is a pathology that has a mixed immune-bacteriological nature. Therefore, it is difficult to treat and is practically not completely cured. Since the primary source of the disease is a streptococcal bacterium (and the immune response is secondary and is a response to the "attack" of a foreign organism), the main task of treatment is to eliminate bacteria and promptly remove their waste products and decay.
The main (and main) drug for combating the causative agent of the disease is bicillin (it is an antibiotic of the penicillin series, has a longer effect than ordinary penicillin).
The first (active) phase of antibiotic therapy lasts from 10 to 14 days. Studies show that a shorter period is inappropriate, since the infection persists, and a longer one is ineffective, since streptococcus begins to produce substances that destroy the antibiotic, and the antibiotic becomes harmful to the patient himself.
Then the second (passive) phase begins. Three weeks after the end of oral administration of bicillin, the patient is injected intramuscularly with the same drug. This treatment should be continued for 5-6 years (1 injection every 3 weeks) to reduce the likelihood of relapse and prevent possible heart complications.
In medical practice, the drug acetylsalicylic acid has proven itself well. Taking aspirin has many contraindications (period of gestation and lactation, fragility of blood vessels, problems with the digestive system), however, such therapy for rheumatism has a significant effect in articular and neurological forms of the disease. Aspirin relieves pain and reduces inflammation in the joints. The first two weeks are taken in the maximum allowable doses.
After the main period of therapy, aspirin is taken for another 30 days at a dosage of 2 g / day.
Caution: Aspirin irritates the lining of the stomach and duodenum. This side effect is quite common, especially if the recommendations for taking the drug are violated. This leads to erosion, stomach ulcers, gastroduodenitis and ulcerative bleeding.
In the treatment of severe forms of rheumatism, prednisolone is used in the maximum permissible dosage.
If the disease is mild, a semi-bed regime is prescribed for up to 10 days. If there is a severe course, it is necessary to exclude any motor activity, because it aggravates the process. Bed rest is prescribed for up to a month.
To assess the effectiveness of treatment, they resort to laboratory tests. As soon as the indicators approach normal values, bed rest can be canceled. If the disease is difficult, with severe cardiac arrhythmias, joint pain, inpatient treatment is necessary, which lasts up to two months.
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Disability with rheumatism
There is no single list of diseases for which the patient will be guaranteed the degree of disability.
The medical commissions determine the disability group based on three main criteria:
- Self-service ability;
- General health and quality of life;
- Work ability and employment opportunities.
Depending on the severity of the course of rheumatism, the ability for self-care, as well as for independent movement, can drop sharply. Many factors of work can cause exacerbation in patients, for example, work associated with physical exertion or high physical activity. The quality of life is determined by the frequency of relapses and the severity of their course.
Based on these criteria, medical commissions appoint patients with either the third or the second group of disability. There are rare cases of the appointment of the first group.
Group III is assigned if there are no pronounced functional disorders, the patient is able to serve himself, and the manifestations of relapses occur no more than 3 times a year. Disabilities in this case are minimal and relate only to physical exertion and immobilization during periods of exacerbations.
Group II can be assigned if the patient has vivid manifestations of rheumatism. Exacerbations are frequent (more than 3 times a year), the ability to self-service is reduced during periods of exacerbations. Employment is permissible in places where constant physical activity is not required, there is no dampness and cold.
Group I is assigned in case of severe functional disorders. Exacerbations are frequent and protracted. Even during periods of remission, symptoms persist and manifest in the form of pain in the joints and heart. The ability to work is significantly impaired, the periods of inability to work range from 3 months to six months.
Prevention of rheumatism
Prevention of an initial streptococcal infection is the only possible measure for the prevention of rheumatism. If antibiotic treatment is started in a timely manner, the likelihood of developing the disease is minimized.
Preventive measures can reduce the likelihood of illness:
- Increased immunity. The main cause of rheumatism is the penetration of streptococcal infection with blood flow to organs and systems. Most often, the reason for the unhindered penetration of infection is reduced immunity, which is not able to suppress the activity of the pathogen in time. To strengthen the immune system, a correct fortified diet and proper rest are required;
- Avoiding contact with streptococcus. You should follow the rules of personal hygiene and, if possible, try to get sick with infectious diseases less often. You should also exclude contact with people infected with streptococcal infection;
- Timely treatment of colds. The formation of rheumatism is facilitated not only by repeated contact with the causative bacterium, but also by a long period without treatment. At the first symptoms of a cold, an urgent need to consult a doctor. Moreover, this recommendation applies to persons with confirmed streptococcal lesions or who have already had the disease earlier;
- Preventive sanitation after contact with the pathogen. It is recommended to take bicillin in an adequate dosage (1.5 million units once, intramuscularly).
Thus, rheumatism is complex in nature, both in terms of etiology and in terms of symptoms. The disease is not well understood, therefore, there are difficulties with the correct diagnosis, and it is not completely cured.
However, modern methods of treatment make it possible to eliminate the negative manifestations of pathology, minimize the danger to life and harmful consequences, and also ensure a high quality of life for patients with rheumatism.
Author of the article: Kaplan Alexander Sergeevich | Orthopedist
Education: diploma in the specialty "General Medicine" received in 2009 at the Medical Academy. I. M. Sechenov. In 2012 completed postgraduate studies in Traumatology and Orthopedics at the City Clinical Hospital named after Botkin at the Department of Traumatology, Orthopedics and Disaster Surgery.