Rheumatism: symptoms and treatment
- What is rheumatism?
- Causes and factors provoking the development of rheumatism
- Mechanism of disease development
- Classification of rheumatism
- Symptoms of rheumatism
- Diagnosis of rheumatism
- Treatment of rheumatism
- Principles of treatment of rheumatism in children
- Prevention of rheumatism
Currently, rheumatism is considered one of the most common and dangerous diseases of mankind. Therefore, despite the fact that significant progress has been made in its treatment, it is difficult to overestimate the importance of this pathology, both in the medical and social aspects. As a rule, the disease develops in childhood, but the heart lesions, due to the dominant latent flow, are detected only in adult patients, often resulting in temporary loss of ability to work, and in 10% of cases even disability.
What is rheumatism?
Rheumatism (in translation from Greek "spreading throughout the body") is a systemic inflammatory disease that occupies a rather peculiar position among other connective tissue diseases. The primary site for the localization of this pathology is the cardiovascular system (rheumatism affects all the membranes of the heart and leads to deformation of the valvular apparatus, which is the reason for the development of heart failure). The causative agent of rheumatic fever is streptococcal infection. An important role in the development of the disease is played by pathological heredity.
It is characteristic that, while the infectious agent circulates in the blood, rheumatism can not be cured. At present, the human population, due to objective reasons, can not get rid of streptococcus. Therefore, to date, there is no panacea for rheumatism, that is, it is included in a group of chronic incurable diseases.
Causes and factors provoking the development of rheumatism
Rheumatism is a disease of infectious nature. Its pathogen is β-hemolytic group A streptococcus, affecting the upper respiratory tract. The factors that provoke the development of a pathological condition include:
- exacerbation of chronic tonsillitis;
- scarlet fever;
- adverse living conditions;
- genetic predisposition;
Mechanism of disease development
The mechanism of the origin and development of the disease is associated with two main factors: the presence of the causative agent of antigenic substances, common to the tissue of the heart shells and cardiotoxic effects of enzymes produced by β-hemolytic streptococcus.
With the penetration of infection, the body begins to develop anti-streptococcal antibodies, forming immune complexes with antigens of the infectious agent, capable of circulating in the blood and settling in the microcirculatory bed. However, streptococcal enzymes and toxic products of its vital activity have a damaging effect on connective tissue and cardiac muscle.
The place of localization of the inflammatory process most often becomes the cardiovascular system. Also, a nonspecific inflammatory reaction in joints and serous membranes often develops.
For rheumatism, as for any other autoimmune pathology, a wave-like course is characteristic, with periods of exacerbations and remissions. Provoke the development of exacerbation of various infectious agents, stress, physical overexertion and hypothermia.
The pathological process can extend to all cardiac membranes (this condition in clinical terminology is called "pancarditis"), or to affect one of them.
In the early stages of the disease, its clinical picture determines myocarditis (it is in the myocardium that primary morphological disturbances are detected). Approximately 1.5-2 months after the onset of painful symptoms, inflammatory changes in the inner layer of the cardiac membrane (endocardium) are observed. As a rule, rheumatism initially affects the mitral valve, then follows the aortic valve, followed by the tricuspid valve.
Classification of rheumatism
- Cardiac form (rheumatic carditis). In this condition, heart membranes become inflamed (rheumopancarditis), but first of all - myocardium (rheumomyocarditis).
- Articular form (rheumatic polyarthritis). There are inflammatory changes in the joints characteristic for rheumatism.
- Cutaneous form.
- Pulmonary form (rheumatic fever).
- Rheumatic chorea (dances of St. Witt). Increased activity of dopaminergic structures.
Symptoms of rheumatism
Rheumatism is a polysymptomatic disease, for which, along with general changes in the condition, signs of affection of the heart, joints, nervous and respiratory system, and also other organic structures are characteristic. Most often, the ailment makes itself felt 1-3 weeks after the infectious disease caused by group A beta-hemolytic streptococcus. In subsequent cases, the incubation period is usually reduced.
In a separate group of patients, primary rheumatism may occur 1-2 days after hypothermia, even without infection.
From the very beginning of the disease, patients complain of constant pain in the region of the heart, dyspnea, observed both during exercise and at rest, with increased heart rate. Often in the right hypochondrium, due to circulatory failure in a large circle, edema appears, accompanied by a sense of heaviness. This condition is a consequence of the increase in the liver and signals the development of a heavily current diffuse myocarditis.
Pericarditis (rheumatic pericardial lesion) is a relatively rare form of pathology. Dry pericarditis is accompanied by constant pain in the heart area, and with exudative pericarditis, as a result of the accumulation in the cardiac bag of the exudate inflammatory fluid that separates the pericardium leaves, the pain disappears.
With the defeat of the musculoskeletal system, gradually increasing pain develops in the knee, elbow, wrist, shoulder and ankle joints. Articular joints swell, and they restrict active movements. As a rule, with articular rheumatism, after taking non-steroidal anti-inflammatory drugs, the pains quickly stop.
With the development of cutaneous rheumatism, the permeability of capillaries increases. As a consequence, small hemorrhages (petechiae) occur on the lower extremities (in the area of the extensor surface of the joints). Also, often on the skin of the lower legs and forearms appear dense, painless nodules (their sizes range from a millet grain to a large pea). At the same time, it is possible to form dark red painful large seals (the size of a cherry) penetrating the thickness of the skin and slightly rising above the surface. This pathological condition is called nodal erythema. It can be localized not only in the limb region, but also on the skin of the skull.
This is a relatively rare form of pathology (found in 5.4% of patients suffering from rheumatism). The development of the pathological process is accompanied by the emergence of intense pains that increase with inspiration, an increase in body temperature to 38-40 C. In patients, there are attacks of dry painful cough, in the affected half of the chest can hear pleural noise. Over time, the pain begins to subside, as well as pleural noise. However, the patient's condition worsens. Shortness of breath, febrile condition, respiratory noises begin to disappear, there is a strong weakness, cyanosis. Sometimes, due to the large amount of inflammatory exudates, there may be a lag in the breathing of one half of the chest, a sharp bulging of the intercostal spaces, very severe shortness of breath. Such patients take a forced semi-sitting position.
It should be noted that severe symptoms in rheumatic lung disease are relatively rare. More often the disease is accompanied by lighter manifestations of rheumatic fever.
Rheumatic disorders of the nervous system
With rheumatism, there is sometimes a lesion of the meninges, subcortical layer and brain substance. One of the manifestations of the disease is rheumachorea (dances of St. Witt). This pathology, characterized by involuntary convulsive contraction of the striated muscles, develops in childhood and adolescence. With a convulsive contraction of the glottis, there may be an attack of suffocation, leading to a sudden fatal outcome.
Rheumatic peritonitis, a pathological condition that often occurs with acute primary rheumatism, is typical only for all children and adolescents. The disease develops suddenly. The body temperature rises sharply, and signs of dysphagia appear (nausea, vomiting, stool disorders, cramping abdominal pains).
Diagnosis of rheumatism
When diagnosing "primary rheumatism" there are often certain difficulties. This is explained by the fact that rheumatic manifestations are very nonspecific, that is, they can be observed in other pathologies. And only the detection of a prior streptococcal infection and the presence of two or more signs of the disease may indicate a greater likelihood of rheumatic damage. Therefore, the diagnosis is based on the presence of syndromes (syndromic diagnosis of rheumatism stage I).
Clinico-Epidemiological Syndrome (availability of data indicating the association of pathology with the infectious process caused by group A beta-hemolytic streptococcus);
Clinico-immunological syndrome (subfebrile condition, weakness, fatigue and violation of heart rate after angina or other nasopharyngeal infection). In 80% of patients the antistreptolysin titer is elevated, in 95% antibodies to cardiovascular antigen are detected. Biochemical signs of inflammation include accelerated ESR, dysproteinemia, detection of C-reactive protein;
Instrumental diagnosis of rheumatism (cardiovascular syndrome).
Instrumental methods of research include:
- ECG (on the cardiogram, infringements of a warm rhythm quite often are revealed);
- Ultrasound of the heart;
- X-ray examination (allows to determine the increase in the size of the heart, the change in its configuration, as well as a decrease in the contractile function of the myocardium);
Laboratory diagnostics. In the general analysis of blood there is an increase in ESR, shift of the leukocyte formula to the left, anemia. In the immunological analysis, the titer of ASH increases, the number of immunoglobulins of class A, G, M increases, C-reactive protein, anticardial antibodies and circulating immune complexes are detected.
Treatment of rheumatism
The best therapeutic effect is achieved with the early diagnosis of rheumatism, which helps prevent the development of heart disease. Treatment is carried out in stages and in a complex. It is aimed at suppressing the activity of β-hemolytic streptococcus and preventing the development of complications.
I stage of treatment of rheumatism
At the first stage, the patient is assigned inpatient treatment. It includes medicamental therapy, diet therapy and exercise therapy. Appointments are made taking into account the characteristic features of the disease and the severity of the damage to the heart muscle.
To eliminate the infectious agent, antibacterial therapy is performed. The only antibiotic that can cope with pyogenic streptococcus is penicillin. Currently, adults and children over 10 years of age are prescribed phenoxymethylpenicillin. In more severe cases, benzylpenicillin is recommended. As drugs of an alternative action, macrolides and lincosamides are used. The duration of the course of antibiotic therapy is at least 14 days. With frequent colds and exacerbations of chronic tonsillitis, another antibacterial drug (amoxocycline, cephalosporins) may additionally be used.
Antirheumatic therapy includes the use of non-steroidal anti-inflammatory drugs, which, depending on the patient's condition, can be used in isolation, or in combination with hormonal agents (no more than 10-14 days). NSAIDs should be applied until signs of an active pathological process are removed (an average of 1-1.5 months).
With prolonged and latent flow of rheumatism, patients are shown taking quinoline-based drugs (plaquenil, delagil). They are applied by long courses, from several months, to one or two years.
Also during the period of inpatient treatment, foci of chronic infection must be eliminated (2-3 months after the onset of the disease, with an inactive process, it is recommended to remove tonsils).
II stage of treatment of rheumatism
The main task of this stage is the restoration of the normal functioning of the cardiovascular system and the achievement of complete clinical and biochemical remission. The second stage of treatment is carried out in specialized cardio-rheumatological sanatoriums, where patients are assigned a special health regimen, exercise therapy, hardening procedures, differentiated motor activity. Also, spa treatment of rheumatism includes mud therapy (applications on the affected joints), radon, hydrogen sulphide, chloride sodium, oxygen and carbon dioxide baths.
III stage of treatment of rheumatism
Dispensary observation, prevention of relapse prevention of disease progression. At this stage, therapeutic measures are carried out, contributing to the elimination of the active course of the pathological process. Patients with heart disease show symptomatic treatment of circulatory disorders. The issues of rehabilitation, work ability of the patient and his employment are also solved.
Principles of treatment of rheumatism in children
In the treatment of rheumatism in children, first of all, effective antibacterial therapy (single intramuscular injection of penicillin G sodium salt) is prescribed. When hemorrhagic manifestations shows the use of oral acid-fast penicillin V. In the presence of allergies to this drug, it can be replaced with erythromycin or azithromycin.
The period of taking non-steroidal anti-inflammatory drugs is at least 21 days.
Rheumatism is a disease that does not pose an immediate threat to the life of the patient. Exceptions are acute meningoencephalitis and diffuse myocarditis, which occur mainly in childhood. In adults, for which the cutaneous and articular forms of the disease are more characteristic, the course is most favorable. With the development of rheumatic fever, there are minor changes in the heart.
The main prognostic criterion for rheumatism is the degree of reversibility of his symptoms, as well as the presence and severity of heart disease. In this case, the most unfavorable are constantly recurrent rheumatic carditis. However, an important role is played by the start of treatment (the later the therapy is started, the higher the probability of developing a defect). In childhood, rheumatism is much more severe than in adults and often causes permanent valve changes. In the case of the development of the primary pathological process in patients who have reached the age of 25, there is a favorable course of the disease without the formation of a defect.
It should be noted that changes in cardiac structures occur only in the first three years after the onset of initial signs of the disease. If during this time there are no valvular disorders, then the subsequent probability of their occurrence is rather low, even with the preserved activity of rheumatism.
Prevention of rheumatism
Primary prevention (prevention of disease)
- Timely isolation of a patient who has a streptococcal infection.
- Follow-up monitoring of persons in contact with him (preventive single administration of bicillin).
- Hardening of the body.
- Balanced diet.
- Organization of a healthy life.
- An obligatory diagnostic examination of a person who has undergone streptococcal infection, and a subsequent 2-month follow-up with a doctor.
Secondary prevention of rheumatism (prevention of recurrence)
In this situation, preventive measures are a set of methods used for a long time (several months and even years). They include:
- Dispensary observation.
- Measures to strengthen the body's resistance (hardening, constant improvement of immunity, balanced nutrition, exercise therapy).
- Prophylactic antibacterial treatment.
- Sanitation of foci of chronic infection.
- Antirheumatic therapy, which provides for the long-term use of non-steroidal anti-inflammatory drugs.
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