Rheumatoid arthritis: a personal story. Rheumatoid Arthritis: A Personal History Synovial Fluid Test and Biopsy

Rheumatoid arthritis is autoimmune disease, affecting connective tissue and including systemic complications. The joints are primarily affected - the disease is characterized by symmetrical polyarthritis small joints. Extra-articular symptoms include muscle, heart, lung, liver, gastrointestinal tract etc. Rheumatoid arthritis is severe and causes disability in 70% of patients.

The exact causes of the development of rheumatoid arthritis have not been established. Modern scientists are inclined to two main hypotheses for the development of the disease:

Genetic predisposition– if rheumatoid arthritis was diagnosed in parents, then the likelihood of its occurrence in children increases. The rule of genetic predisposition is clearly expressed in monozygotic twins. Recent research has identified certain histocompatibility antigens that code for malfunctions in the body's immune responses. In patients with rheumatoid arthritis, these antigens are present and can be inherited.
Viral pathogen– according to clinicians, the vast majority of patients have high titers of antibodies to the Epstein-Barr virus in their blood. It is important to note the similarity between certain fragments of the virus and a portion of the histocompatibility antigen chain. It is also assumed that the disease can be caused by herpes viruses, rubella, papilloma B 19, etc.
Bacterial agents– Recent studies have shown that the entry of bacteria into the body is accompanied by an immune response to the so-called “stress proteins” synthesized by microbes. It is assumed that these components are capable of triggering a complex pathogenetic mechanism leading to the formation of rheumatoid factor.
Trigger components of the disease– these are conditions that contribute to the launch of a pathological reaction. In healthy people, triggers do not cause disease, but if a person is predisposed, they trigger pathogenesis. These include:
- frequent hypothermia;
- smoking and alcohol;
- joint injuries;
- hormonal changes;
- stress;
- harmful ecology.

According to statistics, the disease develops:

more often than in men;
over the age of 45;
for frequent diseases of the respiratory system, arthritis, anomalies of the musculoskeletal system;
with a family history;
in the presence of the above antigens.

Occurrence and course of the disease

The pathogenesis of rheumatoid arthritis is a very complex autoimmune process. In our article we will only look at key points, allowing the average reader to understand the mechanism of development of pathology. The disease is based on a pathological immune response that attacks healthy cells. connective tissue, mistakenly recognizing them as foreign. This autoimmune process occurs in several stages:

Synoviocytes located in connective tissue produce large amounts of inflammatory substances (cytokines) and activate special cells immune system– T-helper type 1.
Helper T cells secrete interferon gamma, which activates another immune cell - macrophages and monocytes. The latter also produce specialized inflammatory substances:
- tumor necrosis factor – promotes the release of the liquid part of the blood into the area of inflammation, forming edema and inflammation.
- IL-1 contributes to the development of osteoporosis in the joint area and an increase in body temperature.
- IL-6 - activates liver cells, which produce large amounts of C-reactive protein, and also promote the transformation of B lymphocytes into plasma cells.
- IL-8 – increases the concentration of neutrophils in the joint fluid.
Plasma cells produce modified immunoglobulins M and G, which attack the connective tissue, and when interacting with unchanged immunoglobulins G, they damage the microvasculature of the joint.
The release of endothelial growth factor leads to additional formation of capillaries in the connective tissue, as well as specialized tissue called pannus. This tissue has signs of a tumor and can grow in the joint cavity, causing its deformation.

Classification of rheumatoid arthritis

To formulate the correct diagnosis, the doctor must know the classification of the disease. Clinicians use the International Classification of Diseases, 10th revision (ICD-10), which is more convenient for correctly formulating a diagnosis. For a patient, such a classification is too complicated, so we will analyze the types of rheumatoid arthritis according to the following criteria:

For joint syndrome:
- monoarthritis– one joint is involved;
- oligoarthritis– inflammation of two joints;
- polyarthritis– involvement of 3 or more joints.
By radiographic stages:
- first– thickening of cartilage and articular capsule walls, small areas of osteoporosis;
- second– formation of erosion foci on cartilage, narrowing of the joint space, development of a large zone of osteoporosis;
- third– deformation and periodic dislocations in the affected joints;
- fourth– complete disappearance of the joint space, there may be signs of bone fusion.
According to the clinical picture:
- low activity– morning stiffness in the joints for up to 30 minutes, slight pain during the day, moderate swelling of the joints, erythrocyte sedimentation rate (ESR) up to 30 mm/hour, test for C-reactive protein (CRP) +;
- average activity– stiffness in the first half of the day, moderate pain (possible without exercise), severe swelling over the affected area. ESR up to 40 mm/hour, CRP ++, increased levels of inflammatory blood enzymes;
- high activity– stiffness in the joints continues all day, complications include damage to internal organs, ESR more than 40 mm/hour CRP +++, a pronounced predominance of inflammatory enzymes.
According to the progression of the disease:
- very early stage– pathology develops within six months;
- early stage– the clinical picture of rheumatoid arthritis is characterized by the duration of symptoms from 6 to 12 months;
- advanced stage– the disease lasts for more than 12 months without significant destruction of the joints;
- late stage– pathological processes last more than 2 years with severe deformation of the joints.
By limiting physical activity:
- first degree– maintaining efficiency and normal lifestyle;
- second degree– periodic loss from the usual way of life;
- third degree– inability to carry out work activities.
- fourth degree– lack of ability to self-care, disability.
According to laboratory tests for rheumatoid factor:
- – based on the results, rheumatoid factor is detected;
- – rheumatoid factor is absent.

It is important to mention several options from ICD-10:

– is a chronic rheumatoid arthritis that occurs in children with predominantly joint damage.
- inflammation of the joint capsules. The shoulder joints are predominantly affected.
– a complication in which the clinical picture is accompanied by an enlarged spleen and a decrease in granulocytes in the blood.

Symptoms of rheumatoid arthritis

The course and development of the disease is expressed by articular and extra-articular manifestations. The articular lesion develops primarily and represents inflammatory polyarthritis. Extra-articular signs, or complications of the underlying disease, are involved in the pathology later and are characterized by multiple lesions (skin, muscles, internal organs, fundus, lymph nodes).

What joints are affected by rheumatoid arthritis?

Arthritis is characterized by damage to the same type of joints on the right and left sides - for example, arthritis of the knee joints on the right and left. It is important to note that small-caliber joints are predominantly affected.

The onset of the disease is usually preceded by:

sudden changes in climate - spring or autumn;
suffered from acute respiratory viral infections, pneumonia, etc.;
stress or psycho-emotional stress;
injuries;
hormonal changes in the body - puberty, or menopause.

When a doctor questions a patient, a so-called prodromal period or a period of precursors is often revealed, appearing several weeks before the onset of the disease. This period corresponds to:

general weakness, loss of strength;
periodic lack of appetite, weight loss;
slight rises in temperature and sweating;
slight joint pain and morning stiffness.

Pain in the joints occurs due to the concentration of inflammatory substances in the connective tissue.

The onset of development is usually subacute or latent, in which the symptoms are mild, and the disease progresses gradually - complaints of pain in the joints do not appear immediately. Gradually, the pain increases, forcing the person to consult a doctor. Sometimes the disease begins acutely, accompanied by severe joint pain, morning stiffness, and fever.

Above the affected joint you can find:

swelling and redness;
pain reaction when touched;
increase in local temperature.

Stiffness also occurs in the joint. Later, mobility decreases, which ultimately leads to complete absence mobility with subsequent joint deformation. The most common targets for rheumatoid attack are the joints of the hands and feet, elbows, knees and shoulders. Less commonly involved in pathology are the hip, sacroiliac and ankle. The exception joints for rheumatoid arthritis are the distal interphalangeal joint (located just above the nail plate), the proximal interphalangeal joint of the little finger, and the metacarpophalangeal joint. thumb(located at its base).

Rheumatoid lesions of the hand joints

The goals of rheumatoid lesions are:

metacarpophalangeal joints 2 to 5 are the joints near the base of the fingers;
proximal interphalangeal joints from 1 to 4 fingers;
all the wrist joints and the carpometacarpal joints are a series of small joints in the area of the palm itself.

As a rule, the small joints listed above are affected first. Soreness leads to the fact that the patient is unable to clench his hand into a fist, and his fingers become very swollen. After a few months, the intermetacarpal muscles begin to atrophy, which leads to retraction of the skin on the palm and back of the hand. Deformations and subluxations of the metacarpophalangeal joints occur, as a result of which the fingers bend with a deviation towards the little finger. The little finger itself bends less than the other fingers. Clinicians call this deformity “major's fin.” Then a curvature of the fingers occurs according to the “swan neck” principle - the proximal interphalangeal joints of the fingers are bent, and the distal joints are excessively extended.

Sometimes deformities occur with flexion of the metacarpophalangeal and extension of the lower interphalangeal joints (button loop). All of these changes greatly impair the functions of the hand.

Ultimately pathological changes brushes can lead to:

to shortening of the fingers, fusion of the phalanges with each other and complete loss mobility;
tenosyviitis - inflammation of the finger flexor tendons, as well as their synovial canals.

The result of tenosyviitis is swelling of the finger and severe pain. When the branches of the median nerve that pass near the affected joints are compressed, loss of sensation from fingers 1 to 3 is possible. At long-term compression the pain may spread throughout the forearm to the elbow.

Later, the disease attacks the wrist, elbow and shoulder joints.

Deformation of the listed joints in rheumatoid arthritis manifests itself after the development of inflammation and is irreversible.

Wrist rheumatoid arthritis leads to pain, swelling of the affected area, and limited flexion and abduction of the hand. Wrist arthritis is often complicated by synovitis and median nerve neuralgia.
The elbow joint is formed by the articulations of three bones - the ulna and radius bones of the forearm, as well as the humerus. Therefore, arthritis can involve all three joints that form the compound elbow joint. Local arthritis accompanied by severe pain during flexion and extension - contracture may develop in an intermediate position. With severe inflammation, it is impossible to carry out rotational movements (supination and pronation).
Arthritis of the shoulder joint is characterized by the spread of inflammation to the tendon bursae, collarbone, and muscle frame. Swelling, pain and limited movement gradually develop.
Inflammation can spread to the axillary lymph nodes. Due to the fact that the shoulder joint has only one ligament and is strengthened due to muscle tone, myalgia, turning into atrophy, leads to habitual subluxation of the shoulder.

After the hand, the second target for rheumatoid arthritis is the foot. Most often, inflammation develops in the metatarsal-phalangeal joints of the 2-4 fingers and is accompanied by pain when walking, standing on tiptoes, and jumping. Visually, swelling of the dorsum of the foot, hammertoe deformity, subluxation of the listed joints, and hallux valgus are noted.

Later, arthritis is accompanied by inflammation of the synovial bursae and synovitis, leading to compression of the plantar nerves. Traumatic effects on the nerves lead to loss of sensation in the foot, pain that can rise up to the knee joint.

characterized by pain and swelling in the knees. The pain intensifies with flexion movements, during squats, and when climbing stairs. Often, with severe edema, fluid oozes out when touching the anterolateral area of the knee. Severe pain can lead to the development of contracture in the semiflexion position, as well as protrusion of the joint capsule in the posterior sections (Baker's cyst). Long-term arthralgia of the knee joint forms atrophy of the anterior group of thigh muscles.

Damage to the temporomandibular joint

The temporomandibular joint is a combined joint - its functionality is accompanied by synchronous movements in both capsules. Arthritis is always accompanied by only bilateral pain. Morning stiffness causes particular discomfort to the patient - difficulty opening the mouth and pain during chewing makes eating much more difficult. This leads to weight loss and nervousness. At severe course Neighboring anatomical structures may be involved in the inflammatory process:

chewing and temporal muscles;
adjacent cellular spaces;
parotid salivary gland;
branches of the trigeminal and facial nerves.

Damage to the joints of the spinal column

Vertebral joints are extremely rarely involved in the clinical picture of rheumatoid arthritis. Arthritis usually develops at the junction of the head with the first cervical vertebrae (atlanto-occipital joint), and at the junction of the first and second cervical vertebrae (median and lateral atlanto-axial joints). Clinically, inflammation manifests itself as pain in the upper neck, characterized by the inability to painlessly turn the head to the side.

Extra-articular manifestations of rheumatoid arthritis (complications)

These lesions occur during a long course of the disease, mainly in seropositive patients. Clinicians attribute these pathologies to complications of rheumatoid arthritis, since they develop with a systemic effect on the body.

Muscle damage

Myopathy in rheumatoid arthritis begins with damage to three muscle groups of the hand:

eminence of the thumb;
elevation of the little finger;
intermediate muscles.

Later, the myopathy rises and affects the posterior group of muscles of the forearm. In the lower extremity, the disease attacks the anterior muscles of the thigh and gluteal region. Myopathy is characterized by pain during muscle contraction, which aggravates movement processes.

Skin changes

With a long course of rheumatoid arthritis, the skin dries out and becomes thinner, and numerous hemorrhages appear on the skin throughout the body. The nail plates become more brittle, with transverse striations. Small areas of soft tissue death are noted under or near the nails.

These are small dense formations located under the skin. They are usually mobile and painless, loosely connected to the surrounding tissues. They are usually located on the dorsum of the elbow joint, the extensor side of the forearm and the back of the head. Sometimes found in the myocardium, heart valves, between the membranes of the brain or spinal cord, V lung tissue. They usually form during periods of exacerbation, and during remission they can disappear completely or significantly decrease. There is such a serious complication as rheumatoid nodulosis - the presence of nodules scattered throughout the body with multiple swelling of the joints, the presence of cysts and an elevated level of rheumatoid factor in the blood.

Lymph node involvement

This complication is detected during an exacerbation and is characterized by an increase in a number of lymph nodes, usually near the affected joints:

with arthritis of the joints of the upper limb, there is an increase in the elbow, axillary and cervical nodes;
temporomandibular arthritis is accompanied by enlargement of the submandibular and cervical lymph nodes;
arthritis of the joints of the lower limb leads to temporary hypertrophy of the inguinal lymph nodes.

Lymphadenopathy is often accompanied by an enlarged spleen.

Damage to the stomach, intestines and liver

Damage to the stomach is characterized by suppression of the synthesis of gastric juice, the formation of numerous erosions and ulcers. The result of such complications is dull nagging pain in the epigastrium, the formation of plaque on the mucous membrane of the tongue, and decreased appetite.
Rheumatoid arthritis can be complicated by inflammation of the small and large intestines – enteritis and colitis. Intestinal damage leads to acute and chronic pain, bloating, stool disorders, nausea and vomiting.
Sometimes the liver becomes enlarged and its boundaries expand.

Pulmonary complications

Damage to the lungs in rheumatoid arthritis usually occurs in parallel with damage to their membrane, the pleura. Damage to the pleura is characterized by inflammatory changes - pleurisy.

Pleurisy can be dry or exudative. In the first case, friction of dry, inflamed pleura during breathing causes the patient severe discomfort. Exudative pleurisy is characterized by the effusion of liquid blood into the pleural cavity, followed by compression of the lung, which leads to shortness of breath and a feeling of heaviness on the affected side. Lung damage is manifested by the development of pneumonitis and fibrosing alveolitis. A characteristic feature of complications of the lungs and pleura is the weak effectiveness of antibiotics and the rapid effect of using anti-inflammatory drugs.

Heart damage in rheumatoid arthritis manifests itself in the following diseases:

Inflammation of the muscle membrane – myocarditis.
Damage to the outer membrane in the form of pericarditis.
Formation of acquired malformations of the heart due to damage to the inner lining of the heart - endocarditis.
Damage to the pericardial vessels - the aorta (aortitis) and coronary arteries (coronary arteritis).

Inflammatory changes in the heart and blood vessels are manifested by complaints of shortness of breath and chest pain. A more accurate diagnosis is made by a cardiologist after undergoing an appropriate examination.

Kidney complications

Kidney damage in rheumatoid arthritis involves the glomerular apparatus in the inflammatory process, resulting in the development of rheumatoid glomerulonephritis and renal amyloidosis. As a result of renal complications, anemia may develop in rheumatoid arthritis, which forms when the disease becomes chronic.

Damage to the organ of vision

Eye damage in rheumatoid arthritis is very rare and is manifested by inflammation of the outer layer of the eyeball - the sclera. Inflammatory changes are characterized by severe pain, dilation of capillaries, and sometimes the formation of small rheumatoid nodules. With combined pathologies, the development of dry conjunctivitis is possible, in which the closure of the eyelid is accompanied by severe pain.

Complications from the nervous system

Defeat nervous system characterized by the following symptoms:

Frequent headaches and dizziness indicate impaired blood supply to the brain and encephalopathy.
Reaction to temperature changes, increased sweating and changes in diuresis indicate damage to the autonomic nervous system.
Weakness in the affected limbs and difficulty moving speak in favor of ischemic neuropathy.
Stitching pain in the limbs and parasthesia occur when the corresponding nerves are pinched and with neuralgia.

Other complications

If rheumatoid arthritis develops over a long period of time, combined complications may occur, such as inflammation of the pleura and pericardium, multiple hemorrhages in the internal organs.

Establishing diagnosis

Articular lesions occur over late stages development of the disease. Since the articular syndrome does not manifest itself at the onset of the disease, diagnosing rheumatoid arthritis in the early stages is very difficult.

There are certain criteria for diagnosing rheumatoid arthritis:

morning stiffness in joints for at least an hour;
arthritis of three or more joints;
damage to the joints of the hand;
symmetrical involvement of joints in the clinical picture;
presence of rheumatoid nodules;
presence of rheumatoid factor;
joint x-ray picture.

The diagnosis of rheumatoid arthritis is positive when four of the above symptoms are detected. It is important to note that the first four symptoms should persist for one to two months. Indisputable evidence of rheumatoid arthritis is synchronous small polyarthritis. To identify the criteria described above, as well as additional diagnostic parameters, laboratory and instrumental methods research.

Laboratory methods

General blood test - with high activity of the process, anemia may develop (a drop in hemoglobin, leukocytes). An increase in ESR in rheumatoid arthritis is an indirect sign of the development of the disease.
A biochemical blood test is informative for determining the degree of inflammation activity and identifying complications. First of all, attention is paid to an increase in C-reactive protein, fibrinogen, seromucoid, sialic acids, haptoglobin, globulins and a decrease in albumin levels.
Immunological blood testing is one of the informative methods. Rheumatoid arthritis is supported by the presence of rheumatoid factor and cryoglobulins. Antikeratin antibodies, LE cells, and circulating immune complexes are often found in the blood.

Instrumental research methods

Instrumental diagnosis involves the use of methods that allow visual identification of arthritis. The most common methods include: X-ray examination, magnetic resonance imaging, examination of synovial fluid followed by biopsy.

X-ray examination

This type of study is the most informative because it allows us to identify inflammation and deformation in the joints. The main radiographic signs of rheumatoid arthritis:

diffuse or focal osteoporosis;
reduction of joint space;
the appearance of erosions on the articular surfaces.

X-ray stages of rheumatoid arthritis are determined by the doctor depending on the listed criteria.

Synovial fluid examination and biopsy

Synovial fluid - produced by cells of the joint capsule to reduce friction during movement. Thanks to synovial fluid, the coefficient of friction in joints is 0.01. Articular fluid reflects all pathological changes in the joint, so taking it for analysis significantly complements the diagnostic criteria. A biopsy of the joint capsule with the presence of fibrin and inflammatory elements will leave the diagnosis of rheumatoid arthritis beyond any doubt.

Main characteristics of synovial fluid

Differential diagnosis

Differential diagnosis is a thorough analysis of examination results in order to filter out inappropriate diagnoses with similar symptoms. Differential diagnosis of rheumatoid arthritis is carried out with reactive arthritis and osteoarthritis.

Reactive arthritis– this is damage to the joints after suffering diseases of infectious etiology.
Osteoarthritis– a set of diseases of various etiologies with damage to the joints with subsequent deformation.

The main differences between these three types of diseases are shown in the table below.

Differential differences between rheumatoid arthritis, reactive arthritis and osteoarthritis:

Criterion	Reactive arthritis	Osteoarthritis
Age	any	20-40 years	over 40 years old
Pain symptom	strong	strong	average
Morning stiffness	strong	average	can not be
Symmetry of the lesion	present	absent	absent
Arthritis	permanent	during periods of exacerbation	weak or absent
Joint damage	minor polyarthritis	large on the lower limb	any
Course of the disease	progresses	amenable to therapy	progresses slowly
Muscle atrophy	present	absent	absent
Link to infection	absent	present	absent
ESR	greatly increased	increased	does not change
Rheumatoid factor	positive	negative	negative
Antigen HLA B27	negative	positive	negative

Treatment

Treatment of rheumatoid arthritis is a complex process that requires a responsible approach from both the attending physician and the patient. By modern research It is impossible to cure the disease; therapy is aimed only at alleviating symptoms and slowing down the progression of joint damage. Treatment includes drug therapy and. Prevention of the disease includes physical therapy and spa treatment. As a supplement, treatment is possible folk remedies, but only under the supervision of the attending physician.

Drug therapy

Drug therapy includes symptomatic treatment– necessary for removal pain and basic therapy – the purpose of which is to maintain the integrity of the musculoskeletal system and prevent complications.

Relieving pain and inflammation in joints

Hormonal painkillers – glucocorticoids – are also the drugs of choice. Symptomatic therapy significantly alleviates the patient’s suffering, but does not cure the underlying disease; when it is discontinued, the symptoms gradually recur.
NSAIDs for rheumatoid arthritis are prescribed in the following sequence:

selective NSAIDs– have a minimum of side effects and last a long time. These drugs can be taken for a long time - from several months to several years. The most popular drugs from this group are: Meloxicam, Movalis, Celebrex, Nimesil, Nise, Nimid, Revmoxib.
non-selective NSAIDs– are appointed when the selective group is ineffective. These drugs have a rapid effect, but have pronounced side effects– especially from the gastrointestinal tract. As efficiency increases and toxic effects they are divided into first and second stages. The first step drugs are Diclofenac, Ibuprofen, Ketoprofen. The second stage is represented by Indomethacin, Ketorolac and Piroxicam. Symptomatic therapy

Attention! With absence positive effect maximum within a week - you need to contact your doctor to change the drug.

Glucocorticoids for rheumatoid arthritis they have a strong analgesic effect. They are hormonal drugs, so their overdose can cause the following side effects:

hormonal imbalances;
hyperfunction of the adrenal cortex;
pancreatitis, diabetes mellitus;
decreased immunity, frequent ARVI;
thrombosis and bleeding;
the appearance of edema;
gastrointestinal disorders;
other disorders: itching of the mucous membranes of the respiratory tract, diseases of the sensory organs.

The drugs of choice are: medrol, diprospan, methylprednisolone, triamcinolol, dexamethasone, betamethasone.

Basic therapy

Basic therapy for rheumatoid arthritis includes groups of long-acting drugs that significantly slow down destructive changes in connective tissue.

Cytostatics– these drugs are used primarily in oncology, but are the best means of basic therapy for rheumatoid arthritis. The mechanism of their action is aimed at inhibiting the growth of pannus and slowing down destruction in the joints.

The most popular cytostatics:

Arawa;
Remicade.

Biological drugs– their effect is aimed at binding tumor necrosis factor, which plays a key role in the pathogenesis of rheumatoid arthritis. An important point is that these drugs are prescribed separately from each other due to the high likelihood of severe side effects.

Drugs of choice include:

Anakinra;
Actemra;
Rituximab;
Etanercept;
Humira;
Orence.

Chondroprotectors- prescribed for the purpose of restoring cartilage tissue and increasing its resistance to autoimmune attacks of rheumatoid arthritis.

These include:

Teraflex;
Artra;
Alflutop;
Hyaluron.

Other basic therapy drugs are various groups of drugs that are aimed at strengthening the immune system:

Bicilin-3;
Penicillamine;
Cycloferon;
Delagil.

Physiotherapy

Physiotherapy is a set of methods based on therapeutic effects natural and artificially created factors on the human body. The most popular physical therapy methods for rheumatoid arthritis are massage, electrophoresis, acupuncture and cryotherapy.

Massage for rheumatoid arthritis is used only during periods of remission, during which pain significantly decreases, swelling subsides, and the patient’s general well-being normalizes. The massage is performed by a specialist on the affected joints and surrounding soft tissues.

Beneficial properties of massage:

improves blood circulation and tissue trophism;
promotes the absorption of exudate into circulatory system and reduces swelling;
hinders local atrophic changes in muscles;
prevents the deposition of calcium salts in joints;
normalizes movements in the joint, reduces stiffness in the morning;
prevents joint deformation.

Electrophoresis

This is a technique based on the use of drugs and the combined effects of galvanization. Electrophoresis for rheumatoid arthritis has a strong analgesic effect, as it is used in combination with glucocorticoids. The advantage of the method compared to conventional medication is that side effects are minimized and effectiveness is significantly prolonged.

Acupuncture and cryotherapy

Acupuncture is a physiotherapeutic procedure based on the reflex action of needles on certain areas located nearby major nerves. Cryotherapy is based on the effect of cold air on the affected area, about -180 degrees Celsius. Acupuncture and cryotherapy for rheumatoid arthritis are considered distracting procedures and are used as an addition to the main methods to relieve pain symptoms.

Traditional medicine and rheumatoid arthritis

Salt baths, tinctures and decoctions based on leaves and medicinal herbs. For salt baths for rheumatoid arthritis, use sea or table salt, magnesium sulfate, potassium bromide. Taking salt baths helps normalize blood circulation, improves local metabolism, and reduces swelling of surrounding tissues.

Mumiyo for rheumatoid arthritis is used together with honey - stir 50 g of mumiyo and 100 g of honey and take 1 teaspoon 30 minutes before breakfast.

Also beneficial properties Gelatin, ginger and tomatoes are helpful for rheumatoid arthritis. The presence of these products in the diet has a general strengthening effect on the body and on cartilage tissue in particular.

Prevention

Prevention of rheumatoid arthritis is divided into primary and secondary. Primary prevention involves preventing the onset of the disease in a healthy person, and secondary prevention is aimed at preventing the development of relapses and complications in people suffering from rheumatoid arthritis.

Primary prevention includes:

diagnosis and treatment of infectious diseases;
identification chronic infection in organism;
strengthening the immune system and maintaining healthy image life.

Secondary prevention implies:

strict adherence to doctor's recommendations for taking medications, attending physiotherapeutic procedures, and;
spa treatment during periods of remission;
constant exercise therapy.

Rheumatoid arthritis primarily affects small joints. Typically, the disease begins with inflammation of the metacarpophalangeal joints (located at the base of the finger) of the index and middle fingers and inflammation of the wrist joints. Moreover, this inflammation is symmetrical, that is, it develops on both hands at once. Joints swell and hurt. Moreover, the pain intensifies at night, in the morning, and until about noon the person suffers from unbearable pain. Patients themselves often compare this pain to toothache. However, by warming up or simply after any vigorous activity, the pain usually decreases. This is the difference between rheumatoid arthritis and arthrosis, in which physical activity the pain intensifies. In the middle of the day the pain subsides and by evening it is almost unnoticeable.

Almost simultaneously with the damage to the joints of the hands, the joints of the feet also become inflamed. The joints at the base of the fingers are predominantly affected.

Pain and swelling may last for several months.

After some time, from several weeks to several months, more large joints- ankle, knee, elbow, shoulder. However, in older people aged 65-70 years, the disease can begin with damage to large joints and only then inflammation of small ones occurs.

Another characteristic symptom of rheumatoid arthritis is morning stiffness. It can manifest itself as a feeling of a stiff body, and a feeling of tight gloves on your hands. Some patients feel as if their body is in a corset in the morning. In mild forms of the disease, this stiffness lasts about two hours after waking up; in severe forms, the stiffness can last throughout the first half of the day.

Joint deformity, which develops in the later stages of the disease, greatly affects the quality of life. It happens that the hands are fixed in an unnatural position and deviate outward. This is an ulnar deformity and develops 1-5 years after the onset of the disease. And it happens that the mobility of the wrist joints decreases. In this case, patients have to make great efforts to straighten or bend the hand at the wrist. Later, the mobility of other compounds also decreases.

Knee joints can not only become deformed. Quite often, fluid accumulates in the joint cavity. This is called a Baker's cyst. This cyst stretches the joint capsule, and in severe cases even ruptures it. Then the liquid pours into soft fabrics shins. In this case, swelling of the lower leg develops, and sharp pain appears in the leg.

It happens that not only the joints are affected, but also the spine. Moreover, the cervical spine is predominantly affected. In this case, patients complain of neck pain.

In severe cases, the cricoid-arytenoid joint may be affected. Then the sufferer’s voice becomes rougher, shortness of breath and dysphagia appear. When this joint is damaged, the patient increasingly develops bronchitis.

With rheumatoid arthritis, patients complain of constant weakness, loss of appetite, weight loss up to cachexia (extreme exhaustion), and poor sleep. The temperature rises to low-grade levels, this condition is accompanied by chills. However, in some cases the temperature may rise to 39°C. Rheumatoid nodules often form on the skin - dense, rounded formations the size of a pea. Most often they are located below the elbows, on the hands, and on the feet. There are usually not many nodules. They may disappear and reappear, or they may remain in place for many years. There is no harm to health from them, however, appearance they spoil the patient. However, in some cases, rheumatoid nodules may be localized in the lungs (Kaplan syndrome).

Rheumatoid nodules are an extra-articular manifestation of rheumatism, it can occur not only on the skin. May be affected the cardiovascular system, in this case, vasculitis, pericarditis, and early atherosclerosis develop. The kidneys may be affected, in which case amyloidosis and, rarely, nephritis develop. There may be unpleasant complications from the blood - anemia, thrombocytosis, neutropenia. When the eyes are affected, keratoconjunctivitis, episcleritis or scleritis develops. The muscles and nervous system may also be affected.

Description

Rheumatoid arthritis is a rather serious disease, which in a few years turns an able-bodied person into a helpless disabled person. This disease continues for many years. Some suffer from it all their lives.

It is known that rheumatoid arthritis is an autoimmune disease. For some reason, a large number of immune complexes are formed in the body, which circulate in the blood and enter the joints, causing inflammation, which later leads to destruction. In addition, these immune complexes can attack other organs and tissues, leading to extra-articular manifestations of rheumatoid arthritis. Rheumatoid nodules are formed by a collection of immune cells, lymphocytes around a small area of dead tissue, but it is not known what attracted these cells there and what came first - tissue necrosis or accumulation of immune cells. And what contributes to the activation of lymphocytes is unknown. There are hypotheses that viruses, bacteria, allergies, injuries, heredity and many other factors are to blame for the development of this disease. The onset of the disease after severe stress is also possible.

There are many forms of rheumatoid arthritis:

acute polyarthritis , in which the joints of the hands and feet are predominantly affected, rheumatoid factor (autoantibodies to class G immunoglobulins) is often detected in the blood;
acute monoarthritis , in which large joints are affected;
symmetrical polyarthritis , which is characterized by a gradual increase in pain and stiffness in the small joints of the arms and legs;
monoarthritis of the knees or shoulder joints , in which the knee or elbow joints are first affected, and then the small joints of the feet or hands are affected quite quickly;
polyarthritis - a disease that mainly affects young people, which, in addition to joint pain, is characterized by fever, enlargement of the liver and spleen;
palindromic rheumatism - multiple recurrent attacks of acute symmetrical polyarthritis of the hands, lasting several hours or days and ending with complete recovery;
generalized myalgia begins with stiffness, depression, carpal tunnel syndrome, muscle pain, and joint damage comes later.

There are also special clinical forms of rheumatoid arthritis:

Adult Still's disease, which is characterized by recurrent fever, arthritis, and skin rash;
Felty's syndrome, which is characterized by an enlarged liver and spleen, joint damage, hyperpigmentation of the skin of the legs, lung lesions, Sjögren's syndrome and frequent infectious complications.

With rheumatoid arthritis, osteoporosis develops. And depending on the condition of the bones, there are 4 stages of this disease:

Stage I, initial, which is characterized only by periarticular osteoporosis;
Stage II, in which the joint space narrows, but osteoporosis affects the bones only around the joint;
Stage III, which is characterized by all the signs of the second stage and bone erosion;
Stage IV combines signs of the third and ankylosis (complete immobility of the joint, resulting from any changes in it) of the bones.

You can find out what stage of the disease a patient has with the help of an X-ray examination.

Rheumatism usually occurs in waves, with exacerbations and remissions. In less than 10% of cases with this disease there is spontaneous long-term remission . In 15% of cases there is intermittent flow , in which spontaneous or treatment-induced remissions alternate with exacerbations, during which previously unaffected joints are seized. In approximately 60% of cases, the course of the disease progressive . At the same time, in pathological process New joints are constantly involved, and this course is also characterized by extra-articular manifestations. In the remaining cases, the course of the disease rapidly progressive . This course is characterized by rapid development of the disease with severe extra-articular manifestations.

Diagnostics

The diagnosis is made by a rheumatologist. However, you may need to consult a neurologist and ophthalmologist. Typically, a physician will refer a patient to a rheumatologist if the characteristic symptoms last more than 6 weeks, more than three joints are inflamed, or morning stiffness lasts more than 30 minutes.

To make a correct diagnosis, it is necessary to do a general and biochemical blood test, and conduct a study of rheumatoid factors in the blood. The following studies are also prescribed:

radiography of the hand, foot, lungs;
spinal densitometry and femur.

Treatment

To treat rheumatoid arthritis, drugs that suppress the immune system are used. If the drug does not have an effect within three months, it is changed. This basic therapy. Hormonal drugs are also used to relieve inflammation in the form of ointments, creams and tablets. Non-steroidal anti-inflammatory drugs can also be used to relieve inflammation.

Prevention of osteoporosis is also of great importance. For this purpose, special medications and a diet high in calcium are used.

The immune system can also be stimulated by physical methods:

plasmaphoresis, in which plasma with a large amount of rheumatoid factors is removed and donor plasma is administered to the patient;
lymphocytophoresis, in which lymphocytes and monocytes are removed from the blood using a centrifuge, which reduces blood reactivity and the degree of inflammation;
irradiation of lymphoid tissue, in which the lymph nodes, spleen, and thymus are sequentially irradiated;
drainage of the thoracic lymphatic duct, in which the lymph is centrifuged, the cellular sediment is separated, and the liquid part of the lymph is returned back to the lymphatic duct.

Physiotherapy is widely used to treat rheumatoid arthritis. At an early stage, laser therapy is indicated; however, a course of more than 15 procedures is not recommended. Ultraviolet irradiation and electrophoresis with dimethyl sulfoxide are also indicated in the early stages. Cryotherapy is often used to reduce pain.

At later stages, phonophoresis with hydrocortisone, pulsed currents and magnetic therapy are used.

To restore joint function it is indicated physiotherapy.

Prevention

Prevention of rheumatoid arthritis is divided into primary and secondary. Primary prevention is measures aimed at preventing disease. It consists of timely treatment of infectious diseases, as well as sanitation of foci of infection, for example, carious teeth. It is important to strengthen the body, toughen up, play sports and lead an active lifestyle, and, if necessary, take vitamins.

Secondary prevention involves preventing exacerbations and complications in those suffering from rheumatoid arthritis. It includes physical therapy and timely administration of necessary medications. It is also important to follow a diet. It is necessary to limit the consumption of fats, sugar, salt, eat more vegetables and fruits, dairy products, and cereals.

Rheumatoid arthritis affects the small joints of the hands

Today, rheumatoid arthritis is considered an autoimmune disease that primarily affects the small joints of the hands. Over time, this pathology leads to deformation of bone tissue and dysfunction of the hand.

According to statistics, the pathology occurs in 0.8% of the population, and it is diagnosed much more often in women. There has also been an increase in the number of cases in age category after 50 years.

What are the causes of this disease?

The exact causes of rheumatoid arthritis have not yet been established. A role in the development of the pathology of certain infections is assumed: mycoplasma, Epstein-Barr virus, cytomegalovirus, rubella virus. The infection causes chronic damage to the synovium of the joint. Subsequently, this leads to the formation of new antigens on its inner surface, and so-called autoimmune inflammation develops.

What is the clinical picture of rheumatoid arthritis?

The onset of the disease, as a rule, does not have specific symptoms. The patient may experience general weakness, increased fatigue, low-grade fever, and pain in small and large joints for several months.
Very rarely, in 10% of cases, there is a rapid onset of the disease with high temperature, enlarged lymph nodes.

The next stage in the development of the disease is direct damage to the joints themselves with characteristic signs:

Pain that gets worse with movement
Swelling and tenderness of the tissue around the joint
Joint stiffness, especially in the morning, for at least an hour
Local increase in temperature, especially in large joints

What joints are affected by rheumatoid arthritis?

Mainly, localization is noted on the hands. Moreover, the lesion is always selective; the proximal interphalangeal and metacarpophalangeal joints are much more often involved. But the inflammatory process in the distal interphalangeal joints is observed much less frequently.

In addition, other joints of the upper extremities can be affected in parallel: wrist, elbow. On the lower extremities these are most often the knee, ankle, and metatarsal joints.

The next stage in the development of rheumatoid arthritis is the appearance of deformities in the affected areas of the limbs. On the hands, they deviate to the radial side, and the fingers to the ulnar side, the so-called Z-shaped deformity. Characterized by limited mobility of the thumb, which prevents the patient from grasping small objects.

Many patients also experience extra-articular manifestations of the disease.

These include: damage to the heart, lungs, pleura, development muscle atrophy, rheumatoid nodules. Rheumatoid nodules are small, painless lumps located around the affected joint and do not cause concern to the patient.

Methods for diagnosing the disease

X-ray of hand joints with arthritis

Today the main diagnostic method is initial examination patient and identification of characteristic clinical signs of the disease. The following additional studies have found application:

radiography of joints;
MRI of the hands;
detection of increased titers of rheumatoid factor during biochemical studies;
antibodies to cyclic citrullinated peptide, it is the most specific indicator of rheumatoid arthritis.

Treatment of rheumatoid arthritis

The first group of drugs used to treat rheumatoid arthritis are nonsteroidal anti-inflammatory drugs (NSAIDs). They quickly eliminate inflammation in the joints, relieve pain, but, unfortunately, do not stop the progression of the disease.

The second group is glucocorticoid hormones. They are used in small doses, fractionally. A positive aspect of their use is that they slow down the progression of the disease, in particular the formation of bone destruction. There are also methods for their intra-articular administration.

Drugs that affect the immune stages of inflammation in the joints are also used. These include immunosuppressants, cytostatics, gold preparations, sulfasalazine and others. They need to be taken for a long time, many of them have a number of serious side effects.

Of those offered in Lately methods of treatment, methods of extracorporeal hemocorrection are used. These are technologies for cryomodification of autoplasma and incubation of cell mass with immunomodulators. Their essence is to take blood from the patient and extract autoimmune complexes from it. The treated blood plasma is then returned to the patient.

In each specific case of rheumatoid arthritis, a whole range of therapeutic measures is carried out.

It depends on the severity of the disease, stage of development, and the presence of concomitant lesions of internal organs. Only a specialist rheumatologist will be able to correctly prescribe a treatment regimen that will reduce the manifestations of the disease and its progression.

» What joints are affected by rheumatoid arthritis

Rheumatoid arthritis - dangerous disease with a wide area of damage, including not only joints, but also the main systems of human life, which is why it is called systemic. Therefore, it is extremely important to recognize its earliest symptoms. The first signs of pathology are still reversible, but chronic pathology is much more difficult to treat, and it can lead to destruction of joints and other organs and an unfavorable prognosis. How to treat rheumatoid arthritis - this is what the pages of this article are devoted to.

I="">Causes of rheumatoid arthritis

According to the classics in medicine, the following are distinguished: possible reasons occurrence of the disease:

Autoimmune processes, the mechanism of which is activated under the influence of genetic factors
Infectious factors:

These may be viruses of the following diseases:

measles, mumps, acute viral infection
hepatitis B
herpes, Eppstein-Barr virus
herpes zoster
retroviral infection leading to malignant tumors in the lymphatic and circulatory systems

The fact that rheumatoid arthritis could be caused by some kind of infection is indicated by a reactive reaction of increased erythrocyte sedimentation rate. But the bacterial therapy used too often does not bring results, which gives some reason to doubt the reliability of the infectious theory.

Provoking factors):

hypothermia or sunstroke

intoxication

taking mutagens:

for example, colchicine in the treatment of gout

cytostatics for the treatment of tumor processes

immunosuppressants used in organ transplants

endocrine system diseases

stress

Stages of rheumatoid arthritis

The disease rarely manifests itself in all its multiple symptoms at once.

In the first stage, local swelling and pain occur near the joint, and the temperature on the surface of the skin may also increase

Within a month and a half, these symptoms are reversible and can be easily treated with anti-inflammatory drugs

In the second stage, the joints become rougher, becoming larger:

This is due to progressive cell division, due to which the synovial membrane becomes inflamed and becomes denser

In the third stage, irreversible destruction of joints and deformation begins under the influence of protein enzymes secreted by the inflamed synovium

The photo shows the stages of rheumatoid arthritis:

I-3="">Disease symptoms

There is something common, regardless of the cause of arthritis - this is the presence of specific antibodies in the blood, called rheumatoid factor.

To make a diagnosis, donating blood for a rheumatic test is the first prerequisite.

But rheumatoid factor itself does not mean the presence of arthritis, since it can be detected in some infectious diseases, chronic liver pathologies, and even in healthy people.

Rheumatoid arthritis, in addition to changes in blood tests, has its own clinical symptoms.

They can be divided into three groups:

General symptoms

Fatigue, weakness and weakness
Flu-like symptoms, including fever and joint pain
Dryness of the mucous membranes of the eyes and mouth
Depression and lack of appetite
Cold sweating

Joint symptoms

Pain at night and in the morning
Formation of nodules on joints according to a symmetrical type:

Initially, rheumatoid arthritis affects the small joints on both hands or feet, and then moves to larger ones.
The following types of joints are primarily affected:

second and third metacarpophalangeal
proximal interphalangeal
knee
wrist
elbow
ankle

The occurrence of contracture in the joint (limited range of motion)

Edema of the extremities

Deviation of the limbs from the axis of symmetry: for example, the fingers or toes deviate towards the little finger

In the photo - rheumatoid arthritis of the foot:

I-6="">Extra-articular symptoms

Rheumatoid arthritis gives rise to a simply enormous number of various symptoms and syndromes. Its forms clinical manifestation varied. This inflammatory disease joints is influenced by:

On the cardiovascular and respiratory systems, causing:

Pericarditis, atherosclerosis, vasculitis, cardiac and respiratory failure, pleurisy, pneumofibrosis

Urinary system:

Nephritis, amyloidosis, nephropathy

Hematopoiesis:

Thrombocytosis, neutropenia, anemia

Nervous system:

Various types of neuropathy, mononeuritis, myelitis

Organs of vision:

Conjunctivitis, scleritis, ulcerative keratopathy

Skin surfaces:

Rheumatic nodules, malnutrition, uneven mesh coloration of the skin

The photo shows the surface of the skin with a mesh pattern in rheumatoid arthritis:

I-7="">Types of rheumatoid arthritis

Rheumatoid arthritis in two thirds of cases is polyarthritis, that is, it affects many joints. Much less often, several or one joint is affected by the disease

Symptoms of the disease can be mixed or relate to a specific group of patients:

If both joints and organs are affected, this disease is called articular-visceral.
If the disease occurs before the age of 16 years, then such arthritis is called juvenile
The combination of several signs at once is called a syndrome.

Syndromes in rheumatoid arthritis

Still's syndrome:

Juvenile rheumatoid arthritis of seronegative type with erymatous rash, increased leukocytes, ESR and enlarged lymph nodes

Pseudoseptic syndrome:

Fever with chills predominates, increased sweating, muscle weakness and anemia

In the background are symptoms of arthritis

Allergoseptic syndrome:

The onset of the disease is rapid:

Temperature up to 40 °C, polymorphic rash, arthralgia, swelling of joints

Possible heart problems and liver enlargement

This syndrome is characteristic of juvenile arthritis

Felty's syndrome:

Polyarthritis is combined with splenomegaly (enlarged spleen)

A variant without splenomegaly is possible, but with a decrease in leukocytes, neutrophils and inflammation of internal organs (visceritis)

The disease is usually associated with ulcerative lesion skin and respiratory tract infections

In the photo - Felty's syndrome:

I-9="">Diagnosis of the disease

Making an accurate diagnosis is difficult, since rheumatoid arthritis in its symptoms resembles many diseases:

Rheumatism
Gout
Infectious arthritis (gonococcal, syphilitic, chlamydial)
Reactive (Reiter's syndrome)
Lyme disease (borreliosis)

Of fundamental importance for diagnosis are:

Biochemical and general blood test:

with calculation of erythrocyte sedimentation rate (ESR) and platelets
determination of antibody titer to cyclic peptide ACRF (rheumatoid factor)

Identification of markers of joint syndromes

General clinical signs

Specific signs:

The presence of nodules and typical deformities (for example, rheumatoid hand or foot)

Skin color

X-ray examination of joints

Diagnostics allows you to make a preliminary prognosis of the disease.

Adverse Signs

Unfavorable signs are considered:

Steady involvement of new joints with each new attack
Increase in ESR and antibody titers
Non-responsiveness of the patient to basic medications
Early and rapid destruction of joints, visible on x-ray

The photo shows an x-ray of the affected joint:

I-11="">Treatment of rheumatoid arthritis

If an injection is detected during diagnosis, then antibacterial treatment is prevailing.

I-12="">Selection of NSAIDs and GCS

If symptoms of articular manifestations predominate, select an appropriate non-steroidal anti-inflammatory drug (NSAID) or glucocorticosteroids (GCS)

Of course, you can choose aspirin, diclofenac, and ibuprofen, which are COX-1 inhibitors (cyclooxykenase, which synthesizes prostaglandins, which are responsible for inflammation).
But the duration of treatment for arthritis dictates the need to take drugs from this series that are less harmful to the gastrointestinal tract, which include COX-2 inhibitors:

Movalis (meloxicam), nimesulide, celecoxib

At the same time, injections of glucocorticosteroids are administered into the affected joints

In case of predominance of inflammatory processes, GCS can be used as a means of systemic rather than local treatment

The best long-acting drug for the treatment of rheumatoid arthritis is betamezone (diprospan)

Basic drugs

NSAIDs and corticosteroids can help with the early stages of rheumatoid arthritis. They also serve to relieve pain attacks. But for chronic arthritis, other, non-symptomatic remedies are needed.

Today, rheumatologists have slightly changed the previous treatment regimen - moving from a gradual increase in doses basic drugs to a sharp aggressive attack on the disease immediately after the diagnosis revealed rheumatoid arthritis. In some ways, this scheme is reminiscent of chemotherapy for oncology.

Such harsh treatment is justified when the consequences of the disease are worse than complications from medications.

The following drugs are used:

Sulfasalazine, penicillamine, leflunomide, aminoquinol, etc.

I-14="">Complex therapy

How to cure rheumatoid arthritis?

The treatment regimen is individual for each patient. After all, there is such a variety of symptoms:

For example, the content of leukocytes or neutrophils in the blood can be either increased or decreased
Both violent extra-articular manifestations in the form of fever, myotrophy, sweating, and their absence against the background of joint pain are possible
Absence or presence of visceral symptoms

However, the main thread of treatment is:

The use of NSAIDs and corticosteroids for exacerbation of pain and inflammation
Taking basic medications:

Methotrexate, sulfasalazine, D-penicillamine

Immunosuppressants - drugs that suppress the immune system, for example:

Cyclophosphomide, cyclosporine, azathioprine

Taking biological genetically engineered drugs:

Drugs that block harmful enzymes synovial membrane:

TNF (tumor necrosis factor) inhibitors:

infliximab, etanercept, etc.

B lymphocytes:

Actemra (tocilizumab), Mabthera (rituximab)

Surgery

Surgical treatment of rheumatoid arthritis is used only if it is necessary to remove a completely destroyed joint or for its fusion.

Surgery becomes especially relevant for instability in the cervical spine that threatens the spinal cord.

Basic surgical method- this is arthrodesis, that is, artificial ankylosis of the vertebrae.

Additional measures

In addition, to combat rheumatoid arthritis you need:

Physiotherapy (electro- and phonophoresis)
Physiotherapy
Prevention of osteoporosis:

taking calcium supplements with the regulation of this element in the body: in combination with vitamin D
food containing dairy products (cheese, cottage cheese, sour cream) and nuts

Elimination of risk factors

Sanatorium treatment

The influence of pregnancy on the course of the disease

Of course, for a young woman such a terrible disease looks like a tragedy, because treatment with basic drugs can lead to infertility and is unsafe for the health of the woman herself. Nevertheless, the desire to have a child turns out to be stronger. How do rheumatoid arthritis and pregnancy get along together?

https://www.youtube.com/embed/3kIh75hBLxE?feature="oembed="">

Joints often affected by rheumatoid arthritis are the wrists, hands, legs, and ankles. The disease can affect the elbow, shoulder, hip, knee, neck and jaw joints.

It usually affects joints on both sides of the body at the same time, such as the joints of both hands. The joints most often affected are the joints of the hands and feet.

Extra-articular signs and symptoms also occur in rheumatoid arthritis. Unlike osteoarthritis, which affects only the bones and muscles, rheumatoid arthritis can affect the entire body, including organs such as the heart, blood vessels, lungs and eyes. Rheumatoid arthritis causes changes in many joints at once, whereas osteoarthritis usually causes changes in only one or a few joints, even though several joints may be affected at once.

Small bumps called rheumatoid nodules form under the skin of the elbows, hands, knees, toes and back of the head. These nodules, usually painless, range in size from a pea to a walnut.

“Which joints are affected by rheumatoid arthritis” and other articles from the Arthritis section

Rheumatoid arthritis - chronic systemic disease connective tissue, affecting mainly the joints. This is one of the most serious diseases, affecting approximately 1% of the world's population.

Signs

Rheumatoid arthritis primarily affects small joints. Typically, the disease begins with inflammation of the metacarpophalangeal joints (located at the base of the finger) of the index and middle fingers and inflammation of the wrist joints. Moreover, this inflammation is symmetrical, that is, it develops on both hands at once. Joints swell and hurt. Moreover, the pain intensifies at night, in the morning, and until about noon the person suffers from unbearable pain. Patients themselves often compare this pain to toothache. However, by warming up or simply after any vigorous activity, the pain usually decreases. This is the difference between rheumatoid arthritis and arthrosis, in which pain intensifies due to physical activity. In the middle of the day the pain subsides and by evening it is almost unnoticeable.

Almost simultaneously with the damage to the joints of the hands, the joints of the feet also become inflamed. The joints at the base of the fingers are predominantly affected.

Pain and swelling may last for several months.

After some time, from several weeks to several months, larger joints become inflamed - ankle, knee, elbow, shoulder. However, in older people aged 65-70 years, the disease can begin with damage to large joints and only then inflammation of small ones occurs.

Knee joints can not only become deformed. Quite often, fluid accumulates in the joint cavity. This is called a Baker's cyst. This cyst stretches the joint capsule, and in severe cases even ruptures it. Then the liquid pours into the soft tissues of the lower leg. In this case, swelling of the lower leg develops, and sharp pain appears in the leg.

It happens that not only the joints are affected, but also the spine. Moreover, the cervical spine is predominantly affected. In this case, patients complain of neck pain.

With rheumatoid arthritis, patients complain of constant weakness, loss of appetite, weight loss up to cachexia (extreme exhaustion), and poor sleep. The temperature rises to low-grade levels, this condition is accompanied by chills. However, in some cases the temperature may rise to 39°C. Rheumatoid nodules often form on the skin - dense, rounded formations the size of a pea. Most often they are located below the elbows, on the hands, and on the feet. There are usually not many nodules. They may disappear and reappear, or they may remain in place for many years. There is no harm to health from them, however, they spoil the patient’s appearance. However, in some cases, rheumatoid nodules may be localized in the lungs (Kaplan syndrome).

Rheumatoid nodules are an extra-articular manifestation of rheumatism, it can occur not only on the skin. The cardiovascular system may be affected, in which case vasculitis, pericarditis, and early atherosclerosis develop. The kidneys may be affected, in which case amyloidosis and, rarely, nephritis develop. There may be unpleasant complications from the blood - anemia, thrombocytosis, neutropenia. When the eyes are affected, keratoconjunctivitis, episcleritis or scleritis develops. The muscles and nervous system may also be affected.

Description

It is known that rheumatoid arthritis is an autoimmune disease. For some reason, a large number of immune complexes are formed in the body, which circulate in the blood and enter the joints, causing inflammation, which later leads to destruction. In addition, these immune complexes can attack other organs and tissues, leading to extra-articular manifestations of rheumatoid arthritis. Rheumatoid nodules are formed by an accumulation of immune cells and lymphocytes around a small area of dead tissue, but it is not known what attracted these cells there and what came first - tissue necrosis or accumulation of immune cells. And what contributes to the activation of lymphocytes is unknown. There are hypotheses that viruses, bacteria, allergies, injuries, heredity and many other factors are to blame for the development of this disease. The onset of the disease after severe stress is also possible.

There are many forms of rheumatoid arthritis:

acute polyarthritis , in which the joints of the hands and feet are predominantly affected, rheumatoid factor (autoantibodies to class G immunoglobulins) is often detected in the blood;
acute monoarthritis , in which large joints are affected;
symmetrical polyarthritis , which is characterized by a gradual increase in pain and stiffness in the small joints of the arms and legs;
monoarthritis of the knee or shoulder joints , in which the knee or elbow joints are first affected, and then the small joints of the feet or hands are affected quite quickly;
polyarthritis - a disease that mainly affects young people, which, in addition to joint pain, is characterized by fever, enlargement of the liver and spleen;
palindromic rheumatism – multiple recurrent attacks of acute symmetrical polyarthritis of the hands, lasting several hours or days and ending with complete recovery;
generalized myalgia It begins with stiffness, depression, carpal tunnel syndrome, muscle pain, and joint damage comes later.

There are also special clinical forms of rheumatoid arthritis:

Adult Still's disease, which is characterized by recurrent fever, arthritis, and skin rash;
Felty's syndrome, which is characterized by an enlarged liver and spleen, joint damage, hyperpigmentation of the skin of the legs, lung lesions, Sjögren's syndrome and frequent infectious complications.

With rheumatoid arthritis, osteoporosis develops. And depending on the condition of the bones, there are 4 stages of this disease:

Stage I, initial, which is characterized only by periarticular osteoporosis;
Stage II, in which the joint space narrows, but osteoporosis affects the bones only around the joint;
Stage III, which is characterized by all the signs of the second stage and bone erosion;
Stage IV combines signs of the third and ankylosis (complete immobility of the joint, resulting from any changes in it) of the bones.

You can find out what stage of the disease a patient has with the help of an X-ray examination.

Rheumatism usually occurs in waves, with exacerbations and remissions. In less than 10% of cases with this disease there is spontaneous long-term remission . In 15% of cases there is intermittent flow , in which spontaneous or treatment-induced remissions alternate with exacerbations, during which previously unaffected joints are seized. In approximately 60% of cases, the course of the disease progressive . At the same time, new joints are constantly involved in the pathological process, and extra-articular manifestations are also characteristic of this course. In the remaining cases, the course of the disease rapidly progressive . This course is characterized by rapid development of the disease with severe extra-articular manifestations.

Diagnostics

To make a correct diagnosis, it is necessary to make a general and biochemical analysis blood, conduct a study of rheumatoid factors in the blood. The following studies are also prescribed:

Treatment

To treat rheumatoid arthritis, drugs that suppress the immune system are used. If the drug does not have an effect within three months, it is changed. This is basic therapy. Hormonal drugs are also used to relieve inflammation in the form of ointments, creams and tablets. Non-steroidal anti-inflammatory drugs can also be used to relieve inflammation.

Prevention of osteoporosis is also of great importance. For this purpose, special medications and a diet high in calcium are used.

The immune system can also be stimulated by physical methods:

plasmaphoresis, in which plasma with a large amount of rheumatoid factors is removed and donor plasma is administered to the patient;
lymphocytophoresis, in which lymphocytes and monocytes are removed from the blood using a centrifuge, which reduces blood reactivity and the degree of inflammation;
irradiation of lymphoid tissue, in which the lymph nodes, spleen, and thymus are sequentially irradiated;
drainage of the thoracic lymphatic duct, in which the lymph is centrifuged, the cellular sediment is separated, and the liquid part of the lymph is returned back to the lymphatic duct.

At later stages, phonophoresis with hydrocortisone, pulsed currents and magnetic therapy are used.

Physical therapy is indicated to restore joint function.

Prevention

Prevention of rheumatoid arthritis is divided into primary and secondary. Primary prevention is measures aimed at preventing the disease. It consists of timely treatment of infectious diseases, as well as sanitation of foci of infection, for example, carious teeth. It is important to strengthen the body, toughen up, play sports and lead an active lifestyle, and, if necessary, take vitamins.

Rheumatoid arthritis- systemic inflammatory disease of connective tissue with predominant damage to joints, such as chronic progressive erosive-destructive polyarthritis. It occurs in all climatic and geographical zones in approximately 0.4-1% of the population, mainly in middle-aged and elderly women.

ETIOLOGY AND PATHOGENESIS
According to the multifactorial theory, rheumatoid arthritis can develop under the influence of a variety of influences environment subject to genetic predisposition. Among the possible etiological factors, some infectious agents are considered; group B streptococci. mycoplasmas, retroviruses, Epstein-Barr virus.

Rheumatoid arthritis is based on a chronic inflammatory process in the synovium of the joints, caused by the development of a local immune reaction with the formation of aggregated immunoglobulins (mainly the IgG class), to the Fc receptors of which autoantibodies are formed, called rheumatoid factors.
Autoantibodies can form immune complexes by combining with both the C1g component of complement and other proteins. Immune complexes, entering the synovial fluid, are phagocytosed by neutrophils, which are destroyed during phagocytosis. As a result, various lysosomal enzymes are released that can activate inflammatory mediators - kinins, prostaglandins, complement components, which have anaphylactogenic, cytotoxic and chemotactic properties. The latter contributes to the influx large number neutrophils into the joint cavity, which increases the accumulation of inflammatory mediators in it. In the synovial membrane itself, activated lymphocytes are concentrated, which, in the process of a cooperative immune response, release various lymphokines that have a damaging effect on joint tissue and promote the formation of granulomas (rheumatoid nodules). The pathogenesis of most extra-articular (systemic) manifestations of rheumatoid arthritis is associated with the development of immune complex vasculitis, as well as direct damage to various tissues by activated lymphocytes and autoantibodies.

CLINICAL PICTURE
The most typical is the gradual slow development of the disease (the so-called classic variant of the course).
As if gradually, pain, a feeling of stiffness and swelling of the joints appear. A relatively small number of joints are initially affected. Joint pain is moderate and occurs only with movement. Characteristic is a feeling of stiffness in the joints, more pronounced in the morning. There is swelling of the affected joints, pain on palpation, hyperthermia of the skin over them, the color of which, as a rule, is not changed. From the very beginning of the disease, symmetry of arthritis is characteristic. In approximately 10% of patients, rheumatoid arthritis begins and lasts for a long time in the form of mono- or oligoarthritis, mainly of large joints.

In a small proportion of patients, rheumatoid arthritis may begin acutely. High “unreasonable” fever with chills is the first and most pronounced symptom of this variant of the disease. The clinical picture is also determined by symptoms of intoxication and systemic manifestations such as serositis, carditis, enlarged lymph nodes, liver, spleen, as well as leukocytosis, increased ESR.
Signs of arthritis may initially be absent (only polyarthralgia is present) or may be moderate. Only after several weeks or even months does persistent articular syndrome become apparent. In the future, especially under the influence of treatment, a transformation into the classic version of the course of rheumatoid arthritis may be observed, but the tendency to an aggressive course often persists, with fever persisting during the period of exacerbation.

Rare variants of the onset of rheumatoid arthritis include recurrent arthritis. There is an acute or subacute development of arthritis of one or more joints, which disappears without a trace after a short period of time without treatment. Repeated “attacks” of arthritis may precede the development of the typical persistent polyarthritis characteristic of rheumatoid arthritis for a number of years. Extremely rarely, rheumatoid arthritis can begin with the appearance of rheumatoid nodules located subcutaneously or in internal organs (for example, in the lungs), the so-called rheumatoid nodulosis.
Joint damage develops later.

Articular syndrome forms the basis of the clinical picture. Almost any joints, as well as periarticular tissues (ligaments, tendons, muscles, etc.) can be involved in the pathological process. The most characteristic feature of rheumatoid arthritis is the tendency to develop erosive polyarthritis with symmetrical damage to the joints and their deformation. Typical symptoms of rheumatoid arthritis include arthritis of the proximal interphalangeal joints, which causes the fingers to become spindle-shaped, and inflammation of the metacarpophalangeal joints. Inflammation of the wrist, metacarpal, carpal and intercarpal joints is often observed. One of the early symptoms of rheumatoid arthritis is a decrease in the mass of the interosseous muscles on the back of the hand, caused by a decrease in their functional activity, less often by myositis.

Tendon damage and muscle changes play a leading role in the formation of persistent hand deformities: lateral deviation of the fingers, “button loop” finger deformities (flexion contracture of the proximal and hyperextension of the distal interphalangeal joints) or “swan neck” (flexion contracture of the distal and hyperextension of the proximal interphalangeal joints) . These deformities occur almost exclusively in rheumatoid arthritis and define the term “rheumatoid hand.” Rheumatoid nodules may be found in the area of the elbow joints. Most often they are located in the area of the olecranon and proximal part ulna. The nodules are usually painless, moderately dense, and small in size.

Arthritis of the metatarsophalangeal joints is almost constant in rheumatoid arthritis. The consequence of persistent arthritis of these joints is hammertoe deformity of the toes, subluxation of the heads of the metatarsal bones towards the sole of the feet, and outward deviation of the toes. As a result of these changes, flat feet are formed, painful “corns”, hallux valgus and bursitis in the area of the first metatarsophalangeal joint occur. The complex of these changes is commonly called “rheumatoid foot.” Arthritis of the ankle joints is common and can lead to varus deformity of the foot.

When the knee joints are affected, atrophy of the quadriceps femoris muscle begins early. In a number of patients, obvious deformation of the joint may be associated not with effusion into its cavity, but with thickening of the periarticular tissues. Fibrous changes in the joint capsule and muscle tendons that attach to the knee joint can lead to the development of flexion contractures. Sometimes synovial fluid accumulates mainly in the posterior parts of the joint - a Baker cyst develops, sometimes reaching large sizes.

Impaired mobility and pain in hip joint in rheumatoid arthritis are sometimes associated with aseptic necrosis of the femoral head, which usually occurs against the background long-term treatment corticosteroids.

Arthritis of the sternoclavicular and temporomandibular joints is relatively rare. Damage to the joints of the arytenoid cartilages can lead to hoarseness, and damage to the joints auditory ossicles- to hearing loss.

With rheumatoid arthritis, subluxation of the joints, flexion contractures, and bone ankylosis can develop (usually in the intercarpal and radiocarpal joints, less often in the proximal interphalangeal joints and joints of the feet).

Pain and a feeling of stiffness in the cervical spine are common complaints of patients with rheumatoid arthritis. Rare feature defeats cervical spine spine in rheumatoid arthritis is the development of subluxation in the atlanto-axial joint due to softening and thinning of the transverse atlas ligament. Subluxations of other cervical vertebrae (usually CIII-CIV) can lead to spinal cord trauma, which in mild cases manifests itself only as fatigue when walking, paresthesia, and in severe cases - sensory disturbances and motor disorders, up to tetraplegia.

Polyneuropathy is a manifestation of vasculitis of the vessels that supply peripheral nerves. Characteristically, there is damage to the distal parts of the nerve trunks, most often the peroneal nerve, with the development of sensitivity disorders. Patients are concerned about numbness, burning, and chilliness in the distal parts of the extremities. There is pain on palpation not only of the affected joints, but also of tissues located at a distance from them, a decrease or increase in sensitivity in the area of nerve damage. Movement disorders occur less frequently. As a rule, polyneuropathy is observed in patients with seropositive R. a. simultaneously with the presence of subcutaneous rheumatoid proteins.

Rheumatoid vasculitis causes the appearance of pinpoint areas of necrosis, most often in the area of the nail bed (the so-called digital arteritis); painless ulcers, usually localized on the lower leg; episcleritis, microinfarctions or hemorrhages in the pulmonary, cerebral, coronary or mesenteric vessels.

Heart damage in rheumatoid arthritis is most often manifested by pericarditis and myocarditis, predominantly granulomatous, focal. Very rarely, heart defects (mitral or aortic valve insufficiency) can form.

Rheumatoid lung damage includes: diffuse fibrosing alveolitis, nodular lesion of logical tissue, vasculitis. Serositis (usually pleurisy, pericarditis) is detected only when x-ray examination(moderately expressed adhesive process).

Rheumatoid kidney damage (glomerulonephritis) is less common. than amyloidosis and drug-induced nephropathies, and is characterized by moderate proteinuria and microhematuria.

The combination of rheumatoid arthritis with damage to the exocrine glands, mainly salivary and lacrimal, is observed, according to various authors, in 10-15% of patients and is called Sjogren's syndrome.

The combination of rheumatoid arthritis with hepatosplenomegaly and leukopenia is called Felty's syndrome, and the simultaneous presence of rheumatoid arthritis and silicosis with nodular lesions of the lungs is called Kaplan's syndrome.

One of the most serious complications of rheumatoid arthritis is amyloidosis. It develops in 10-15% of patients, usually many years after the onset of the disease, but in some patients it occurs already in the first years.

In accordance with the classification adopted in our country, rheumatoid mono-, oligo- or polyarthritis and systemic manifestations are distinguished, which also include Felty, Kaplan and Sjögren syndromes. There are seropositive (in the presence of rheumatoid factor in the blood serum) and seronegative (in its absence) rheumatoid arthritis. The presence of rheumatoid factors (antiglobulin antibodies of various classes of immunoglobulins), especially in high titers, has not only diagnostic but also prognostic significance in rheumatoid arthritis.

The classification also distinguishes three degrees of process activity depending on the severity of arthritis, the number of affected joints, extra-articular manifestations and changes in laboratory indicators of inflammation activity, as well as variants of the course (rapidly progressive or slowly progressive), the radiological stage of the process and three degrees of functional joint insufficiency.

DIAGNOSIS
In early recognition of rheumatoid arthritis great importance have persistent arthritis of small joints of the hands and feet, symmetry of the process, the presence of general mild signs of the disease (low-grade fever, fatigue, weight loss), detection of IgM-rheumatoid factor in the blood (latex test) in medium and high titers, and the presence of rheumatoid nodules.

Synovial fluid in rheumatoid arthritis is cloudy, its viscosity is reduced, the protein and leukocyte content is increased (mainly due to neutrophils), the mucin clot is loose, IgM-rheumatoid factor and so-called ragocytes are detected - neutrophils containing immune complexes in the cytoplasm; hemolytic activity of complement and glucose levels are reduced.

X-ray changes, especially early detected in the joints of the hands and feet, also have great diagnostic value. The main signs in this case are periarticular epiphyseal osteoporosis, narrowing of the joint space, and the development of marginal bone erosions (usur). Periarticular osteoporosis is characterized by a uniform decrease in bone density; The normally clearly visible trabecular pattern of the epiphyses is noticeably “blurred.” Narrowing of the joint space during R. a. occurs evenly throughout. The earliest erosive changes in the articular surfaces in rheumatoid arthritis are observed in the proximal interphalangeal, metacarpophalangeal (usually in the heads of the II-III metacarpal bones) joints, carpal bones, in the wrist joint (especially in the area of the styloid process of the ulna), as well as in the metatarsal heads bones. From a diagnostic point of view, it is important that bone erosions in rheumatoid arthritis are always observed simultaneously with narrowing of the gap of the corresponding joint and periarticular osteoporosis. With rheumatoid arthritis, various sizes (usually small) racemose enlightenments in the area of the epiphyses can be observed. In some cases, they are caused by the development of rheumatoid granulomas in bone tissue.

In diagnosing rheumatoid arthritis, it is recommended to use the criteria proposed by the American Rheumatological Association: morning stiffness for at least 1 hour over a period of at least, 6 weeks; arthritis in at least three joints for at least 6 weeks; arthritis of the hand joints (wrist and metacarpophalangeal or proximal interphalangeal), lasting at least 6 weeks, symmetrical nature of the arthritis; rheumatoid nodules; rheumatoid factor in blood serum; X-ray changes typical of rheumatoid arthritis (periarticular osteoporosis or erosion). If any 4 signs are present, the diagnosis of rheumatoid arthritis is considered reliable.

Early diagnosis of rheumatoid arthritis is often difficult, because complex characteristic features does not appear in the first months. Therefore, at the onset of the disease, it is necessary to carry out a differential diagnosis with some variants of diseases such as ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, osteoarthritis, gout.

IN differential diagnosis with ankylosing spondylitis, the detection of radiological signs of sacroiliitis, as well as the histocompatibility antigen B27, which occurs in rheumatoid arthritis no more often than in the population (5-8%), and in ankylosing spondylitis - in 90-95% of cases, is crucial. With Reiter's syndrome, the frequency of detection of the B27 histocompatibility antigen is also increased, but in contrast to ankylosing spondylitis and rheumatoid arthritis, characteristic urological (urethritis, balanitis), ocular (conjunctivitis) and skin (keratodermia blenorhagica) manifestations are noted. In the differential diagnosis of these diseases with R. a. it is necessary to take into account their development predominantly in men young, which is less typical for rheumatoid arthritis.

Joint damage in psoriatic arthritis, as a rule, differs from rheumatoid arthritis in asymmetry, the presence of widespread periarticular edema, involvement of the distal interphalangeal joints of the hands, and typical skin manifestations. The latter may be observed inconsistently in these patients and localized only on rarely examined parts of the body (for example, on the scalp).

Secondary synovitis in osteoarthritis with predominant damage to the joints of the hands differs from rheumatoid arthritis in that it develops only in those joints that are more often involved in the process in osteoarthritis - distal, less often proximal interphalangeal, and practically does not occur in the metacarpophalangeal joints (with the exception of I finger), as well as the absence of rheumatoid factor.

In some cases, there is a need for a differential diagnosis with systemic lupus erythematosus, Sjögren's disease, reactive arthritis, sarcoidosis, tuberculous arthritis, and pyrophosphate arthropathy.

TREATMENT
Proposed for the treatment of rheumatoid arthritis various methods, the choice of which depends on the form of the disease, the degree of activity of the process, the course, the nature of changes in the joints, systemic manifestations and other factors. In the early stages of the disease and in the absence of clinical signs of systemicity, treatment of rheumatoid arthritis is usually. should begin with the selection of non-steroidal anti-inflammatory drugs. Among them, the most commonly used are acetylsalicylic acid (average daily dose 3 g), ortofen (0.15 g), indomethacin (0.15 g), ibuprofen (1.2 g), naproxen (0.75 g). This fast-acting drugs, the maximum therapeutic effect of which is revealed after 1-2 weeks. By sequential administration, the most effective and well-tolerated drug in each case is selected, which is used almost continuously, in combination with other drugs. Intra-articular administration of corticosteroids (hydrocortisone suspension, but preferably long-acting drugs - Kenalog, Depo-Medrol) is widely used, especially with a small number of affected joints. The administration of oral corticosteroids is absolutely indicated only for patients with generalized vasculitis, especially with febrile reactions. Prednisolone is usually used, the dose of which is selected individually (on average 15-20 mg per day). In all other cases, the prescription of corticosteroids should be approached as a forced and, most importantly, temporary measure. The need for this arises, as a rule, with multiple joint lesions with severe pain syndrome, which does not decrease under the influence of non-steroidal anti-inflammatory drugs and intra-articular administration of corticosteroids. The initial daily dose of prednisolone in such situations is 10-15 mg. When activity subsides, it is necessary in all cases to try to gradually reduce the dose and completely discontinue the drug, using long-acting agents for this purpose.

Progression of the disease, despite treatment with non-steroidal anti-inflammatory drugs, is an indication for the addition of slow-acting (“basic”) drugs. At the first stage, the issue of appointing one of the the following means: hingamine, hydroxychloroquine, gold preparations, penicillamine, salazosulfapyridine. By therapeutic effect Gold preparations occupy the first place. Hingamine is used at 0.25 g per day, hydroxychloroquine (Plaquenil) at 0.2 g per day. At the same time, once every 3-4 months. It is necessary to examine the patient by an ophthalmologist to prevent complications from the visual organs. Krizanol is administered intramuscularly at the rate of 17-34 mg of metallic gold per injection (1 ml of 5% solution of krizanol contains 17 mg of gold). Penicillamine is prescribed 150-300 mg per day for the first 3 months, then, if there is no effect, a daily dose every 4 weeks. increase by 150 mg. The maximum daily dose of the drug should usually not exceed 750-900 mg. When using crizanol and penicillamine, it is necessary to conduct weekly urine and blood tests to diagnose and prevent the development of drug-induced nephropathy and cytopenias. In recent years, salazosulfapyridine, as well as salazopyridazine (2 g per day), have become quite widely used.

The results of 3-6 months of continuous treatment with any of the slow-acting drugs determine further tactics for using these drugs. A significant improvement in the patient’s condition serves as the basis for continuing treatment for that period of time (sometimes many years) while the achieved effect remains. If there is no positive result of treatment, another drug of this group is prescribed.

Immunosuppressants, also classified as long-acting treatments for rheumatoid arthritis, are usually used as a last resort when other basic drugs are ineffective. However, in some cases, with a rapidly progressing course, persistent high titers of rheumatoid factor in the blood, as well as the presence of systemic signs (rheumatoid nodules, polyneuropathy, etc.), immunosuppressants are the drugs of choice. For rheumatoid arthritis (methotrexate is usually used in medium doses (5-7.5-10 mg per week), less often clorbutin (daily dose 5-10 mg). Preference is given to methotrexate due to better tolerability. However, when prescribing this drug to patients Those who have had hepatitis in the past and abuse alcohol should take into account the possibility of toxic liver damage.

With progressive signs of systemicity, for example polyneuropathy, digital arteritis, Felty's syndrome, it is possible to use pulse therapy - intravenous administration of 1000 mg of methylprednisolone for 3 days, with particularly severe vasculitis, 500-1000 mg of cyclophosphamide is administered simultaneously with methylprednisolone on one and three days. In Felty's syndrome, gold drugs or methotrexate in combination with prednisolone are prescribed with great caution.

Physiotherapeutic methods of treatment for rheumatoid arthritis are of auxiliary value. The most widely used are hydrocortisone phonophoresis and thermal procedures (paraffin or ozokerite applications). Mud and balneotherapy are more effective when the disease activity is minimal and in most cases only complement drug therapy.

Physical therapy is of great importance, exercises of which should be carried out by patients with rheumatoid arthritis daily and are limited only when the disease is highly active and the pain syndrome is significantly pronounced. When the activity of rheumatoid arthritis subsides, most patients are indicated for therapeutic massage.

Surgical treatment is used for rheumatoid arthritis to preserve, restore or improve joint function. Depending on the stage of the disease and especially on the stage of the process in the affected joint, early (preventive) and restorative-reconstructive surgery. Early surgery includes surgical interventions such as synovectomy, tenosynovectomy, in which pathologically altered synovial membrane of the joint or tendon sheath is excised. As a result, in many patients the inflammatory process is permanently stopped: within a period of up to 5 years, good results from early synovectomy of the knee joint are maintained in approximately 80% of patients.

Reconstructive operations are performed in later stages of the disease, incl. in the presence of persistent joint deformities that reduce the function of the musculoskeletal system. To this group surgical interventions includes extended synocapsulectomy, when, along with excision of the affected synovial membrane, altered areas of cartilage, osteophytes, and granulation tissue are removed. The indication is persistent arthritis of a functionally important joint (knee, elbow, metacarpophalangeal) with severe pain, depending not only on the inflammatory process, but also on mechanical causes associated with destructive and reparative changes. For flexion contractures, corrective operations such as capsulotomy and osteotomy are used.

Arthrodesis, i.e. creation of joint ankylosis is indicated for pronounced destructive processes in the joints, provided that the function of adjacent joints is satisfactory, which in general can provide compensation for lost movements in the operated joint and improve the function of the limb as a whole. Arthroplasty is used in the reconstructive treatment of significantly affected joints, for example, in destructive and ankylosing arthritis of the elbow, metatarsophalangeal or metacarpophalangeal joints. Endoprosthetics methods have become widespread, the indications for which are pronounced destructive or ankylosing arthritis of the hip, knee, elbow, and metacarpophalangeal joints.

FORECAST For the vast majority of patients with rheumatoid arthritis, life expectancy is favorable. It worsens with the appearance of clinical signs of vasculitis and the addition of amyloidosis. Relatively worse prognosis for functional state joints is observed in patients with the onset of rheumatoid arthritis under the age of 30 years, with continued activity of the process for more than 1 year from the onset of the disease, in the presence of subcutaneous rheumatoid nodules and a high titer of rheumatoid factor in the blood serum.

Juvenile rheumatoid arthritis

Juvenile rheumatoid arthritis (synonymous with juvenile chronic arthritis) is an independent nosological form, and not a “childhood” variant of rheumatoid arthritis. Children predominantly over 5 years old are affected; girls get sick almost 2 times more often than boys.

Clinical picture. There are two variants of the onset of juvenile rheumatoid arthritis: predominantly articular (monoarthritis, oligoarthritis, polyarthritis) and predominantly systemic (Still and Wissler-Fanconi syndromes). Juvenile rheumatoid arthritis, regardless of the onset of the disease, is characterized by damage to predominantly large and medium-sized joints (knees, ankles, wrists), frequent involvement of the joints of the cervical spine, the development of uveitis, and the extreme rarity of detection of rheumatoid factors in the blood.

The main signs of joint damage in juvenile rheumatoid arthritis are pain, swelling, and morning stiffness. The severity of joint pain in children is usually less than in adults; sometimes complaints of pain, as well as morning stiffness, are absent altogether. More often than others, the knee, ankle, and wrist joints are affected. Approximately 1/3 of patients are involved intervertebral joints cervical spine (especially CII-CIII) with the development of pain and limitation of movements. Arthritis of the temporomandibular joints is often observed.

Characteristic features of juvenile rheumatoid arthritis include slowing physical development, growth retardation, impaired growth of individual segments of the skeleton (in the “zone” of the affected joints), for example, underdevelopment of the lower jaw - microgiatia, shortening or lengthening of the phalanges of the fingers or other bones.

One of the most serious extra-articular manifestations of the disease is chronic uveitis, leading in some cases to blindness. Uveitis more often develops in girls with mono- or oligoarthritis in the presence of antinuclear factor in the blood serum. Eye damage does not correspond to the severity of the articular manifestations of the disease.

In addition to joint damage, Still and Wissler-Fanconi syndromes are characterized by high body temperature (38-39°) and chills. The fever is intermittent, temperature rises are observed 1-2 times a day, more often in the afternoon: it decreases only when prescribed acetylsalicylic acid in large doses or glucocorticosteroids. In Still's syndrome, fever is accompanied by a pinkish rash, localized primarily on the trunk and proximal extremities. This so-called rheumatoid rash “blooms” during a rise in body temperature and when the skin is rubbed (Koebner's sign).

Typical extra-articular manifestations of Still's syndrome are exudative pericarditis (less commonly pleurisy, peritonitis), generalized lymphadenopathy, enlargement of the liver, and sometimes the spleen. Other rarer systemic manifestations include myocarditis, endocarditis (with slow development of mitral and aortic valve insufficiency), pneumonitis, glomerulitis (manifested only by intermittent microhematuria and slight proteinuria).

Rheumatoid subcutaneous nodules, polyneuropathy, digital arteritis, so characteristic of rheumatoid arthritis in adults, occur in only 5-10% of sick children, usually in the presence of rheumatoid factor in the blood serum.

A number of patients with juvenile rheumatoid arthritis with multiple progressive joint damage and systemic manifestations may develop amyloidosis with predominant kidney damage several years after the onset of the disease.

Changes in laboratory parameters are nonspecific. Neutrophilic leukocytosis is characteristic, especially pronounced (up to 15-50 × 109/l) in the systemic variant of the disease. Many patients have normocytic hypochromic anemia, an increase in ESR, an increase in the level of fibrinogen, a2-globulins, the appearance of C-reactive protein. These changes usually correspond to disease activity. Rheumatoid factor in the blood serum is detected in no more than 20% of patients and, as a rule, after a long period of time from the onset of the disease. Antinuclear factor is detected in 40% of patients. The nature of changes in synovial fluid is generally the same as in rheumatoid arthritis, but ragocytes are less common.

In all variants of the onset of juvenile rheumatoid arthritis, the earliest radiological changes in the joints are swelling of the soft periarticular tissues and periarticular osteoporosis, as well as (not always) such a peculiar sign as periostitis, more often in the area of the proximal phalanges of the hands, bones of the metacarpus and metatarsus. Erosive changes and ankylosis of the joints are also observed in juvenile rheumatoid arthritis, but usually after a much longer period than in adults. The rapid development of destructive changes in joints is possible in adolescence, when the growth of the bone skeleton accelerates. A typical radiological sign of juvenile rheumatoid arthritis is spondyloarthritis of the cervical spine with the formation of ankylosis of the intervertebral joints.

Polyarthritis from the very beginning of the disease is observed in 35-50% of patients. The number of joints affected is usually fewer than in rheumatoid arthritis in adults. The onset of the disease can be acute, but more often it is gradual, accompanied by low-grade body temperature, general weakness, decreased appetite, irritability and increased fatigue. Large joints are primarily affected, less commonly small joints of the hands and feet. Generalized lymphadenopathy, hepatosplenomegaly, pericarditis and pneumonitis are possible. The current is usually wavy; exacerbations alternate with incomplete or even complete remissions of varying duration. A number of patients have persistently active polyarthritis, gradually leading to the development of contractures or Still's syndrome.

Mono- or oligoarticular variants of the onset of the disease are observed in approximately 1/3 of patients. Mostly large joints (knee and ankle) are affected. In the mono- or oligoarticular variant of juvenile rheumatoid arthritis, uveitis is most common. In girls who develop juvenile rheumatoid arthritis before the age of 2 years and have antinuclear factor, the risk of developing uveitis is almost 100%. Over time, approximately 20% of patients persistently retain mono- or oligoarthritis, the severity of which can spontaneously change. Characteristic complete remissions, lasting from several months to many years. In a number of patients, the number of affected joints gradually increases, but still usually remains small (2-4 joints, usually large ones). Some patients experience a transition to the polyarticular form.

Diagnosis. The following criteria are proposed early diagnosis: arthritis lasting more than 3 weeks. (mandatory sign): damage to 3 joints during the first 3 weeks. diseases: symmetrical damage to small joints; damage to the cervical spine: effusion in the joint cavity; morning stiffness; tenosynovitis or bursitis; uveitis; rheumatoid nodules: epiphyseal osteoporosis; narrowing of the joint space; compaction of periarticular tissues; increase in ESR more than 35 mm per hour; detection of rheumatoid factor in blood serum; characteristic findings of synovial membrane biopsy. If any 3 criteria are present, the diagnosis of juvenile rheumatoid arthritis is considered probable, 4 - definite, 7 - classic: in all cases, the presence of the first criterion is a prerequisite.

To make a diagnosis of juvenile rheumatoid arthritis, it is also necessary to exclude a fairly large number of diseases accompanied by joint damage. In contrast to rheumatism, systemic lupus erythematosus, and the septic process, juvenile rheumatoid arthritis is characterized by the following clinical features, as the absence (with mono- and oligoarticular variants of the onset of the disease) of pronounced pain in the joints, their redness and disorders general condition patient, as well as the development of uveitis and rheumatoid rash. In contrast to rheumatism, a different nature of heart damage is observed. Isolated pericarditis is typical, but myocarditis and especially endocarditis are not typical; arthritis is more persistent and does not have a migratory nature; an increase in the titer of antistreptolysin-0, although observed in approximately 1/3 of patients, is usually small.

With systemic lupus erythematosus in children, the differential diagnosis is with juvenile R. a. difficult until such typical symptoms of lupus as characteristic erythema, alopecia, and damage to the central nervous system appear. and jade. They also matter laboratory parameters: hypocomplementemia, positive LE test, high titer of antibodies to native DNA, which is not typical for juvenile rheumatoid arthritis (antinuclear factor has no differential diagnostic value).

In differential diagnosis, it should also be taken into account that children more often than adults have arthritis due to rubella, measles, hepatitis B, sepsis, and tuberculosis. It is also necessary to keep in mind that juvenile R. a. can mimic bone tumors and also acute leukemia, some congenital immunodeficiency conditions (usually isolated IgA deficiency, less often deficiency of the 2nd complement component and agammaglobulinemia).

The differential diagnosis is especially difficult for the monoarticular variant of juvenile rheumatoid arthritis: it is carried out with traumatic arthritis; arthritis caused by plant thorns getting into the periarticular tissues; hemophilia; Ehlers-Danlos syndrome, Legg-Calvé-Perthes disease, Osgood-Schlatter disease, etc.

Treatment. In the vast majority of cases, treatment usually begins with the administration of acetylsalicylic acid (75-100 mg/kg per day), which, even in large doses, is well tolerated by children and has a pronounced analgesic and anti-inflammatory effect. After 2-1 weeks. treatment decide on continuing to take this drug or prescribing another non-steroidal anti-inflammatory drug: indomethacin (daily dose 1-3 mg/kg), ortofen (2-3 mg/kg), ibuprofen (20-30 m/kg). The method of intra-articular administration of hydrocortisone and especially triamcinolone acetonide (25-50 mg and 5-20 mg, respectively) has proven itself to be effective.

If there is no sufficient effect from the above treatment after 4-6 months, especially in the case of polyarthritis, the use of slow-acting drugs is indicated. Of these, gold preparations, quinoline derivatives, and penicillamine are usually used. The first injection of gold preparations (cryzanol, etc.) is carried out at the rate of 1 mg of metallic gold (regardless of the child’s body weight). If well tolerated, 5 mg is administered after a week, then injections are made weekly, increasing the dose each time by 5 mg until the average weekly dose is reached, calculated taking into account the patient’s body weight (0.75 mg/kg). If well tolerated, the administration of gold preparations is continued for at least 20 weeks. (total dose is about 15 mg/kg). If a positive result is achieved, therapy is continued further (indefinitely), gradually increasing the intervals between injections to 2-3-4 weeks. Blood and urine tests are performed weekly.

Chingamine and hydroxychloroquine are prescribed in the first 6-8 weeks. at the rate of 5-7 mg/kg per day (no more than 0.2-0.25 g per day), then half the dose is recommended. In this case, regular ophthalmological monitoring is required (once every 3-4 months). The presence of a pronounced positive effect during treatment with these drugs is an indication for continuing their use.

Glucocorticosteroids for oral administration are rarely prescribed for rheumatoid arthritis - only for special indications and usually for short term. Indications for the use of these drugs (preferably prednisolone) are: a systemic variant of the disease with high body temperature, pericarditis and other characteristic extra-articular manifestations in the absence of effect from large doses of acetylsalicylic acid (the initial dose of prednisolone is 0.5-1 mg/kg per day, with when systemic manifestations subside, usually after 2-3 weeks, it is gradually reduced to a minimum and the drug is completely discontinued); presence of intractable uveitis local application glucocorticosteroids (and anticholinergics); pronounced exacerbation of articular syndrome in the polyarticular variant of juvenile rheumatoid arthritis (the dose of prednisolone is usually no more than 10-15 mg per day, and it is divided into several doses).

Long-term use of glucocorticosteroids in patients with juvenile rheumatoid arthritis often and quickly leads to the development of complications (the main one is growth impairment) and does not allow sufficient control of articular manifestations and influence the course of the disease.

Immunosuppressants are used for this disease in extreme cases with the system option.

Physical therapy and massage are of great importance in the treatment of patients with juvenile rheumatoid arthritis in order to develop skeletal muscles, prevent deformities of the limbs and flexion contractures of the joints.

The prognosis for juvenile rheumatoid arthritis is generally relatively good. Many patients experience long-term remissions; the number of affected joints is usually small; Significant functional impairments rarely develop. However, in approximately 1/3 of patients, as a result of chronic progressive arthritis, significant limitations of movement in the joints gradually arise, contractures and ankylosis develop. This is especially often observed in patients with systemic and polyarticular onset of the disease. The development of uveitis and secondary amyloidosis sharply worsens the prognosis.

Source: medkarta.com