Rheumatoid Arthritis: A Personal History. Rheumatoid Arthritis: A Personal Story Synovial fluid examination and biopsy

Rheumatoid arthritis is an autoimmune disease that affects connective tissue and includes systemic complications. The joints are primarily affected - the disease is characterized by symmetric polyarthritis of small joints. Extra-articular symptoms include damage to the muscles, heart, lungs, liver, gastrointestinal tract, etc. Rheumatoid arthritis is severe and causes disability in 70% of patients.

The exact reasons for 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 is diagnosed in parents, then the likelihood of its occurrence in children increases. The rule of genetic predisposition is pronounced in monozygotic twins. Recent studies have identified certain histocompatibility antigens, encoding failures 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 similarities 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 viruses of herpes, rubella, papilloma B 19, etc.
Bacterial agents- recent studies have shown that the ingress 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 illness, and 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 men;
over the age of 45;
with frequent diseases of the respiratory system, arthritis, anomalies in the development of the musculoskeletal system;
with a burdened heredity;
in the presence of the above antigens.

The onset and course of the disease

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

Synoviocytes located in the connective tissue produce a large amount of inflammatory substances (cytokines) and activate special cells of the immune system - T-helpers of the first type.
T-helpers 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 - promotes 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 conversion 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 connective tissue, and when interacting with unchanged immunoglobulins G, they damage the microvasculature of the joint.
The release of endothelial growth factor leads to the additional formation of capillaries in the connective tissue, as well as a specialized tissue called pannus. This tissue has signs of a tumor and is able to grow in the joint cavity, causing its deformation.

Classification of rheumatoid arthritis

To formulate the correct diagnosis, the physician must know the classification of the disease. Clinicians use the international classification of diseases of the 10th revision (ICD-10), which is more convenient for the correct formulation of the 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 articular syndrome:
- monoarthritis- one joint is involved;
- oligoarthritis- inflammation of two joints;
- polyarthritis- involvement of 3 or more joints.
By radiological stages:
- the first- Thickening of the cartilage and walls of the articular bag, small zones of osteoporosis;
- second- the formation of foci of erosion on the cartilage, narrowing of the joint space, the development of an extensive zone of osteoporosis;
- third- deformity 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 up to 30 minutes, during the day, slight pain, moderate swelling of the joints, erythrocyte sedimentation rate (ESR) up to 30 mm / hour, analysis for C-reactive protein (CRP) +;
- average activity- stiffness in the morning, moderate pain (possible without load), severe swelling over the affected area. ESR up to 40 mm / h, CRP ++, increased levels of inflammatory blood enzymes;
- high activity- stiffness in the joints lasts all day, complications in the form of damage to internal organs join, ESR is more than 40 mm / h 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 clinic of rheumatoid arthritis is characterized by the duration of symptoms from 6 to 12 months;
- expanded stage- the disease lasts more than 12 months without pronounced destruction of the joints;
- late stage- pathological processes last more than 2 years with severe deformity of the joints.
By limiting physical activity:
- first degree- preservation of working capacity and habitual way of life;
- second degree- periodic loss from the usual way of life;
- third degree- inability to carry out labor activities.
- fourth degree- lack of opportunity for self-service, disability.
According to laboratory tests for rheumatoid factor:
- - according to the results, the rheumatoid factor is revealed;
- - there is no rheumatoid factor.

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

- is a chronic rheumatoid arthritis that occurs in children with primary involvement of the joints.
- inflammation of the joint capsules. Mainly the shoulder joints are affected.
- a complication in which an increase in the spleen and a decrease in granulocytes in the blood join the clinical picture.

Rheumatoid Arthritis Symptoms

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

Which joints are affected by rheumatoid arthritis

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

The onset of the disease is usually preceded by:

sharp changes in climate - spring or autumn;
transferred ARVI, pneumonia, etc.;
stress or psycho-emotional overstrain;
trauma;
hormonal changes in the body - puberty, or menopause.

When the doctor asks the patient, the so-called prodromal period or the period of precursors, which appears several weeks before the onset of the disease, is often revealed. 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.

A painful symptom 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 soreness increases, forcing a person to see a doctor. Sometimes the disease begins acutely, accompanied by severe joint pain, morning stiffness, fever.

Above the affected joint, you can find:

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

There is also stiffness in the joint. Later, mobility decreases, which ultimately leads to a complete lack of mobility with subsequent deformation of the joint. The most common targets for rheumatoid attack are the joints of the hands and feet, elbows, knees and shoulders. Less often, the hip, sacroiliac and ankle are involved in the pathology. The joints of exception in 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 of the thumb (located at its base).

Rheumatoid damage to the joints of the hand

The goals of rheumatoid lesions are:

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

As a rule, the small joints listed above are the first to be affected. Soreness leads to the fact that the patient is unable to clench the hand into a fist, and the fingers become very swollen. After a few months, the intercarpal muscles begin to atrophy, which leads to the 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 are bent with a deviation towards the little finger. The little finger itself is curved less than the other fingers. Clinicians refer to this deformity as "major fin". Then there is a curvature of the fingers according to the principle of the "swan neck" - the proximal interphalangeal joints of the fingers are bent, and the distal ones are excessively unbent.

Sometimes there are deformities with flexion of the metacarpophalangeal joints and extension of the lower interphalangeal joints (button loop). All of these changes severely disrupt the function of the hand.

Ultimately, pathological changes in the hand can lead to:

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

The result of tenosiviitis is finger swelling and severe soreness. When the branches of the median nerve, which pass near the affected joints, are compressed, loss of sensitivity from 1 to 3 fingers is possible. With prolonged compression, pain can spread to the entire 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.

Radiocarpal rheumatoid arthritis causes 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 of the forearm, as well as the humerus. Therefore, arthritis can involve all three joints that form a complex elbow joint. Local arthritis is accompanied by severe pain during flexion and extension - contracture may develop in an intermediate position. With severe inflammation, it is impossible to perform rotational movements (supination and pronation).
Arthritis of the shoulder joint is characterized by the spread of inflammation to the tendon bursae, the clavicle, and the muscle frame. Puffiness, soreness and limited movement gradually develop.
The 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 the usual shoulder subluxations.

The second target for rheumatoid arthritis after hand injury is the foot. Most often, inflammation develops in the metatarsophalangeal joints of 2-4 fingers and is accompanied by pain when walking, standing on tiptoes, and jumping. Visually, there is a swelling of the dorsum of the foot, hammer-like deformity of the fingers, subluxation of the listed joints, hallux valgus.

Later, inflammation of the synovial bags and synovitis join arthritis, leading to compression of the plantar nerves. An injured effect on the nerves leads to loss of sensitivity in the foot, painful sensations that can rise up to the knee joint.

characterized by pain, swelling in the knees. The pain increases with flexion movements, during squats, when climbing stairs. Often, with severe edema, fluid balloons are noted when the anterolateral region of the knee is touched. Severe pain can lead to the development of contracture in the semi-flexion position, as well as to the protrusion of the joint capsule in the posterior regions (Baker's cyst). Long-term arthralgia of the knee joint forms atrophy of the anterior thigh muscle group.

Damage to the temporomandibular joint

The temporomandibular joint is combined - 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 - due to the difficulty in opening the mouth and pain during chewing, food intake is significantly hampered. This leads to weight loss, nervousness. In severe cases, adjacent 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.

Lesion of the joints of the spinal column

Vertebral joints are rarely involved in the clinical picture of rheumatoid arthritis. Usually arthritis develops at the junction of the head with the first cervical vertebrae (atlantooccipital joint), joints of the first and second cervical vertebrae (median and lateral atlantoaxial 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 prolonged course of the disease, mainly in seropositive patients. Clinicians attribute these pathologies to complications of rheumatoid arthritis, since they develop with systemic effects on the body.

Muscle damage

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

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

Later, myopathy rises and engages the posterior forearm muscles. On the lower limb, the disease attacks the anterior muscles of the thigh and gluteal region. Myopathy is characterized by soreness during muscle contraction, which complicates the movement processes.

Skin changes

With a prolonged course of rheumatoid arthritis, the skin dries out and becomes thinner, numerous hemorrhages appear on the skin all over the body. The nail plates become more brittle, with transverse striation. Small zones of soft tissue death are noted under the nails or near them.

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, in the lung tissue. They are usually formed 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 a suspended level of rheumatoid factor in the blood.

Lymph node involvement

Such a 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 an increase in 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 enlargement of the spleen.

Damage to the stomach, intestines and liver

The defeat of the stomach is characterized by suppression of the synthesis of gastric juice, the formation of numerous erosions and ulcers. The result of such complications are dull pulling pains in the epigastrium, the formation of plaque on the mucous membrane of the tongue, and a decrease in appetite.
Rheumtoid 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 enlarges, its boundaries expand.

Pulmonary complications

The defeat of the lungs in rheumatoid arthritis usually proceeds in parallel with the defeat of their membrane - the pleura. The defeat of the pleura is characterized by inflammatory changes - pleurisy.

Pleurisy can be dry or exudative. In the first case, friction of dry, inflamed pleural layers during breathing causes severe discomfort to the patient. Exudative pleurisy is characterized by the effusion of the liquid part of the blood into the pleural cavity, followed by compression of the lung, which leads to shortness of breath, a feeling of heaviness on the affected side. Damage to the lungs 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 the use of anti-inflammatory drugs.

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

Inflammation of the muscular membrane - myocarditis.
The defeat of the outer shell in the form of pericarditis.
The formation of acquired heart defects with damage to the inner lining of the heart - endocarditis.
Damage to the pericardial vessels - the aorta (aortitis) and coronary arteries (coronary artery).

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 passing the appropriate examination.

Renal complications

Kidney damage in rheumatoid arthritis is carried out with the involvement of the glomerular apparatus in the inflammatory process, which results in the development of rheumatoid glomerulonephritis, 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

Damage to the eyes in rheumatoid arthritis is very rare and is manifested by inflammation of the outer shell of the eyeball - the sclera. Inflammatory changes are characterized by severe painful sensations, dilation of capillaries, and sometimes the formation of small rheumatoid nodules. With combined pathologies, the development of dry conjunctivitis is possible, in which the closing of the eyelid is accompanied by a strong pain sensation.

Complications from the nervous system

Damage to the nervous system is characterized by the following symptoms:

Frequent headaches and dizziness indicate a violation of the blood supply to the brain and encephalopathy.
The reaction to a change in temperature, increased sweating and a change in urine output indicate damage to the autonomic nervous system.
Weakness in the affected limbs, difficulty in movement speaks in favor of ischemic neuropathy.
Stitching pains in the extremities and parasthesias occur when the corresponding nerves are pinched and with neuralgia.

Other complications

If rheumatoid arthritis develops for a long time, there may be associated complications, such as inflammation of the pleura and pericardium, multiple hemorrhages on internal organs.

Establishing diagnosis

Articular lesions occur at a later stage in the development of the disease. Since at the beginning of the disease, the articular syndrome does not appear, the diagnosis of rheumatoid arthritis in the early stages is very difficult.

There are certain criteria for the diagnosis of rheumatoid arthritis:

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

Diagnosis of rheumatoid arthritis is positive when four of the above symptoms are identified. It is important to note that the first four symptoms should persist for one to two months. Synchronous minor arthritis is indisputable evidence of rheumatoid arthritis. To identify the criteria described above, as well as additional diagnostic parameters, laboratory and instrumental research methods are used.

Laboratory methods

Complete blood count - with high activity of the process, anemia may develop (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 the increase in C-reactive protein, fibrinogen, seromucoid, sialic acids, haptoglobin, globulins and a decrease in the level of albumin.
Immunological blood test is one of the informative methods. In favor of rheumatoid arthritis is evidenced by the presence of rheumatoid factor, cryoglobulins. Often, antikeratin antibodies, LE cells, and circulating immune complexes are found in the blood.

Instrumental research methods

Instrumental diagnostics involves the use of methods that allow you to visually determine 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 research is the most informative, since it allows you to identify inflammation and deformity in the joints. The main radiographic signs of rheumatoid arthritis are:

disseminated or focal osteoporosis;
reduction of the joint space;
the appearance of erosion on the articular surfaces.

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

Synovial fluid examination and biopsy

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

Main characteristics of synovial fluid

Differential diagnosis

Differential diagnosis is a careful 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 a lesion of the joints after suffering diseases of an infectious etiology.
Osteoarthritis- a set of diseases of various etiologies with joint damage followed by their 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 old	over 40 years old
Pain symptom	strong	strong	average
Morning stiffness	strong	average	can not be
Symmetry of defeat	is present	absent	absent
Arthritis	permanent	during periods of exacerbation	weak or absent
Joint damage	minor polyarthritis	large on the lower limb	any
The course of the disease	progressing	amenable to therapy	slowly progressing
Muscle atrophy	is present	absent	absent
Infection link	absent	is present	absent
ESR	greatly increased	increased	does not change
Rheumatoid factor	positive	negative	negative
HLA B27 antigen	negative	positive	negative

Treatment

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

Drug therapy

Drug therapy includes symptomatic treatment - needed to relieve pain and basic therapy - the goal of which is to maintain the integrity of the musculoskeletal system and prevent complications.

Relief of pain and inflammation in the joints

The drugs of choice are hormonal pain relievers - glucocorticoids. Symptomatic therapy significantly alleviates the suffering of the patient, but does not cure the underlying disease; when it is canceled, the symptoms gradually recur.
NSAIDs for rheumatoid arthritis are prescribed in the following sequence:

selective NSAIDs- have a minimum of side effects and last for a long time. These drugs are allowed to be taken for a long time - from several months to several years. From this group, the most popular drugs are: Meloxicam, Movalis, Celebrex, Nimesil, Nise, Nimid, Revmoxib.
non-selective NSAIDs- are prescribed when the selective group is ineffective. These drugs have a quick effect, but have significant side effects - especially from the gastrointestinal tract. As their effectiveness and toxicity increase, they are divided into first and second stages. The first stage drugs are Diclofenac, Ibuprofen, Ketoprofen. The second stage is represented by Indomethacin, Ketorolac and Piroxicam.

Attention! In the absence of a positive effect within a maximum of a week, you must contact your doctor to replace the drug.

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

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

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

Basic therapy

Basic therapy for rheumatoid arthritis includes groups of drugs with long-term effects, which significantly slow down destructive changes in connective tissue.

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

The most popular cytostatics:

Arava;
Remicade.

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

The drugs of choice include:

Anakinra;
Aktemra;
Rituximab;
Etanercept;
Humira;
Orencia.

Chondroprotectors- is prescribed to restore cartilage tissue and increase its resistance to autoimmune attacks of rheumatoid arthritis.

These include:

Teraflex;
Arthra;
Alflutop;
Hyaluron.

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

Bitsilin-3;
Penicillamine;
Cycloferon;
Delagil.

Physiotherapy

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

Massage for rheumatoid arthritis is used only during periods of remission, during which soreness significantly decreases, edema subsides, and the patient's general well-being is normalized. The massage is performed by a specialist over the affected joints and surrounding soft tissues.

Useful properties of massage:

improves blood circulation and tissue trophism;
promotes the absorption of exudate into the circulatory system and reduces edema;
prevents local atrophic changes in muscles;
prevents the deposition of calcium salts in the joints;
normalizes movement 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 in 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 the effectiveness is significantly prolonged.

Acupuncture and cryotherapy

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

Traditional medicine and rheumatoid arthritis

As traditional methods of treatment, salt baths, tinctures and decoctions based on leaves and medicinal herbs are used. For salt baths with rheumatoid arthritis, sea or table salt, magnesium sulfate, potassium bromide are used. Taking salt baths helps to normalize blood circulation, improves local metabolism, and reduces swelling of surrounding tissues.

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

Gelatin, ginger and tomatoes also have beneficial properties 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.

Prophylaxis

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

Primary prevention includes:

diagnostics and treatment of infectious diseases;
identification of chronic infection in the body;
strengthening immunity and maintaining a healthy lifestyle.

Secondary prevention implies:

strict adherence to the doctor's recommendations for taking medications, visiting physiotherapy procedures and;
spa treatment during periods of remission;
constant exercise in physiotherapy.

Small joints are primarily affected by rheumatoid arthritis. It usually 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. The joints are swollen and sore. Moreover, the pain intensifies at night, in the morning, and until about noon, a person suffers from unbearable pain. Patients themselves often compare this pain with toothache. However, from a warm-up or just after some kind of vigorous activity, the pain usually diminishes. This is the difference between rheumatoid arthritis and arthrosis, in which the pain increases from physical exertion. In the middle of the day, the pain subsides and by the evening it is almost invisible.

Almost simultaneously with the defeat of the joints of the hands, the joints of the feet also become inflamed. The joints located at the base of the fingers are mainly affected.

Pain and swelling can last for several months.

After a while, from several weeks to several months, the larger joints - ankle, knee, elbow, shoulder, become inflamed. However, in the elderly aged 65-70 years, the disease can begin with damage to large joints and only then inflammation of small joints joins.

Another characteristic symptom of rheumatoid arthritis is morning stiffness. It can be manifested by the feeling of a numb body, and the feeling of tight gloves on the hands. Some patients feel as if their body is in a corset in the morning. In mild forms of the disease, this stiffness continues for about two hours after waking up, in severe forms of stiffness can last the entire first half of the day.

Deformation of the joints, 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 ulnar deformity, it 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 arm at the wrist. Later, the mobility of other compounds also decreases.

Knee joints can not only deform. Quite often, fluid accumulates in the joint cavity. This is called a Baker cyst. This cyst stretches the joint capsule, and in severe cases even ruptures it. Then the liquid is poured into the soft tissues of the lower leg. At the same time, swelling of the lower leg develops, and acute pains appear in the leg.

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

In severe cases, the cricoid-arytenoid joint may be affected. Then the sufferer's voice coarsens, shortness of breath and dysphagia appear. With the defeat of this joint, the patient is increasingly ill with bronchitis.

With rheumatoid arthritis, patients complain of constant weakness, decreased appetite, weight loss up to cachexia (extreme exhaustion), and poor sleep. The temperature rises to subfebrile numbers, this condition is accompanied by chills. However, in some cases, the temperature may rise to 39 ° C. Rheumatoid nodules are often formed on the skin - dense, rounded formations about the size of a pea. Most often they are located below the elbows, on the hands, on the feet. There are usually not many nodules. They can disappear and reappear, or they can 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 can be localized in the lungs (Kaplan's syndrome).

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

Description

Rheumatoid arthritis is a rather serious disease that in a few years turns an able-bodied person into a helpless disabled person. This disease continues for many years. Some people 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, with it they enter the joints, causing their 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 the accumulation of immune cells, lymphocytes around a small area of dead tissue, but it is not known what attracted these cells there, and what happened first - tissue necrosis or the accumulation of immune cells. And what contributes to the activation of lymphocytes is unknown. There are hypotheses that viruses, bacteria, allergies, trauma, heredity and many other factors are to blame for the development of this disease. It is also possible for the onset of the disease after severe stress.

There are many forms of rheumatoid arthritis:

acute polyarthritis , in which the joints of the hands and feet are mainly affected, rheumatoid factor (autoantibodies to immunoglobulins of class G) is often found in the blood;
acute monoarthritis in which large joints are affected;
symmetric 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 affected first, and then, rather quickly, the small joints of the feet or hands are affected;
polyarthritis - a disease that mainly affects young people, for which, in addition to pain in the joints, fever, enlargement of the liver and spleen are characteristic;
palindromic rheumatism - multiple recurrent attacks of acute symmetric polyarthritis of the hands, lasting several hours or days and ending in full recovery;
generalized myalgia begins with stiffness, depression, carpal tunnel syndrome, muscle pain, and joint lesions join later.

There are also special clinical forms of rheumatoid arthritis:

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

With rheumatoid arthritis, osteoporosis develops. And depending on the state 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 near the joint;
Stage III, which is characterized by all the signs of the second stage and bone erosion;
Stage IV combines the signs of the third and ankylosis (complete immobility of the joint, resulting from any changes in it) of the bones.

To find out what stage of the patient's disease is, you can use an X-ray examination.

Rheumatism usually proceeds in waves, with exacerbations and remissions. In less than 10% of cases, this disease is observed spontaneous long-term remission ... In 15% of cases, there is intermittent current , in which spontaneous or treatment-induced remissions alternate with exacerbations, during which previously unaffected joints are captured. In about 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 progressing ... This course is characterized by the 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, the therapist refers the patient to a rheumatologist if the patient has symptoms that last more than 6 weeks, more than three joints are inflamed, or morning stiffness lasts more than 30 minutes.

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

X-ray of the hand, foot, lungs;
densitometry of the spine and femur.

Treatment

For the treatment of rheumatoid arthritis, drugs that suppress the immune system are used. If the drug does not have an effect for three months, it is changed. This is basic therapy. Hormonal preparations 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, special preparations 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 number 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 the reactivity of the blood and the degree of inflammation;
irradiation of lymphoid tissue, in which the lymph nodes, spleen, and thymus gland are successively irradiated;
drainage of the thoracic lymphatic duct, in which the lymph is centrifuged, the cell 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. Also in the early stages, ultraviolet irradiation and electrophoresis with dimethyl sulfoxide are shown. Cryotherapy is often used to relieve pain.

At later stages, phonophoresis with hydrocortisone, impulse currents and magnetotherapy are used.

To restore the functions of the joints, physiotherapy exercises are indicated.

Prophylaxis

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

Secondary prevention is to prevent exacerbations and complications in people with rheumatoid arthritis. It includes physiotherapy exercises, timely intake of necessary medications. It is also important to follow the diet. It is necessary to limit the consumption of fats, sugar, salt, eat more vegetables and fruits, dairy products, cereals.

Rheumatoid arthritis affects the small joints of the hands

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

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

What are the causes of this disease?

The exact causes of rheumatoid arthritis have not yet been established. It is assumed a role in the development of the pathology of some infections: 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, the so-called autoimmune inflammation develops.

What is the clinic for rheumatoid arthritis?

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

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

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

Which joints are affected by rheumatoid arthritis?

Basically, localization is noted on the hands. Moreover, the defeat is always selective, the proximal interphalangeal and metacarpophalangeal joints are much more often involved. But the inflammatory process in the distal interphalangeal joints is much less common.

In addition, in parallel, other joints of the upper extremities can be affected: wrist, elbow. On the lower limbs, 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 are deflected to the radial side, and the fingers to the ulnar, the so-called Z-shaped deformation. Characterized by a limitation of the mobility of the thumb of the hand, due to which the patient cannot grasp small objects.

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

These include: damage to the heart, lungs, pleura, the development of muscle atrophy, rheumatoid nodules. Rheumatoid nodules are small, painless lumps around the affected joint that are not bothersome.

Methods for diagnosing the disease

X-ray of the joints of the hands for arthritis

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

X-ray of the joints;
MRI of the hands;
detection of increased titers of rheumatoid factor in a biochemical study;
antibodies to cyclic citrullineated peptide, it is the most specific indicator of rheumatoid arthritis.

Treatment for rheumatoid arthritis

The first group of drugs used to treat rheumatoid arthritis are non-steroidal 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. The positive thing about their use is that they slow down the progression of the disease, in particular the formation of bone destruction. There are also techniques for their intra-articular administration.

Also, drugs are used that affect the immune stages of inflammation in the joints. These include immunosuppressants, cytostatics, gold preparations, sulfasalazine and others. You need to take them for a long time, many of them have a number of serious side effects.

Of the recently proposed 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 lies in taking blood from a patient and extracting autoimmune complexes from it. The processed 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, the stage of development, 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.

»Which joints are affected in rheumatoid arthritis?

Rheumatoid arthritis is a 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 the destruction of joints and other organs and to an unfavorable prognosis. How to treat rheumatoid arthritis - this is what the pages of this article are about.

I = ""> Causes of rheumatoid arthritis

According to the classics in medicine, the following possible causes of the onset of the disease are distinguished:

Autoimmune processes, the mechanism of which is triggered by genetic factors
Infectious factors:

These can be viruses of the following diseases:

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

The fact that a certain infection could be the cause of rheumatoid arthritis is indicated by a reactive reaction of an increase in the erythrocyte sedimentation rate. But the applied bacterial therapy too often does not bring results, which gives some reason to doubt the reliability of the infectious theory.

Provoking (triggering 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 of its multiple symptoms at once.

In the first stage, local swelling and pain occurs near the joint, and the temperature on the skin surface may also rise

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

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

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

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

In the photo - the stages of rheumatoid arthritis:

I-3 = ""> Symptoms of the disease

There is something in common, regardless of the cause of arthritis, 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 by itself, rheumatoid factor does not mean the presence of arthritis, since it can be found in some infectious diseases, chronic hepatic pathologies and even in healthy people.

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

They can be divided into three groups:

Common Symptoms

Fatigue, weakness and weakness
Flu symptoms, including fever and joint aches
Dryness of the mucous membrane 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 the joints according to the symmetrical type:

Rheumatoid arthritis initially affects the small joints on both hands or feet and then progresses to larger joints.
The following types of joints are primarily affected:

second and third metacarpophalangeal
proximal interphalangeal
knee
wrist
ulnar
ankle

Joint contracture (limited range of motion)

Swelling of the extremities

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

In the photo - rheumatoid arthritis of the foot:

I-6 = ""> Extra-articular symptoms

Rheumatoid arthritis gives rise to just a grandiose number of all kinds of symptoms and syndromes. The forms of its clinical manifestation are varied. This inflammatory joint disease affects:

On the cardiovascular and respiratory systems, causing:

Pericarditis, atherosclerosis, vasculitis, heart and respiratory failure, pleurisy, pulmonary fibrosis

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, hypotrophy, uneven reticular skin coloration

In the photo - 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 refers to 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, such a disease is called articular-visceral
If the disease occurs before the age of 16, then such arthritis is called juvenile
The combination of several signs at once is called a syndrome.

Syndromes in rheumatoid arthritis

Still's Syndrome:

Seronegative juvenile rheumatoid arthritis with erymatous rash, elevated leukocytes, ESR, and swollen lymph nodes

Pseudoseptic syndrome:

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

In the background are the symptoms of arthritis.

Allergoseptic syndrome:

The onset of the disease is stormy:

Fever up to 40 ° C, polymorphic rash, arthralgia, joint swelling

Possible heart problems and enlarged liver

This syndrome is common in juvenile arthritis.

Felty's syndrome:

Polyarthritis combined with splenomegaly (enlarged spleen)

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

The disease is usually associated with skin ulcers 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 resembles many diseases in its symptoms.:

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 the erythrocyte sedimentation rate (ESR) and platelets
determination of the titer of antibodies to the cyclic peptide ACCP (rheumatoid factor)

Identification of markers of articular syndromes

General clinical signs

Specific signs:

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

Skin color

X-ray examination of joints

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

Adverse signs

Adverse signs are:

Consistent involvement of new joints in the process with each new attack
Growth of ESR and antibody titers
Patient's failure to respond to basic medications
Early and rapid joint destruction visible on x-ray

In the photo - an X-ray of the affected joint:

I-11 = ""> Treatment of rheumatoid arthritis

If the diagnosis reveals an injection, then antibacterial treatment is predominant.

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

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

Of course, you can choose aspirin, and diclofenac, and ibuprofen, which are related to COX-1 inhibitors (cyclooxygenase, which synthesizes prostaglandins, through which inflammation occurs).
But the duration of the treatment of arthritis dictates the need to take drugs of 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 injected into the affected joints

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

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

Basic drugs

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

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

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

The following drugs are used:

Sulfasalazine, penicillamine, leflunomide, aminoquinol, etc.

I-14 = ""> Complex therapy

How is rheumatoid arthritis cured?

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

Nevertheless, the main thread of treatment:

The use of NSAIDs and corticosteroids for exacerbation of pain and inflammation
Reception of basic medicinal preparations:

Methotrexate, sulfasalazine, D-penicillamine

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

Cyclophosphamide, cyclosporine, azathioprine

Reception of biological genetically engineered drugs:

Drugs that block harmful synovial enzymes:

TNF (tumor necrosis factor) inhibitors:

infliximab, etanercept, etc.

B-lymphocytes:

Actemra (tocilizumab), Mabthera (rituximab)

Surgery

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

The operation becomes especially important in case of instability in the cervical spine, which threatens the spinal cord.

The main surgical method is arthrodesis, that is, artificial ankylosis of the vertebrae.

Additional measures

In addition, to fight rheumatoid arthritis you need:

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

taking calcium preparations 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

Impact of pregnancy on the course of the disease

Of course, for a young woman, such a formidable 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?

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

The joints commonly affected by rheumatoid arthritis are the joints of the wrists, hands, feet, and ankles. The disease can affect the elbow, shoulder, hip, knee, neck and jaw joints.

Usually, joints on both sides of the body are affected at the same time, for example, the joints of both hands. The joints of the arms and legs are most commonly affected.

Extra-articular signs and symptoms also occur in rheumatoid arthritis. Unlike osteoarthritis, which affects only 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 the same time, 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 the back of the head. These nodules, usually painless, range in size from a pea to a walnut.

"What joints are affected in rheumatoid arthritis" and other articles from the Arthritis section

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

Signs

Almost simultaneously with the defeat of the joints of the hands, the joints of the feet also become inflamed. The joints located at the base of the fingers are mainly affected.

Pain and swelling can last for several months.

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

Description

There are many forms of rheumatoid arthritis:

acute polyarthritis , in which the joints of the hands and feet are mainly affected, rheumatoid factor (autoantibodies to immunoglobulins of class G) is often found in the blood;
acute monoarthritis in which large joints are affected;
symmetric 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 affected first, and then, rather quickly, the small joints of the feet or hands are affected;
polyarthritis - a disease that mainly affects young people, for which, in addition to pain in the joints, fever, enlargement of the liver and spleen are characteristic;
palindromic rheumatism - multiple recurrent attacks of acute symmetric polyarthritis of the hands, lasting several hours or days and ending in full recovery;
generalized myalgia begins with stiffness, depression, carpal tunnel syndrome, muscle pain, and joint lesions join later.

There are also special clinical forms of rheumatoid arthritis:

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

With rheumatoid arthritis, osteoporosis develops. And depending on the state 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 near the joint;
Stage III, which is characterized by all the signs of the second stage and bone erosion;
Stage IV combines the signs of the third and ankylosis (complete immobility of the joint, resulting from any changes in it) of the bones.

To find out what stage of the patient's disease is, you can use an X-ray examination.

Diagnostics

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

Treatment

Prevention of osteoporosis is also of great importance. For this, special preparations 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 number 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 the reactivity of the blood and the degree of inflammation;
irradiation of lymphoid tissue, in which the lymph nodes, spleen, and thymus gland are successively irradiated;
drainage of the thoracic lymphatic duct, in which the lymph is centrifuged, the cell sediment is separated, and the liquid part of the lymph is returned back to the lymphatic duct.

At later stages, phonophoresis with hydrocortisone, impulse currents and magnetotherapy are used.

To restore the functions of the joints, physiotherapy exercises are indicated.

Prophylaxis

Rheumatoid arthritis- systemic inflammatory disease of the connective tissue with a predominant lesion of the joints of the type of chronic progressive erosive-destructive polyarthritis. Occurs in all climatogeographic 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 environmental influences, subject to a genetic predisposition. Some infectious agents are considered among the possible etiological factors; group B. streptococci, mycoplasma, retroviruses, Epstein-Barr virus.

At the heart of rheumatoid arthritis is a chronic inflammatory process in the synovial membrane of the joints, due to the development of a local immune reaction with the formation of aggregated immunoglobulins (mainly IgG-class), to the Fc receptors of which autoantibodies are formed, called rheumatoid factors.
Autoantibodies can form immune complexes by connecting with both the C1g component of the complement and with other proteins. Immune complexes, getting into the synovial fluid, are phagocytosed by neutrophils, which are destroyed in the process of phagocytosis. As a result, various lysosomal enzymes are released that can activate inflammatory mediators - kinins, prostaglandins, complement components that have anaphylactogenic, cytotoxic and chemotactic properties. The latter promotes the influx of a large number of neutrophils into the joint cavity, which enhances 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, secrete various lymphokines, which have a damaging effect on the joint tissues and contribute to the formation of granulomas (rheumatoid nodules). The pathogenesis of most extra-articular (systemic) manifestations of rheumatoid arthritis is associated with the development of immunocomplex vasculitis, as well as with direct damage to various tissues by activated lymphocytes and autoantibodies.

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

In a small proportion of patients, rheumatoid arthritis can begin acutely. High "causeless" fever with chills is the first and most pronounced symptom of this variant of the disease. The clinical picture is also determined by the symptoms of intoxication and such systemic manifestations as serositis, carditis, enlarged lymph nodes, liver, spleen, as well as leukocytosis, increased ESR.
Signs of arthritis may initially be absent (there are only polyarthralgias) or are moderately pronounced. Only after a few weeks or even months does persistent articular syndrome become evident. In the future, especially under the influence of treatment, there may be a transformation into the classic version of the course of rheumatoid arthritis, but often a tendency towards an aggressive course persists with persistence during an exacerbation of fever.

A rare variant of the onset of rheumatoid arthritis is recurrent arthritis. There is an acute or subacute development of arthritis of one or several joints, which pass 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. Very 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.
In this case, the defeat of the joints develops later.

Articular syndrome forms the basis of the clinical picture. Almost any joints can be involved in the pathological process, as well as periarticular tissues (ligaments, tendons, muscles, etc.). The most characteristic of rheumatoid arthritis is the tendency to the development of erosive polyarthritis with symmetrical joint damage and deformation. Typical of rheumatoid arthritis is arthritis of the proximal interphalangeal joints, which results in fusiform fingers, and inflammation of the metacarpophalangeal joints. Inflammation of the wrist, metacarpal, wrist, and intercarpal joints is common. One of the early symptoms of rheumatoid arthritis is a decrease in the mass of the interosseous muscles on the back of the hand, due to a decrease in their functional activity, less often myositis.

Tendon damage and muscle changes play a leading role in the formation of persistent hand deformities: lateral deviation of the fingers, deformities of the toe of the "button loop" type (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". In the area of the elbow joints, rheumatoid nodules may be found. Most often they are located in the region of the olecranon and the proximal part of the ulna. The nodules are usually painless, moderately dense, and small in size.

Metatarsophalangeal arthritis is almost common in rheumatoid arthritis. The consequence of persistent arthritis of these joints is hammer-shaped deformity of the fingers, subluxation of the heads of the metatarsal bones towards the soles of the feet, deflection of the fingers outward. As a result of these changes, flat feet are formed, painful corns, hallux valgus and bursitis occur in the region of the first metatarsophalangeal joint. The complex of these changes is called "rheumatoid foot". Ankle arthritis is common and can lead to varus deformity of the foot.

With the defeat of the knee joints, atrophy of the quadriceps muscle of the thigh begins early. In a number of patients, a clear deformation of the joint may be associated not with effusion into its cavity, but with a thickening of the periarticular tissues. Fibrous changes in the joint capsule, muscle tendons attached to the knee joint, can lead to the development of flexion contractures. Sometimes synovial fluid accumulates mainly in the posterior parts of the joint - Baker's cyst develops, sometimes reaching large sizes.

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

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

In rheumatoid arthritis, joint subluxations, flexion contractures, and bone ankylosis (more often in the intercarpal and wrist joints, less often in the proximal interphalangeal joints and joints of the feet) can develop.

Pain, a feeling of stiffness in the cervical spine are frequent complaints of patients with rheumatoid arthritis. A rare feature of lesions of the cervical spine in rheumatoid arthritis is the development of subluxation in the atlanto-axial joint due to softening and thinning of the transverse ligament of the atlas. Subluxation of other cervical vertebrae (more often CIII-CIV) can lead to trauma to the spinal cord, which manifests itself in mild cases only by fatigue when walking, paresthesias, and in severe cases - by sensory disturbances and movement disorders, up to tetraplegia.

Polyneuropathy is a manifestation of vasculitis of the vessels supplying the peripheral nerves. Characterized by damage to the distal nerve trunks, most often the peroneal nerve, with the development of sensitivity disorders. Patients are worried about numbness, burning, chilliness in the distal 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 are less common. As a rule, polyneuropathy is observed in patients with seropositive R. and. 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 basin of the pulmonary, cerebral, coronary or mesenteric vessels.

Heart damage in rheumatoid arthritis is manifested more often by pericarditis and myocarditis, mainly granulomatous, focal. It is extremely rare that heart defects (mitral or aortic valve insufficiency) can form.

Rheumatoid lung damage includes: diffuse fibrosing alveolitis, nodular lesion of logical tissue, vasculitis. Serositis (more often pleurisy, pericarditis) is detected only by X-ray examination (moderately pronounced adhesive process).

Rheumatoid kidney disease (glomerulonephritis) is less common. than amyloidosis and drug nephropathy, and is characterized by moderate proteinuria and microhematuria.

The combination of rheumatoid arthritis with lesions of 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 lung disease is called Kaplan's syndrome.

One of the most serious complications of rheumatoid arthritis is amyloidosis. It develops in 10-15% of patients, as a rule, 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 the Felty, Kaplan and Sjogren syndromes. Distinguish between seropositive (in the presence of rheumatoid factor in the blood serum) and seronegative (in the absence) rheumatoid arthritis. The presence of rheumatoid factors (antiglobulin antibodies of various classes of immunoglobulins), especially in a high titer, is not only diagnostic, but also prognostic in rheumatoid arthritis.

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

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

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

X-ray changes, especially early detected in the joints of the hands and feet, are also of great diagnostic value. The main signs are periarticular epiphyseal osteoporosis, narrowing of the joint space, the development of marginal bone erosions (usur). Periarticular osteoporosis is characterized by a uniform decrease in bone density; The trabecular pattern of the epiphyses, which is clearly visible in the norm, is noticeably "blurred". Narrowing of the joint space at R. and. occurs evenly throughout. The earliest erosive changes in articular surfaces in rheumatoid arthritis are noted in the proximal interphalangeal, metacarpophalangeal (more often in the heads of the II-III metacarpal bones) joints, wrist bones, in the wrist joint (especially in the area of the styloid process in the ulna plus bones. From a diagnostic point of view, it is important that bone erosion in rheumatoid arthritis is always observed simultaneously with a 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 pineal glands can be observed. In some cases, they are caused by the development of rheumatoid granulomas in the bone tissue.

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

Early diagnosis of rheumatoid arthritis is often difficult because a complex of characteristic signs 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 such diseases as ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, osteoarthritis, gout.

In the differential diagnosis with ankylosing spondylitis, the detection of X-ray 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 of decisive importance. In Reiter's syndrome, the frequency of detection of the B27 histocompatibility antigen is also increased, but unlike ankylosing spondylitis and rheumatoid arthritis, there are characteristic urological (urethritis, balanitis), ocular (conjunctivitis) and skin (keratodermia blenorhagica) manifestations. At differential diagnosis of these diseases with R. and. it is necessary to take into account their development mainly in young men, which is less characteristic of rheumatoid arthritis.

The defeat of the joints 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 can be noted in these patients inconsistently and localized only on rarely examined parts of the body (for example, on the scalp).

Secondary synovitis in osteoarthritis with a predominant lesion of 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 precisely 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, it becomes necessary to carry out a differential diagnosis with systemic lupus erythematosus, Sjogren's disease, reactive arthritis, sarcoidosis, tuberculous arthritis, pyrophosphate arthropathy.

TREATMENT
For the treatment of rheumatoid arthritis, various methods have been proposed, 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 systemic treatment of rheumatoid arthritis, as a rule. 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). These are fast-acting drugs, the maximum therapeutic effect of which is revealed in 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 suspensions, but preferably long-acting drugs - kenalog, depot-medrol) is widely used, especially with a small number of affected joints. The appointment of oral corticosteroid preparations is absolutely indicated only for patients with generalized vasculitis, especially with febrile reactions. Usually, prednisolone is used, the dose of which is selected individually (on average, 15-20 mg per day). In all other cases, the appointment of corticosteroids should be approached as a forced and, most importantly, a temporary measure. The need for this arises, as a rule, with multiple joint lesions with severe pain syndrome that does not decrease under the influence of nonsteroidal anti-inflammatory drugs and intra-articular administration of corticosteroids. The initial daily dose of prednisone in such situations is 10-15 mg. When the activity subsides, it is necessary in all cases to try to gradually reduce the dose and completely cancel the drug, using long-acting agents for this purpose.

The 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 question of prescribing one of the following agents is considered: hingamine, hydroxychloroquine, gold preparations, penicillamine, salazosulfapyridine. According to the therapeutic effect, the first place is occupied by gold preparations. Hingamin is used at 0.25 g per day, hydroxychloroquine (Plaquenil) - 0.2 g per day. Moreover, once every 3-4 months. examination of the patient by an ophthalmologist is necessary to prevent complications from the organs of vision. Chrysanol is administered intramuscularly at the rate of 17-34 mg of metallic gold per injection (1 ml of 5% chrysanol solution contains 17 mg of gold). Penicillamine is prescribed at 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 chrysanol and penicillamine, it is necessary to conduct weekly urine and blood tests in order to diagnose and prevent the development of drug nephropathy and cytopenias. In recent years, salazosulfapyridine and salazopyridazine (2 g per day) have been widely used.

The results of 3-6 months of continuous treatment with any of the slow-acting drugs determine the further tactics of using these drugs. A significant improvement in the patient's condition is the basis for continuing treatment during that period of time (sometimes many years) while the achieved effect is maintained. In the absence of a positive result of treatment, another drug of this group is prescribed.

Immunosuppressants, also referred to as long-acting drugs for the treatment of rheumatoid arthritis, are used, as a rule, in the last place, when other basic drugs are ineffective. However, in some cases with a rapidly progressive course, persistent high titers of rheumatoid factor in the blood, as well as the presence of signs of systemicity (rheumatoid nodules, polyneuropathy, etc.), immunosuppressants are the drugs of choice. With rheumatoid arthritis (usually methotrexate is used in medium doses (5-7.5-10 mg per week), less often clorbutin (daily dose 5-10 mg). Preference is given to methotrexate because of its better tolerance. However, when this drug is prescribed to patients who have had hepatitis in the past, abuse alcohol, the possibility of toxic liver damage should be taken into account.

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 especially pronounced vasculitis, 500-1000 mg of cyclophosphamide are administered simultaneously with methylprednisolone in one and three days. In Felty's syndrome, gold preparations or methotrexate in combination with prednisolone are prescribed with great caution.

Physiotherapy treatments for rheumatoid arthritis are of secondary importance. The most widely used are phonophoresis of hydrocortisone and thermal procedures (applications of paraffin or ozokerite). Mud and balneotherapy are more effective with minimal disease activity and in most cases only complement drug therapy.

Physical therapy is of great importance, classes of which should be carried out by patients with rheumatoid arthritis every day and are limited only with high disease activity and a significantly pronounced pain syndrome. When the activity of rheumatoid arthritis subsides, a therapeutic massage is indicated for most patients.

Surgical treatment is used for rheumatoid arthritis to maintain, 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 (prophylactic) and restorative-reconstructive surgical treatment are conditionally distinguished. The early ones include surgical interventions such as synovectomy, tenosynovectomy, in which the pathologically altered synovial membrane of the joint or the tendon sheath is excised. As a result, in many patients the inflammatory process is persistently stopped: within a period of up to 5 years, good results of early synovectomy of the knee joint are preserved in about 80% of patients.

Reconstructive and restorative operations are performed in the later stages of the disease, incl. in the presence of persistent deformities of the joints that reduce the function of the musculoskeletal system. This group of surgical interventions includes extended synovapsulectomy, 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 syndrome, depending not only on the inflammatory process, but also on mechanical causes associated with destructive and reparative changes. With flexion contractures, corrective operations such as capsulotomy and osteotomy are used.

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

FORECAST favorable for life in the overwhelming majority of patients with rheumatoid arthritis. It worsens with the appearance of clinical signs of vasculitis and the addition of amyloidosis. A comparatively worse prognosis in relation to the functional state of the joints is observed in patients with the onset of rheumatoid arthritis at the age of up to 30 years, with the 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 (synonym for juvenile chronic arthritis) is an independent nosological form, not a "childish" variant of rheumatoid arthritis. Children mainly over 5 years old get sick; girls get sick almost 2 times more often than boys.

The 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). For juvenile rheumatoid arthritis, regardless of the variants of the onset of the disease, it is characterized by the defeat of mainly large and medium joints (knee, ankle, wrist), frequent involvement of the joints of the cervical spine, the development of uveitis, the extremely rare detection of rheumatoid factors in the blood.

The main signs of joint damage in juvenile rheumatoid arthritis are pain, swelling, 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 generally absent. More often, the knee, ankle, and wrist joints are affected. In about 1/3 of patients, the intervertebral joints of the cervical spine (especially CII-CIII) are involved with the development of pain and limitation of movement. Arthritis of the temporomandibular joints is common.

The characteristic features of juvenile rheumatoid arthritis include retardation of 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 - microhyatia, shortening or lengthening of the phalanges of fingers or other bones.

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

The Still and Wissler-Fanconi syndromes, in addition to joint damage, are characterized by high body temperature (38-39 °) and chills. The fever is intermittent, the temperature rises 1-2 times a day, more often in the second half of the day: it decreases only with the appointment of acetylsalicylic acid in large doses or glucocorticosteroids. In Still's syndrome, fever is accompanied by a pinkish rash, localized mainly on the trunk and proximal extremities. This so-called rheumatoid rash "blooms" when the body temperature rises and when the skin is rubbed (Kebner's symptom).

Typical extra-articular manifestations of Still's syndrome are exudative pericarditis (less often pleurisy, peritonitis), generalized lymphadenopathy, enlarged liver, and sometimes spleen. Among other more rare systemic manifestations, myocarditis, endocarditis (with the slow development of mitral and aortic valve insufficiency), pneumonitis, glomerulitis (manifested only by intermittent microhematuria and slight proteinuria) are described.

Rheumatoid subcutaneous nodules, polyneuropathy, digital arteritis, so characteristic of rheumatoid arthritis in adults, occur only in 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 renal damage several years after the onset of the disease.

Changes in laboratory parameters are nonspecific. Characterized by neutrophilic leukocytosis, especially pronounced (up to 15-50 × 109 / l) in the systemic variant of the disease. In many patients, normocytic hypochromic anemia, an increase in ESR, an increase in the level of fibrinogen, a2-globulins, and the appearance of C-reactive protein are noted. These changes usually correspond to the activity of the disease. The 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 found 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 X-ray changes in the joints are edema of the soft periarticular tissues and periarticular osteoporosis, as well as (not always) such a peculiar symptom as periostitis, more often in the region of the proximal phalanges of the hands, metacarpal bones 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 the joints is possible in adolescence, when the growth of the bone skeleton is accelerating. Spondyloarthritis of the cervical spine with the formation of ankylosis of the intervertebral joints is considered a typical radiological sign of juvenile rheumatoid arthritis.

From the very onset of the disease, polyarthritis is observed in 35-50% of patients. The number of joints affected is usually less than in adult rheumatoid arthritis. The onset of the disease can be acute, but more often it is gradual, accompanied by subfebrile body temperature, general weakness, decreased appetite, irritability and increased fatigue. First of all, large joints are affected, less often small joints of the hands and feet. Generalized lymphadenopathy, hepatosplenomegaly, pericarditis, and pneumonitis are possible. The current is usually undulating; exacerbations alternate with incomplete or even complete remissions of varying duration. In a number of patients, persistently active polyarthritis is noted, gradually leading to the development of contractures or Still's syndrome.

Mono- or oligoarticular variants of the onset of the disease are observed in about 1/3 of patients. Large joints (knee and ankle) are mainly affected. Uveitis is most common in mono- or oligoarticular juvenile rheumatoid arthritis. In girls with the development of juvenile rheumatoid arthritis before the age of 2 years and the presence of an antinuclear factor, the risk of developing uveitis is almost 100%. Over time, in about 20% of patients, mono- or oligoarthritis persists, the severity of which can spontaneously change. Complete remissions are characteristic, 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, more often large ones). In some patients, a transition to a polyarticular form is noted.

Diagnosis. The following criteria for early diagnosis were proposed: arthritis lasting more than 3 weeks. (mandatory sign): damage to 3 joints during the first 3 weeks. diseases: symmetrical lesion of 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; an increase in ESR of more than 35 mm per hour; detection of rheumatoid factor in blood serum; characteristic data from a biopsy of the synovium. In the presence of any 3 criteria, 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 quite a large number of diseases accompanied by joint damage. In contrast to rheumatism, systemic lupus erythematosus, a septic process, juvenile rheumatoid arthritis is characterized by such clinical features as the absence (with a mono- and oligoarticular variant of the onset of the disease) of pronounced pain in the joints, their redness and disorders of the general condition of the patient, as well as the development of uveitis and rheumatoid rash. Unlike rheumatism, a different nature of heart damage is observed. Isolated pericarditis is typical, and myocarditis and even more so endocarditis are not typical; arthritis is more persistent and does not have a migratory character; an increase in the titer of antistreptolysin-0, although observed in about 1/3 of patients, is usually small.

With systemic lupus erythematosus in children, the differential diagnosis with juvenile R. and. difficult until such typical lupus symptoms as characteristic erythema, alopecia, and c.s.s. and jade. Laboratory indicators are also important: 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 borne in mind that children more often than adults have arthritis with rubella, measles, hepatitis B, sepsis, and tuberculosis. It is also necessary to keep in mind that juvenile R. and. can mimic bone tumors, as well as acute leukemia, some congenital immunodeficiency states (more often isolated IgA deficiency, less often deficiency of the second complement component and agammaglobulinemia).

Differential diagnosis is especially difficult in case of a monoarticular variant of juvenile rheumatoid arthritis: it is carried out with traumatic arthritis; arthritis caused by the penetration of plant thorns into the periarticular tissues; hemophilia; Ehlers-Danlos syndrome, Legg-Calve-Perthes disease, Osgood-Schlatter disease, etc.

Treatment. In the overwhelming majority of cases, treatment usually begins with the appointment 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 whether to continue taking this drug or to prescribe 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 well.

In the absence of a 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 (krizanol, etc.) is carried out at the rate of 1 mg of metallic gold (regardless of the child's body weight). With good tolerance, 5 mg is administered a week later, then injections are performed weekly with an increase in the dose of 5 mg each time until the average weekly dose is reached, calculated taking into account the patient's body weight (0.75 mg / kg). The introduction of gold preparations with good tolerance is continued for at least 20 weeks. (the total dose is about 15 mg / kg). When 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 done weekly.

Hingamin 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 control is required (once every 3-4 months). The presence of a pronounced positive effect in the treatment of these drugs is an indication for the continuation of their intake.

Glucocorticosteroids for oral administration are rarely prescribed for rheumatoid arthritis - only for special indications and usually for a short period. The indications for the appointment of these drugs (preferably prednisone) are: a systemic variant of the disease with high body temperature, pericarditis and other characteristic extra-articular manifestations in the absence of effect from high doses of acetylsalicylic acid (the initial dose of prednisolone is 0.5-1 mg / kg per day, with subsiding of systemic manifestations, usually after 2-3 weeks, it is gradually reduced to a minimum and the drug is completely canceled); the presence of uveitis, which is not relieved by the local use of glucocorticosteroids (and anticholinergics); pronounced exacerbation of articular syndrome in 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 disorders), does not allow sufficient control of articular manifestations and influence the course of the disease.

Immunosuppressants are used in this disease in extreme cases with a systemic variant.

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

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

Source: medkarta.com