Rheumatism – inflammatory infectious and allergic system defeat of connecting fabric of various localization, mainly heart and vessels. Typical rheumatic fever is characterized by temperature increase of a body, multiple symmetric artralgiya of flying character, polyarthritis. Further the ring-shaped eritema, rheumatic small knots, rheumatic a trochee, the phenomenon of a revmokardit with defeat of valves of heart can join. From laboratory criteria of rheumatism positive SRB, increase in a caption of streptococcal antibodies have the greatest value. In treatment of rheumatism NPVS, kortikosteroidny hormones, immunodepressants are used.
Rheumatism (rheumatic fever)
Rheumatism (synonyms: rheumatic fever, Sokolsky's disease — Buyo) proceeds chronically, with tendency to a recurrence, aggravations come in the spring and in the fall. About 80% of the acquired heart diseases are the share of a share of rheumatic damage of heart and vessels. In rheumatic process often are involved joints, serous covers, skin, the central nervous system. Frequency of incidence of rheumatism makes from 0,3% to 3%. Rheumatism usually develops at children's and teenage age (7-15 years); children of preschool age and adults get sick much less often; 3 times more often female persons have rheumatism.
Reasons and mechanism of development of rheumatism
The rheumatic attack is usually preceded by the streptococcal infection caused by a β-hemolytic streptococcus of group A: scarlet fever, tonsillitis, maternity fever, sharp otitis, pharyngitis, ugly face. At 97% of the patients who had a streptococcal infection the resistant immune answer is formed. At other persons of resistant immunity it is not developed, and at repeated infection with a β-hemolytic streptococcus difficult autoimmune inflammatory reaction develops.
Development of rheumatism is promoted by the reduced immunity, young age, big collectives (schools, boarding schools, hostels), unsatisfactory social conditions (food, housing), overcooling, the burdened family anamnesis.
In response to introduction of a β-hemolytic streptococcus in an organism anti-streptococcal antibodies ( - Oh, an antistreptogialuronidaza, anti-streptokinase, an anti-deoxyribonuclease In) which together with anti-genes of a streptococcus and components of system of a complement form immune complexes are developed. Circulating in blood, they are carried on an organism and settle in fabrics and bodies, mainly in cardiovascular system. In places of localization of immune complexes process of an aseptic autoimmune inflammation of connecting fabric develops. Anti-genes of a streptococcus have the expressed cardiotoxic properties that leads to education autoantitet to a myocardium, even more aggravating an inflammation. At repeated infection, cooling, stressful influences pathological reaction is fixed, promoting the recidivous progressing course of rheumatism.
Processes of disorganization of connecting fabric at rheumatism take place several stages: mukoidny swelling, fibrinoidny changes, granulematoz and sclerosis. In an early, reversible stage of mukoidny swelling hypostasis, swelling and splitting of collagenic fibers develops. If at this stage of damage are not eliminated, then there occur the irreversible fibrinoidny changes which are characterized by a fibrinoidny necrosis of fibers of collagen and cellular elements. In a garnulematozny stage of rheumatic process around zones of a necrosis specific rheumatic granulomas are formed. The final stage of a sclerosis is an outcome of a granulematozny inflammation.
Duration of each stage of rheumatic process makes from 1 to 2 months, and all cycle – about half a year. A recurrence of rheumatism promotes emergence of repeated fabric defeats in a zone of already available hems. Defeat of tissue of heart valves from the outcome in a sclerosis leads to deformation of shutters, their union among themselves and serves as the most frequent reason of the acquired heart diseases, and the repeated rheumatic attacks only aggravate destructive changes.
Classification of rheumatism
Clinical classification of rheumatism is made taking into account the following characteristics:
- Disease phases (active, inactive)
In an active phase three degrees are allocated: I – activity is minimum, II– activity moderate, III – activity high. In the absence of clinical and laboratory signs of activity of rheumatism, speak about its inactive phase.
- Current option (sharp, subsharp, long, latent, recurrent rheumatic fever)
At a sharp current rheumatism attacks suddenly, proceeds with sharp expressiveness of symptoms, is characterized by a polisindromnost of defeat and high degree of activity of process, bystry and effective treatment. At the subsharp course of rheumatism duration of the attack makes 3-6 months, the symptomatology is less expressed, activity of process moderate, efficiency from treatment is expressed to a lesser extent.
The long option proceeds with long, more than semi-annual rheumatic attack, with sluggish dynamics, monosyndromic manifestation and low activity of process. Lack of clinical laboratory and tool data is peculiar to a latent current, rheumatism is diagnosed retrospectively, on already created heart disease.
Continuously recidivous option of development of rheumatism is characterized wavy, with bright aggravations and incomplete remissions by the current, a polisinromnost of manifestations and quickly progressing damage of internals.
- Kliniko-anatomichesky characteristic of defeats:
- with a heart involvement (revmokardit, ), with development of heart disease or without it;
- with an involvement of other systems (rheumatic damage of joints, lungs, kidneys, skin and hypodermic cellulose, neurorheumatism)
- Clinical manifestations (carditis, polyarthritis, ring-shaped eritema, trochee, hypodermic small knots)
- Conditions of blood circulation (look: degrees of chronic heart failure).
Rheumatism symptoms extremely of a polimorfna also depend on degree of sharpness and activity of process, and also an involvement into process of various bodies. The typical clinic of rheumatism has direct link with the postponed streptococcal infection (tonsillitis, scarlet fever, pharyngitis) and develops 1-2 weeks later after it. The disease begins sharply with the subfebrilny temperature (38 — 39 °C), weakness, fatigue, headaches, perspiration. To one of early displays of rheumatism serve artralgiya - average or large joint pains (talocrural, knee, elbow, humeral, luchezapyastny).
At rheumatism of an artralgiya carry multiple, symmetric and flying (pains disappear in one and appear in other joints) character. The swelling, puffiness, local reddening and temperature increase, sharp restriction of movements of the affected joints is noted. The course of rheumatic polyarthritis is usually good-quality: in several days sharpness of the phenomena abates, joints are not deformed though moderate morbidity can remain for a long time.
1-3 weeks later the rheumatic carditis joins: heartaches, heartbeat, interruptions, short wind; asthenic syndrome (indisposition, slackness, fatigue). Damage of heart at rheumatism is noted at 70-85% of patients. At a revmokardita all or separate covers of heart inflame. There is a simultaneous defeat of an endokard and a myocardium (endomyocarditis), sometimes to a pericardium involvement (pan-carditis) more often, development of the isolated damage of a myocardium is possible (myocarditis). In all cases at rheumatism the myocardium is involved in pathological process.
At diffusion myocarditis short wind, heartbeat, interruptions and heartaches, cough at physical activity, appear in hard cases – insufficiency of blood circulation, cardiac asthma or hypostasis of lungs. Pulse is small, takhiaritmichny. The miokarditichesky cardiosclerosis is considered a favorable outcome of diffusion myocarditis.
At an endocarditis and endomyocarditis in rheumatic process it is more often involved mitralny (left predserdno-ventricular) the valve, is more rare aortal and trikuspidalny (the right predserdno-ventricular) valves. The clinic of a rheumatic perikardit is similar to perikardita of other etiology.
At rheumatism the central nervous system can be surprised, at the same time is a specific sign, so-called, rheumatic or small a trochee: there are giperkineza – involuntary twitchings of groups of muscles, emotional and muscular weakness. Less often skin displays of rheumatism meet: a ring-shaped eritema (at 7–10% of patients) and rheumatic small knots. The ring-shaped eritema (annulyarny rash) represents ring-shaped, light pink rashes on a trunk and shins; rheumatic hypodermic small knots - dense, roundish, painless, inactive, single or multiple small knots with localization in average and large joints.
Damage of kidneys, an abdominal cavity, lungs, etc. bodies meets at the heavy course of rheumatism, extremely seldom now. Rheumatic damages of lungs proceeds in the form of rheumatic pneumonia or pleurisy (dry or ekssudativny). At rheumatic damage of kidneys in urine erythrocytes, protein are defined, there is a clinic of nephrite. Damage of abdominal organs at rheumatism is characterized by development of an abdominal syndrome: belly-aches, vomiting, tension of belly muscles. The repeated rheumatic attacks develop under the influence of overcooling, infections, a physical overstrain and proceed with prevalence of symptoms of damage of heart.
Development of complications of rheumatism is predetermined by weight, long and continuously recidivous character of a current. In an active phase of rheumatism insufficiency of blood circulation and vibrating arrhythmia can develop.
Outcome of rheumatic myocarditis can be , an endocarditis – heart diseases (mitralny insufficiency, a mitralny stenosis and aortal insufficiency). At an endocarditis tromboembolichesky complications are also possible (a heart attack of kidneys, spleens, retinas, brain ischemia, etc.). At rheumatic defeat adhesive processes of pleural, pericardiac cavities can develop. Also dekompensirovanny heart diseases serve as deadly complications of rheumatism to a thrombembolia of the main vessels.
Diagnosis of rheumatism
As objective diagnostic criteria of rheumatism serve the big and small manifestations developed by WHO (1988), and also confirmation of the previous streptococcal infection. Polyarthritis, a carditis, a trochee, hypodermic small knots and a ring-shaped eritema belong to big displays (criteria) of rheumatism. Small criteria of rheumatism share on: clinical (fever, artralgiya), laboratory (increase in SOE, , positive S-jet protein) and tool (on the ECG - lengthening P-Q intervals).
Serve as the proofs confirming the previous streptococcal infection increase in credits of streptococcal antibodies (an antistreptolizin, anti-streptokinase, an antigialuronidaza), from a pharynx of a β-hemolytic streptococcus of group A, recent scarlet fever.
The diagnostic rule says that existence 2nd big or the 1st big and 2 small criteria and the proof of the postponed streptococcal infection confirms rheumatism. In addition on the roentgenogram of lungs increase in heart and decrease in sokratitelny ability of a myocardium, change of a warm shadow is defined. On ultrasonography hearts () come to light signs of the acquired defects.
Treatment of rheumatism
The active phase of rheumatism demands hospitalization of the patient and observance of a bed rest. Treatment is carried out by the rheumatologist and the cardiologist. The hyposensibilizing and anti-inflammatory medicines, kortikosteroidny hormones (Prednisolonum, ), nonsteroid anti-inflammatory medicines (diclofenac, indometacin, phenylbutazone, an ibuprofen), immunodepressants are applied (, , , 6-merkaptopurin, ).
Sanitation of the potential centers of an infection (tonsillitis, caries, antritis) includes their tool and antibacterial treatment. Use of antibiotics of a penicillinic row at treatment of rheumatism has auxiliary character and is shown in the presence of the infectious center or strong indications of a streptococcal infection.
Resort treatment in sanatoria of Kislovodsk or the Southern coast of the Crimea is carried out to stages of remission. Further for the prevention of a recurrence of rheumatism during the autumn-spring period conduct monthly preventive course NPVP.
Forecast and prevention of rheumatism
Timely treatment of rheumatism practically excludes direct threat for life. Weight of the forecast at rheumatism is defined by damage of heart (existence and weight of defect, degree of a miokardioskleroz). Most adversely from the predictive point of view continuously progressing current of revmokardit.
Danger of formation of heart diseases increases at early developing of rheumatism at children, late begun treatment. At primary rheumatic attack at persons 25 years a current are more senior more favorably, valvate changes usually do not develop.
Measures of primary prevention of rheumatism include identification and sanitation of a streptococcal infection, a hardening, improvement of social, hygienic living conditions and work. The prevention of a recurrence of rheumatism (secondary prevention) is carried out in the conditions of dispensary control and includes preventive reception of anti-inflammatory and antimicrobic medicines in the autumn and spring period.