Rheumatism

Description:

Rheumatism is the disease of connecting fabric of inflammatory character affecting first of all cardiovascular system, and developing in connection with the postponed streptococcal infection. Rheumatism is a general disease. The first displays of rheumatic fever are observed aged from 7 up to 15 years. Rheumatism represents danger in connection with formation of heart diseases with further heart failure. According to the International classification of diseases rheumatic fever enters to a class of diseases of the blood circulatory system.
Thanks to mass carrying out a bitsillinoprofilaktika prevalence of rheumatism sharply decreased. So, if in 1925 incidence made to 2000 cases on 100 000 population, then 70 years later it decreased to 16 on 100 000 population.
However the problem of rheumatism does not lose the relevance also today. In one country it was not succeeded to achieve full elimination of a disease.
References of rheumatism meet in the 5th century B.C. About
to rheumatic fever Hippocrates mentions in the work "Four Books of Diseases". Ancient doctors, without having an opportunity to know about a cause of illness, connected rheumatism with poisonous liquid. This representation gave the name to a disease, "revma" in translation from Greek means "current". Only at the end of the 19th century rheumatism was allocated in a separate nosological form that was promoted by works of doctors Sokolovsky and Buyo. For this reason the second name of rheumatism – Sokolovsky-Buyo's disease.

Rheumatism reasons:

Rheumatism is result of the postponed nasopharyngeal infection of a streptococcal etiology. From all group of streptococci beta and hemolitic streptococcus of group A matters in defeat of connecting fabric. It is connected with a special M-protein which is a part of a streptococcus and possesses revmatogenny action. The M-protein is heterogeneous, the pathogenetic part is assigned to such proteins as M-5, M-6, M-18, by M - 24. In response to influence of antigenic structures of a streptococcus the organism develops the antibodies – ASL-O (antistreptolysin O), anti-deoxyribonucleases and ASG (antistreptogialuronidaza.
The role of genetic factors is confirmed by incidence of children in families where relatives, are more often parents, have rheumatism. A genetic marker of rheumatism – alloantigen of V-lymphocytes. This marker is found in patients with rheumatism and their immediate family. Alloantigen promotes the hyperimmune answer to antigen of a microbe.
Rheumatism develops not at all people who had a streptococcal infection. Approximately at 1-3% of the persons predisposed to rheumatism the mechanism of a rheumatic disease is started.

Pathogeny:

Defeat of cardiovascular system is the most characteristic of rheumatism. The endocardium, a myocardium and a pericardium can be involved separately or in the form of generalized damage of heart – a rheumatic pancarditis. Specific characters of rheumatism - Ashoffa-Talalayev's small knots develop. There is a so-called fibrinoid degeneration of collagen of which hypostasis and fragmentation of fibers of collagen is characteristic. Patients with rough rheumatic heart diseases for the rest of life have Ashoffa-Talalayev's small knots with the expressed proliferative changes.
Terrible cordial display of rheumatism is the warty valvulitis which leads to a heavy stenosis of cardial cavities. Thus the left atrioventricular valve is surprised more often, is more rare – three-leaved (right), and is very rare – the valve of a pulmonary trunk.
Extracardiac displays of rheumatism are in fact exudative processes. In the acute period of rheumatism there are small knots localized subcutaneously. In parallel the synovitis, a plastic pleuritis, a pneumonitis develops. Accession of a chorea is not followed by znachushchy pathomorphologic signs in the central nervous system.

Rheumatism symptoms:

Clinical symptoms of rheumatism are characterized by various manifestations from a cardiovascular and nervous system, joints and skin. There are so-called big diagnostic criteria of rheumatism – polyarthritis, a chorea, a carditis, a regional erythema and hypodermic small knots.
Classical display of rheumatism is polyarthritis with the "flying", migrating arthralgias. The joint syndrome is followed by large joint pains, less often process develops in joints of feet and brushes, a grudinnoklyuchichny joint. Puffiness and a dermahemia over a joint is defined. Despite prevalence of arthritis at rheumatism, it has diagnostic value only in combination with small symptoms of rheumatism.
Carry fever, acceleration of SOE, positive SRB in blood, increase in an interval of PR on the electrocardiogram to small diagnostic characters of rheumatism.
The rheumatic carditis is shown first of all by existence of tachycardia. Auskultativno is diagnosed a so-called cantering rhythm or an embryonal cordial rhythm. Increase in an interval of PR at an ECG speaks about existence to an atrioventricular block of various degree. On a X-ray analysis expansion of borders of heart comes to light. Except cordial noise at auscultation it is possible to listen to a pericardial rub. Gradually heart failure of congestive character develops.
The skin displays of rheumatism which are characterized first of all by emergence of specific rheumatic small knots, representing a swelling in the field of bone ledges painless at a palpation. Integuments are not soldered to small knots.
The rheumatic chorea represents damage of the central nervous system. Disease synonyms – a hysterical chorea, Saint Witt's dancing, Sydenham's chorea. It is shown by the chaotic uncontrollable movements of various parts of a body, with the accompanying muscular weakness. The rheumatic chorea represents late display of rheumatism and therefore it is observed more often when there are no symptoms of polyarthritis any more.
At development of a chorea the patient loses ability to write or sharply handwriting changes. The patient grimaces, falls when walking, the behavior becomes inadequate. Further the involuntary movements extend to extensive body parts, as a result of the increasing muscular weakness of the patient cannot go, stand and sit, paralyzes join. Because of uncontrollable movements of the patient can put self-injuries. During sleep manifestations can cease a little. Emotional instability is shown.
The regional erythema is shown by fast-disappearing rash, with accurate star-shaped contours. It is shown mainly on a trunk, hips, shoulders, and can have various sizes. When pressing pink elements of rash turn pale. The regional erythema is not followed by an itch.

Diagnosis:

For diagnosis of rheumatism laboratory and tool methods of inspection are widely used.
At active rheumatic process the leukocytosis comes to light, the formula of white blood is shifted to the left, anemia, increases SOE. Proteinogramma reveals a disproteinemia. Seromucoid level, a caption of ASG, ASL-O, immunoglobulins A, M and G increases. Definition of an indicator of S-reactive protein, the CEC and anti-cardial antibodies is of great importance.
At assessment of clinical symptoms at rheumatism big and small criteria have diagnostic value. Existence 2nd big or 1 big and 2 small diagnostic criteria testifies in favor of rheumatism.
Diagnosis of a degree of activity of rheumatic process includes assessment of both clinical, and laboratory signs.

Treatment of Rheumatism:

Complex therapy of rheumatism is directed to decrease in symptoms of inflammatory character, suppression of activity of an infection, prevention of development or the termination of progressing of cordial manifestations.
Staging of antirheumatic therapy includes hospitalization, extension of hospitalization in a cardio-rheumatic clinic and the dispensary account at the cardiorheumatologist at the place of residence.
To the patient the bed rest, a rational diet is appointed. Depending on weight of cordial manifestations the bed rest can last about one month.
Etiotropic treatment of rheumatism includes purpose of penicillin, pathogenetic – steroid and non-steroidal anti-inflammatory drugs.
The penicillin therapy is carried out within 2 weeks. The chronic centers of an infection demand more prolonged treatment or a combination of various groups of antibiotics. The penicillin combination with macroleads, cephalosporins is possible. As antiinflammatory drug use NPVS during 1-15, months or glucocorticoids. Therapy by Prednisolonum needs to be accompanied with correction of food – to increase consumption of kaliysoderzhashchy products (prunes, a persimmon, dried apricots, raisin, etc.). It is also possible to use quinolinic drugs, however duration of their appointment can reach 2 years.
Maintenance of a cardiac muscle reasonablly cardiotrophic drugs: solution or tablets of inosine, cocarboxylase, ATP, фосфаден, carnitine, Mildronate and others.
The rheumatic chorea demands purpose of diazepam (Sibazonum), a haloperidol, vitamin therapy, the calming physiotherapy.
Carrying out sanitation of the chronic centers of an infection, in particular is whenever possible shown to a tonsilectomy.
After subsiding of ostrorevmatichesky process patients have to receive courses of recreational sanatorium treatment. The tempering and dosed physical procedures are shown.
Prevention of a recurrence of rheumatism provides introduction of depot drugs – penicillin of the prolonged action. The first introduction of Bicillinum-5 is shown at a stage stationary treatment, then it is entered by each 2-4 weeks all the year round.
After the postponed rheumatic carditis the bitsillinoprofilaktika is carried out to achievement of 21 years by the patient, at a revmoprotsessa without involvement of heart – within 5 years after the last aggravation.

Prevention:

Primary prevention of rheumatism includes measures for the prevention of development of a disease. Hardenings, the good nutrition and other measures increasing immunity are for this purpose shown. It is necessary to diagnose and carry out treatment of streptococcal infections timely. It is necessary to reveal and create risk group on development of rheumatism. These are children from families where parents have rheumatism, often ill children, with the diagnosed adenoid disease.
Secondary prevention is carried out among patients, having rheumatism.
In an active phase of a disease it is necessary to be observed revmokardiology monthly within the first 3 months from the beginning of a disease, and then 1 quarterly. In a year from the beginning of a disease of a revmokardiolog it is necessary to visit annually. Consultations of adjacent specialists – the ENT specialist, the neurologist, the stomatologist, the oculist, the gynecologist are also necessary. Control of blood test is carried out to 6 times a year, the analysis of urine undertakes to 4 times a year. Functional methods of inspection (an ECG, FKG, EhoKG) – quarterly. To 4 times a year the analysis on revmoproba is carried out.
At process attenuation, in an inactive phase, it is necessary to be inspected at a revmokardiolog 2-4 times a year, it is also necessary to consult at adjacent specialists, to control laboratory indicators of blood and urine.