Rheumatism is characterized by a systemic connective tissue inflammatory reaction, mainly cardiovascular, frequent lesions of other organs (joints, central nervous system, skin, subcutaneous fat) and a tendency to relapse. The development of this disease is associated with the persistence of group A B-hemolytic streptococcus, transferred at an early age, angina by individuals with a family history.
The etiology of the development of rheumatism is considered to be β-hemolytic group-A streptococcus. The pathogenesis is based on a genetic predisposition to autoimmune reactions. Confirmation of the streptococcal etiology of ARF (acute rheumatic fever) is the detection of high titers of anti-streptococcal antibodies in patients (antistreptolysin-O - ASL-O, antistreptokinase - ASA).
Symptoms of rheumatism: the main complaints of the patient
The severity of the course, the activity of the process, and the stage of the disease significantly affect the degree of clinical manifestations of ARF. Mostly children of school age are ill. Rheumatic heart disease debuts 2-3 weeks after streptococcal sore throat.
In the case of an acute onset of the process, arthritis occurs first, with a gradual one - carditis and chorea. With an imperceptible onset, the diagnosis is made retrospectively on the basis of the identified heart defect.
Symptoms are characteristic of rheumatic fever:
- Myocarditis - pressing pains in the heart, pallor, cyanosis, palpitations, decreased blood pressure, rhythm disturbances, fever, severe general weakness, dizziness;
- Pericarditis (can be simultaneously with endo- and myocarditis) - a sharp deterioration in general condition, fever, heart pain, annoying cough, nausea, swelling of the face, swelling of the cervical veins, shortness of breath, which increases when lying down;
- Polyarthritis - occurs in every second patient. Against the background of fever and sweating, sleep and appetite deteriorate. The joints swell, become sharply painful, movements are limited. Large joints are more often involved, characterized by a multiplicity of lesions, volatility of the process, severe pain.
- Minor chorea - due to rheumatic lesions of the central nervous system. Hyperkinesis - involuntary, chaotic, irregular, rapid movements of muscle groups, aggravated by emotional stress; muscle hypotonia, coordination disorders, emotional instability;
- Anular erythema (ring-shaped rash) is the appearance on the skin of the chest and abdomen of a pale pink rash with sharply defined round edges and a light center. It can appear and disappear several times a day.
- Rheumatoid nodules - nodular, hard, painless, symmetrical small nodular formations along the tendons, in the area of large joints;
- Vasculitis - including coronary arteries. Pain in the heart of the type of angina pectoris, hemorrhages on the skin, nosebleeds;
- Myositis - severe pain and weakness in the corresponding muscle groups;
- Lung lesions - the development of specific pneumonia and pleurisy;
- It is also possible damage to the kidneys, liver, gastrointestinal tract).
Classification by the severity of the process:
- Acute rheumatic fever (ARF) is a post-infectious complication of streptococcal tonsillitis. It manifests itself as a diffuse inflammatory disease of the cardiovascular connective tissue, often in adolescence, due to the body's autosensitization to streptococcal antigens.
- Chronic rheumatic heart disease (CPA) - refers to a disease, the main manifestation of which is damage to the heart valves or heart disease (failure or stenosis), formed as a result of recurrent ARF.
What are the methods for additional diagnostics of rheumatism?
The diagnosis of acute rheumatic fever is a rather difficult task, since its most frequent manifestations are nonspecific.
Diagnostic criteria for rheumatism:
Big criteria:
- Carditis;
- Polyarthritis;
- Chorea;
- Ring-shaped erythema;
- Subcutaneous rheumatic nodules.
Small criteria:
- Clinical - rheumatic history, joint pain, hyperthermia;
- Laboratory tests - acute phase markers: acceleration of ESR, C-reactive protein, neutrophilic leukocytosis;
- Instrumental - an extended P-R interval according to ECG data.
Additionally, an increased content of seromucoid proteins, fibrinogen, α-1, α-2 globulins, hypoalbuminemia, high titers of ASL-O, ASA, ASH are detected in the blood, and antistreptococcal antibodies are detected.
Also on the ECG, conduction disturbances (AV block I-II degree), extrasystole, atrial fibrillation, T wave changes, ST segment depression, low R wave voltage are noted.
On Ro OGK, an expansion of the heart shadow in all directions is noted. On echocardiography, the marginal clavate thickening of the valves, hypokinesia of the cusps of the mitral valve, aortic regurgitation are determined.
Coagulation time, PTI, heparin tolerance, coagulogram are also determined.
Treatment
Therapy for patients with rheumatism is carried out in a hospital setting. The patient is prescribed strict bed rest until the elimination of clinical signs of activity, diet No. 10 with a recommendation to increase the protein content and reduce salt intake.
Drug Treatment Protocol:
- Etiotropic therapy - antibiotics of the penicillin series 1.5-4 million OD per day for 10-12 days, then - Bicillin-5 1.5 million. every 3 weeks. Alternative - macrolides (erythromycin);
- Pathogenetic treatment.
- Glucocorticosteroids - prednisolone 0.7-1 mg / kg with high activity of the process;
- Non-steroidal anti-inflammatory drugs - Indomethacin, Ortofen, COX-2 inhibitors, salicylates;
- Aminoquinolines - Delagil or Plaquenil with prolonged recurrent course and primary valvular lesion;
- Symptomatic therapy - correction of heart failure, detoxification, antiplatelet agents, cardiac glycosides, tranquilizers, metabolic agents.
Forecast
The prognosis remains conditionally unfavorable (mortality up to 30%). The causes of death can be: progressive heart failure, rhythm disturbances, renal failure, thromboembolic complications. Timely antibiotic therapy in adequate dosages and subject to a long course makes possible an almost absolute cure. Relapses of endocarditis, as a rule, occur a month after the end of antibiotic therapy and cause the development of valvular lesions (40% of cases) and the progression of heart failure, increasing the level of patient disability.
Conclusions
In order to reduce the incidence of rheumatism, it is important to carry out primary prevention measures: preventing the spread of streptococcal infection in children's institutions, sanitizing foci of chronic infection (tonsillitis, adenoiditis, sinusitis, carious teeth). If there is a family history in children who have had streptococcal sore throat, close attention should be paid to nonspecific symptoms and treatment of rheumatism of the heart should be started immediately. To prevent secondary attacks and progression of the disease, prolonged forms of penicillin are recommended.
The duration of extensillin prophylaxis depends on the severity of the transferred process (from 5 years with an uncomplicated course to lifelong use in patients with formed valvular disease).In adulthood and old age, the consequence of the transferred rheumatism is the formation of heart defects (mitral, aortic stenosis and insufficiency), requiring surgical intervention.
