Rheumatism is an inflammation of the connective tissue with a predominant localization of the process in the cardiovascular system.
The development of rheumatism is closely related to the previous acute or chronic nasopharyngeal infection caused by streptococcus, direct or indirect damage of its components and toxins on the body with the development of immune inflammation.
Anti-streptococcal antibodies that cross-react with heart tissue (molecular masking) are responsible for selective damage to the heart valves and myocardium with the development of immune aseptic inflammation.
An important role is assigned to genetic factors, as evidenced by the more frequent incidence of children from families in which one of the parents suffers from rheumatism.
Rheumatism is characterized by a variety of manifestations and flow variability. As a rule, it occurs at school age, less often in preschool children and practically does not occur in children under 3 years of age.
- In typical cases, the first signs of rheumatism in the form of fever, signs of intoxication (fatigue, weakness, headache), pain in the joints and other manifestations of the disease are detected 2-3 weeks after sore throat or pharyngitis.
- One of the earliest signs of rheumatism is pain in the joints, detected in 60-100% of cases ( rheumatoid arthritis ).
- Rheumatoid arthritis is characterized by an acute onset, the involvement of large or medium joints (usually the knee, ankle, elbow), rapid reversal of the process.
- The signs of heart damage are determined in 70-85% of cases. Complaints of a hearty nature (pain in the region of the heart, palpitations, shortness of breath) are noted for marked heart disorders.
- More often, especially at the onset of the disease, a variety of asthenic manifestations (lethargy, malaise, fatigue) are observed.
The rarer symptoms of rheumatism include an annular rash and rheumatic nodules.
Annular rash (ring-shaped erythema) – pale pink dull rashes in the form of a thin ring-shaped rim, not rising above the surface of the skin and disappearing under pressure. Rash is found in 7-10% of patients with rheumatism mainly at the peak of the disease and is usually unstable.
Subcutaneous rheumatoid nodules – round, dense, sedentary, painless, single or multiple formations with localization in the region of large and medium joints, spinous processes of the vertebrae, in the tendons. Currently rare, mainly in severe rheumatism, persisting from several days to 1-2 months.
Abdominal pain, damage to the lungs, kidneys, liver and other organs in rheumatism is now extremely rare, mainly in its severe course.
On an electrocardiogram disturbances of a rhythm quite often come to light.
Radiographically (in addition to the not always expressed increase in the heart), signs of a decrease in the contractile function of the myocardium and a change in the configuration of the heart are determined.
Ultrasound of the heart.
Laboratory indicators in patients with rheumatism reflect signs of streptococcal infection, the presence of inflammatory reactions and immunopathological process.
In the active phase are determined: leukocytosis with a shift to the left, an increase in ESR, often anemia; increase in seromucoid , diphenylamine reaction; dysproteinemia with hypergammaglobulinemia ; increase of ASH, ASL-O titers , increase of immunoglobulins ( Ig ) of A, M and G classes; C-reactive protein (CRP), circulating immune complexes, anti- cardiac antibodies.
The treatment of rheumatism is based on the early prescription of complex therapy aimed at suppressing streptococcal infection and the activity of the inflammatory process, as well as preventing the development or progression of heart disease.
The implementation of these programs is carried out on the principle of phasing:
- Stage I – inpatient treatment,
- Stage II – aftercare at the local cardio-rheumatological sanatorium,
- Stage III – dispensary observation in the clinic.
1. At the first stage in the hospital, the patient is prescribed medication, nutrition correction and physical therapy, which are determined individually, taking into account the characteristics of the disease and, above all, the severity of heart disease.
In connection with the streptococcal nature of rheumatism, treatment is carried out with penicillin.
- Antirheumatic therapy involves one of non-steroidal anti-inflammatory drugs (NSAIDs), which is prescribed in isolation or in combination with hormones, depending on the evidence.
- Antimicrobial therapy with penicillin is carried out for 10–14 days.
- In the presence of chronic tonsillitis , with frequent exacerbations of focal infection, the duration of penicillin treatment is increased or additionally used by another antibiotic – amoxicillin, macrolides (azithromycin, roxithromycin , clarithromycin ), cefuroxime axetil , other cephalosporins in the age dosage.
- NSAIDs are used for at least 1–1.5 months until the signs of the activity of the process are eliminated.
- Prednisolone in the initial dose is prescribed for 10–14 days until the effect is obtained, then the daily dose is reduced by 2.5 mg every 5–7 days under the control of clinical and laboratory parameters, then the drug is canceled.
- The duration of treatment with quinoline drugs for rheumatism ranges from several months to 1-2 years or more, depending on the course of the disease.
In a hospital, they also eliminate chronic foci of infection, in particular, an operation to remove the tonsils, performed 2–2.5 months after the onset of the disease in the absence of signs of activity in the process.
2. The main task at the second stage is to achieve complete remission and restoration of the functional ability of the cardiovascular system.
In the sanatorium they continue the therapy started in the hospital, treat the foci of chronic infection, carry out an appropriate therapeutic and health-improving regime with differentiated physical activity, physical therapy, tempering procedures.
3. Stage III of complex therapy for rheumatism involves the prevention of recurrence and progression of the disease.
For this purpose, penicillin preparations of prolonged action are used, mainly bicillin-5, the first administration of which is carried out during the period of inpatient treatment, and later – once every 2–4 weeks year-round.
Regularly, 2 times a year, carry out an outpatient examination, including laboratory and instrumental methods; prescribe the necessary recreational activities, physical therapy.
In rheumatism without engaging the heart, the bicillin prophylaxis is carried out for 5 years after the last attack.
In the spring and autumn, along with the introduction of bicillin shows the monthly course of NSAIDs.
Prevention of rheumatism is divided into primary and secondary.
Primary prevention is aimed at preventing rheumatism and includes:
1. Enhance immunity (hardening,
alternating exercise and rest, good nutrition, etc.).
2. Identification and treatment of acute and chronic streptococcal infection.
3. Preventive measures for children predisposed to developing rheumatism: from families in which there are cases of rheumatism or other rheumatic diseases; often nosopharyngeal infection; those with chronic tonsillitis or acute streptococcal infection.
Secondary prevention is aimed at preventing the recurrence and progression of the disease in patients with rheumatism in the conditions of follow-up.
Currently, with timely treatment started, the primary lesion of the heart ends with recovery.
The formation of valvular heart defects, often with the development of mitral insufficiency, is determined in 15-18% of cases during the first attack, mainly in severe, prolonged or latent course of the disease.