Classification of rheumatism

Classification and basic forms of rheumatism

Rheumatism is a chronic disease of connective tissue. The first data on rheumatism recorded before our era in the records of doctors of ancient Greece. Even the name of the disease "rheumatism" came to us from the ancient Greek language. In translation, this word means "flow", which shows the chronic nature of the disease and the wide spread of the process. But rheumatism in the ancient world was called only one of the forms of the disease - rheumatic polyarthritis( inflammation of the joints of the limbs), and all other manifestations of this disease were written off to other numerous illnesses in those days.

In the 19th century, there was a breakthrough in the study of rheumatism, and it was defined as a systemic disease, which in addition to polyarthritis of the extremities is characterized by a variety of other clinical manifestations.

Currently, rheumatism continues to be an urgent problem of modern medicine, and its research is allocated considerable funds.

In the 20th century, it was found that this disease has not an infectious, as previously thought, but an autoimmune nature.

The basis of rheumatism is the mechanism of a hyperimmune response to the introduction of hemolytic group A streptococcus into the body. Specific antibodies that are produced to combat streptococcus, for unknown reasons, begin to destroy their own connective tissue, thereby causing various clinical manifestations of the disease. Rheumatism is multifaceted, it can affect the heart and other internal organs, the skin, the vessels of the brain and the joints of the limbs. In addition, there are rare manifestations of the disease, for example rheumatism of the vessels of the eyes, lacrimal glands, muscles of the extremities, neck, chest and back.

Basic forms of rheumatism

pain in rheumatism

It is now believed that rheumatism is characterized by 5 major forms of the disease. And often in one patient several forms of the inflammatory process occur simultaneously.

  1. Cardiac form( rheumatic carditis).With this form of the disease the muscular membranes of the heart are affected - myocardium, endocardium and pericardium. Symptoms of the disease depend on the degree of activity of the process. With a minimum degree of visible changes, it usually does not occur. There is a slight fatigue and dizziness during exercise. There is no lack of blood circulation, working capacity is not compromised. In the middle and severe degree, symptoms such as fever, weakness, tachycardia, shortness of breath come to the fore. At auscultation, characteristic noises in the heart are heard. The electrocardiogram shows changes.
  2. Joint form( polyarthritis of the extremities).The articular form is one of the most frequent manifestations of the disease. It is characterized by numerous lesions of large and small joints of the limbs. With rheumatism, polyarthritis can be a separate clinical manifestation of the disease or be present in conjunction with rheumatic carditis. Changes in the joints are noticeable, and diagnosis is usually not difficult. When rheumatic polyarthritis joints look red, swollen, limb movements are difficult and painful. The patient's body temperature is raised to 38-39 ° C.A characteristic feature of rheumatic polyarthritis is the "flying" symptomatology. The disease should be differentiated from other types of arthritis.
  3. Neurological form( chorea).With the chorea, the symptoms associated with the damage to the brain vessels come to the fore, uncontrolled grimaces and chaotic limb movements. Chorea is a very unpleasant manifestation of the disease. Involuntary twitching of the muscles has a very depressing effect on the patient, often depriving him of the opportunity to eat and take care of himself. Increased muscle tone, uncontrolled movement of the limbs, grimaces and twitching of the eyes force the ill person to adhere to bed rest and take soothing until the final symptoms subsided. Usually, signs of a small rheumatic chorea last for several weeks, and then go on decline. Antirheumatic treatment in this case is ineffective. Since the twitching of the muscles of the face and limbs pass during a dive into sleep, it is desirable to maximize the time of sleep. Small rheumatic chorea should be differentiated from other diseases with neurologic symptoms. For example, limb tremor is a sign of a brain tumor, leukodystrophy, multiple sclerosis, Huntington's chorea and many other dangerous diseases.
  4. Skin form( erythema and tubercles).Rheumatism is characterized by annular erythema and subcutaneous rheumatic tubercles. Skin manifestations are quite specific and easily differentiate from other dermatological diseases.
  5. Respiratory form( pleurisy).Rheumatic pleurisy is a fairly rare manifestation of the disease( no more than 2%).In order not to confuse him with the usual infectious pleurisy, which often complicates the common cold, the diagnosis of rheumatic pleurisy is finally set only when there are additionally other manifestations of rheumatism, for example rheumatic carditis or inflammation of the joints of the extremities.

Lesion of the eye vessels in rheumatism

defeat of glpz rheumatism

Other organs may suffer from rheumatism. Disorganization of connective tissue leads to the destruction of blood vessels throughout the body. One of the organs sensitive to such changes is the human eye. Changes in the visual organs affect both the arteries and veins of the retina.

Rheumatism can manifest itself with such eye diseases as uveitis and retinovascular. As a complication, there may be a thrombosis of the eye vessels.

Uveitis is a concept that includes inflammation of various parts of the choroid of the eyes. Started uveitis can cause partial loss of vision and even blindness. Depending on the localization of the process, several types of uveitis are distinguished. Anterior uveitis is manifested by iritis( inflammation of the iris) and iridocyclitis( inflammation of the iris and ciliary body of the eyes).

The posterior uveitis includes chorioretinitis( inflammation of the choroid with involvement of the retina) and choroiditis( inflammation of the choroid of the eyes).

Depending on the form, uveitis is characterized by bright reddening of the choroid of the eyes, photophobia, irritability of the lacrimal glands, blurring of the visible area and the appearance of dark spots in the field of vision. There may be pain in the eye area.

The second manifestation of rheumatic damage to the organs of vision is retinovascular( retinal vascular lesions in the area of ​​the optic disc).Symptoms of retinovasculitis consist in bright flashes before the eyes, fogging and decrease in visual acuity. When ophthalmologic examination, characteristic areas of the blurred retina of the eye around the optic disc are observed.

The correct diagnosis is made by an ophthalmologist on the basis of examination and rheumatism in an anamnesis. Rheumatic eye injuries must be differentiated from infectious and allergic inflammation of the organs of vision.

Diagnostics includes laboratory tests, measurement of intraocular pressure, ultrasound, visometry, perimetry, ophthalmoscopy and retinography.

Ophthalmologist and rheumatologist are engaged in the treatment of rheumatic eye diseases at the same time. The emphasis is on treating the underlying disease. Drug therapy includes a course of antibiotics followed by the administration of glucocorticosteroids according to the scheme.

Lesion of lacrimal glands with rheumatism

defeat of lacrimal glands with rheumatism

Another rare eye disease that can occur with rheumatism is a rare complication - dacryoadenitis, or inflammation of the lacrimal glands. The clinical symptoms of acute dacryoadenitis are typical, and diagnosis is not difficult. When inflammation of the lacrimal glands, the swelling and soreness of the outer part of the upper eyelid comes to the fore. With the development of the process, edema begins to increase gradually, capturing the temporal region and half of the face. With a severe form of inflammation of the lacrimal glands, the eye gap completely closes. The eyeball is shifted downwards, diplopia appears( the objects are doubled).Movement of the eye is much limited. Inflammation of lacrimal glands affects the conjunctiva of the eye, it becomes swollen and reddened( manifestation of chemosis).

The general condition of the patient is also significantly impaired. Inflammation of the lacrimal gland can be accompanied by fever, poor health, headache, lack of appetite, insomnia and weakness.

In rheumatic acute lesions of the salivary glands, the rate of erythrocyte sedimentation increases sharply, the C-reactive protein and anti-streptolysin( ACL-O) are present in the biochemical analysis.

It is necessary to know that inflammation of the lacrimal gland is a frequent complication of other diseases, for example, angina, influenza and paratitis( inflammation of the parotid glands).In addition, there is a systemic disease of connective tissue - Sjogren's syndrome, a characteristic feature of which is the defeat of the glands of external secretion - lacrimal and salivary.

Treatment should be aimed at fighting the main disease. Locally recommended is the application of anti-inflammatory ointments and UHF.In case of suppuration in the lacrimal gland, surgical intervention is necessary, followed by removal of the abscess and the appointment of a course of antibacterial therapy.

In chronic inflammation of the lacrimal glands, a long-term therapy is used. The outlook is usually favorable. After a while after an adequately prescribed treatment, the inflammation of the lacrimal glands is diminishing.

Muscle rheumatism: symptoms of

Diagnosing this disease is difficult because of common symptoms. Muscle pain, characteristic of rheumatic muscle damage, is a symptom of many other diseases. Depending on the localization of the process, rheumatism of limb muscles is distinguished, which is characterized by pain in the movement of arms and legs and a violation of the ability to fully control them, as well as neck and back rheumatism( cervical, thoracic and lumbar muscles).

The disease must be differentiated from infectious myalgia and pain in the limbs, neck and back of traumatic origin.

For the diagnosis it is necessary to pass laboratory tests to determine the rheumatic components in the blood. Of great importance for the diagnosis is the history of rheumatism in the past or other typical manifestations of the disease( eg, rheumatic carditis or polyarthritis of large joints of the limbs).

Lumbar rheumatism is manifested by pain in the back, usually in the lumbar region, which is often mistaken for osteochondrosis of the spine. Rheumatism of the pectoral muscles is manifested by pain during respiratory movements, laughter, coughing and sneezing. With rheumatic damage to the neck muscles, the head often acquires an immovable position or has a characteristic inclination in one direction, which is also often mistaken for osteochondrosis.

Symptoms of back rheumatism are important to distinguish from the symptoms of another no less dangerous disease - Bechterew's disease, which is additionally manifested by polyarthritis of the extremities.

Classification of rheumatism

Due to the numerous clinical symptoms and several degrees of activity of the process, it becomes necessary to classify this disease.

In our country, the classification of Nesterov, adopted at the symposium in December 1964, is used.

Phases of rheumatism

  1. Active.
    • 1 degree of activity - minimalGeneral condition is not violated, laboratory parameters are slightly changed. Most often this is latent rheumatic heart disease. A rise in temperature is not observed.
    • 2 degree of activity - moderate It is possible skin manifestations, symptoms of chorea, rheumatic carditis and polyarthritis. Antistreptococcal antibodies are increased 2 times, moderate increase in ESR.The temperature is raised to 38 ° C.
    • 3 degree of activity - maximum Severe symptoms of chorea, rheumatic carditis and polyarthritis. Possible additional damage to other organs and circulatory disorders. Antistreptococcal antibodies are increased 4 times or more, ESR over 40 mm per hour. Raise body temperature to 40 ° C.
  2. Inactive.

Remission of the disease. Laboratory parameters are normal, clinical signs of rheumatism are absent for 6 months.

Functional characteristic of blood circulation

  1. There is no circulatory inefficiency - zero degree.
  2. Insufficiency of blood circulation of 1-st degree.
  3. Circulatory failure of the 2nd degree.
  4. Insufficiency of blood circulation of the 3rd degree.

Classification by flow and process activity

  1. Acute.
  2. Subacute.
  3. Sluggishly protracted.
  4. Recurrent.
  5. Latent.

Classification of organ damage

Rheumatism of heart

  1. In active phase:
    • acute rheumatic carditis( with and without blemish);
    • recurrent rheumatic carditis;
    • rheumatism without heart failure.
  2. In the inactive phase:
    • myocardiosclerosis;
    • rheumatic heart disease.

Rheumatism of other organs

  • In the active phase: polyarthritis, pleurisy, chorea, skin lesions, eye vascular lesions, lacrimal glands, rheumatism of the muscles, and rare manifestations - meningoencephalitis, hepatitis, pneumonia, nephritis and thyroiditis.
  • In the inactive phase: effects and residual manifestations of organ damage.

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Rheumatism( rheumatic fever)

Rheumatism( rheumatic fever)

Rheumatism is an inflammatory, infectious and allergic systemic lesion of connective tissue of various localization, mainly of the heart and blood vessels. A typical rheumatic fever is characterized by an increase in body temperature, multiple symmetrical arthralgia of a volatile nature, polyarthritis. In the future, ring-shaped erythema, rheumatic nodules, rheumatic chorea, rheumatic carditis with damage to the heart valves can be attached. Of the laboratory criteria for rheumatism, the most important are positive CRP, an increase in the titer of streptococcal antibodies. In the treatment of rheumatism, NSAIDs, corticosteroid hormones, immunosuppressants are used.

Rheumatism( rheumatic fever)

Rheumatism( synonyms: rheumatic fever, Sokolsky-Buyo disease) occurs chronically, with a tendency to relapse, exacerbations occur in the spring and autumn. The share of rheumatic heart and vascular lesions account for up to 80% of acquired heart defects. In the rheumatic process, joints, serous membranes, skin, and the central nervous system are often involved. The incidence of rheumatism rises from 0.3% to 3%.Rheumatism usually develops in childhood and adolescence( 7-15 years);children of preschool age and adults get sick much less often;3 times more often rheumatism affects the female.

Reasons and mechanism of development of rheumatism

A rheumatic attack is usually preceded by streptococcal infection caused by group A beta-hemolytic streptococcus: scarlet fever, tonsillitis, maternal fever, acute otitis media, pharyngitis, erysipelas. In 97% of patients who underwent streptococcal infection, a stable immune response is formed. The rest of the people do not develop stable immunity, and with repeated infection with β-hemolytic streptococcus a complex autoimmune inflammatory reaction develops.

The development of rheumatism is promoted by reduced immunity, young age, large groups( schools, boarding schools, hostels), unsatisfactory social conditions( food, shelter), hypothermia, family history.

In response to the introduction of β-hemolytic streptococcus in the body, anti-streptococcal antibodies( anti-streptolysin-O, antistreptogyaluronidase, antistreptokinase, antidexoxyribonuclease B) are produced, which together with streptococcal antigens and components of the complement system form immune complexes. Circulating in the blood, they are carried throughout the body and settle in tissues and organs, mainly localized in the cardiovascular system. In the localization of immune complexes, the process of aseptic autoimmune inflammation of connective tissue develops. Streptococcus antigens have pronounced cardiotoxic properties, which leads to the formation of autoantibodies to the myocardium, which further aggravate inflammation. With repeated infection, cooling, stressful effects, the pathological reaction is fixed, contributing to the recurring progressive course of rheumatism.

The processes of connective tissue disorganization in rheumatism go through several stages: mucoid swelling, fibrinoid changes, granulomatosis and sclerosis.

In the early, reversible stage of mucoid swelling, swelling, swelling and cleavage of collagen fibers develops. If at this stage the lesions are not eliminated, irreversible fibrinoid changes occur, characterized by fibrinoid necrosis of collagen fibers and cellular elements. In the granulomatous stage of the rheumatic process around the necrosis zones, specific rheumatic granulomas are formed. The final stage of sclerosis is the outcome of granulomatous inflammation.

The duration of each stage of the rheumatic process is 1 to 2 months, and the entire cycle - about six months. Relapses of rheumatism promote the occurrence of repeated tissue lesions in the area of ​​already existing scars. The defeat of the tissue of the heart valves with the outcome of sclerosis leads to deformation of the valves, their fusion with each other and is the most common cause of acquired heart defects, and repeated rheumatic attacks only exacerbate destructive changes.

Classification of rheumatism

The clinical classification of rheumatism is made taking into account the following characteristics:

  • Phases of the disease( active, inactive)

Three phases are active in the active phase: I - minimal activity, II activity moderate, III - activity high. In the absence of clinical and laboratory signs of the activity of rheumatism, they speak of its inactive phase.

  • Variant of course( acute, subacute, prolonged, latent, recurrent rheumatic fever)

In acute course rheumatism attacks suddenly, proceeds with a sharp severity of symptoms, is characterized by polysyndromy of the lesion and a high degree of activity of the process, rapid and effective treatment.

In subacute rheumatism the duration of the attack is 3-6 months, the symptomatology is less pronounced, the activity of the process is moderate, the effectiveness of treatment is less pronounced.

The protracted variant proceeds with a long, more than half a year's rheumatic attack, with sluggish dynamics, monosyndromic manifestation and low activity of the process.

The latent flow is characterized by the lack of clinical and laboratory and instrumental data, rheumatism is diagnosed retrospectively, according to the already formed heart disease.

Continuously recurrent variant of development of rheumatism is characterized by a wave-like, with bright exacerbations and incomplete remission of course, polysinomicity of manifestations and rapidly progressive defeat of internal organs.

  • Clinical Anatomical Characteristics of Lesions:
  1. with involvement of the heart( rheumatic carditis, myocardiosclerosis), with the development of heart disease or without it;
  2. with involvement of other systems( rheumatic damage of the joints, lungs, kidneys, skin and subcutaneous tissue, neurorrheumatism)
  • Clinical manifestations( carditis, polyarthritis, annular erythema, chorea, subcutaneous nodules)
  • Circulatory states( see: degrees of chronic heart failure).

Symptoms of rheumatism

Symptoms of rheumatism are extremely polymorphic and depend on the degree of acuity and activity of the process, as well as the involvement of various organs in the process.

A typical clinic of rheumatism has a direct connection with a streptococcal infection( tonsillitis, scarlatina, pharyngitis) and develops 1-2 weeks after it. The disease begins with acute subfebrile temperature( 38-39 ° C), weakness, fatigue, headaches, sweating. One of the early manifestations of rheumatism is arthralgia - pain in the middle or large joints( ankle, knee, elbow, shoulder, wrist).With rheumatism arthralgia is multiple, symmetrical and volatile( pain disappears in some and appears in other joints) character. There is swelling, puffiness, local redness and fever, a sharp restriction of movements of the affected joints. The course of rheumatic polyarthritis is usually benign: after a few days the acuteness of the phenomena subsides, the joints do not deform, although moderate soreness can persist for a long time.

After 1-3 weeks, rheumatic carditis joins: pain in the heart, palpitations, interruptions, shortness of breath;asthenic syndrome( malaise, lethargy, fatigue).The defeat of the heart for rheumatism is noted in 70-85% of patients.

In rheumatic heart disease, all or individual membranes of the heart become inflamed. More often there is a simultaneous lesion of the endocardium and myocardium( endomyocarditis), sometimes with pericardial involvement( pancarditis), possibly the development of isolated myocardial damage( myocarditis).In all cases with rheumatism, the myocardium is involved in the pathological process.

In case of diffuse myocarditis, shortness of breath, palpitations, irregularities and pains in the heart, cough during exercise, in severe cases - circulatory insufficiency, cardiac asthma or pulmonary edema. Pulse is small, tachyarrhythmic. A favorable outcome of diffuse myocarditis is myocarditis cardiosclerosis.

With endocarditis and endomyocarditis in the rheumatic process, the mitral( left atrial-ventricular) valve is more often involved, less often the aortic and tricuspid( right atrial-ventricular) valves. Clinic of rheumatic pericarditis is similar to pericarditis of another etiology.

In rheumatism, the central nervous system can be affected, the so-called rheumatic or minor chorea serves as a specific sign: hyperkinesis appears - involuntary jerking of muscle groups, emotional and muscle weakness.

Less common skin manifestations of rheumatism: annular erythema( in 7-10% of patients) and rheumatic nodules. Ring-shaped erythema( annular rash) is a ring-shaped, pale pink rash on the trunk and legs;rheumatic subcutaneous nodules - dense, rounded, painless, inactive, single or multiple nodules with localization in the middle and large joints.

The defeat of the kidneys, abdominal cavity, lungs and other organs occurs in severe rheumatism, very rarely at the present time. Rheumatic lung injury occurs in the form of rheumatic pneumonia or pleurisy( dry or exudative).With rheumatic damage of the kidneys in urine, erythrocytes, protein are determined, a jade clinic arises. The defeat of the abdominal cavity in rheumatism is characterized by the development of abdominal syndrome: abdominal pain, vomiting, abdominal tension.

Repeated rheumatic attacks develop under the influence of hypothermia, infections, physical overstrain and occur with a predominance of heart attack symptoms.

Complications of rheumatism

The development of complications of rheumatism is predetermined by the severity, protracted and continuously recurring nature of the course. In the active phase of rheumatism, circulatory insufficiency and atrial fibrillation may develop.

The outcome of rheumatic myocarditis can be myocardiosclerosis, endocarditis - heart defects( mitral insufficiency, mitral stenosis and aortic insufficiency).When endocarditis is also possible thromboembolic complications( infarction of the kidneys, spleen, retina, cerebral ischemia, etc.).With rheumatic lesions, adhesions of the pleural, pericardial cavities can develop. Mortally dangerous complications of rheumatism are the thromboembolism of the main vessels and decompensated heart defects.

Diagnosis of rheumatism

Objective diagnostic criteria for rheumatism are the large and small manifestations developed by the WHO( 1988), as well as confirmation of a previous streptococcal infection. Great manifestations( criteria) of rheumatism include polyarthritis, carditis, chorea, subcutaneous nodules and annular erythema.

Small criteria for rheumatism are divided into: clinical( fever, arthralgia), laboratory( increase in ESR, leukocytosis, positive C-reactive protein) and instrumental( on ECG - lengthening P-Q interval).

Evidence supporting the previous streptococcal infection is an increase in the titer of streptococcal antibodies( anti-streptolysin, antistreptokinase, anti-hyaluronidase), bacussis from the throat of β-hemolytic streptococcus group A, recent scarlet fever.

The diagnostic rule states that the presence of 2 large or 1 large and 2 small criteria and evidence of a transferred streptococcal infection confirm rheumatism.

In addition, the chest radiograph determines the increase in the heart and a decrease in the contractility of the myocardium, a change in the cardiac shadow. By ultrasound of the heart( Echocardiography), signs of acquired defects are revealed.

Treatment of rheumatism

The active phase of rheumatism requires hospitalization of the patient and compliance with bed rest. Treatment is carried out by a rheumatologist and cardiologist. Hypersensitizing and anti-inflammatory drugs, corticosteroid hormones( prednisolone, triamsinolone), nonsteroidal anti-inflammatory drugs( voltaren, indomethacin, butadione, brufen), immunosuppressants( plaquenyl, delagil, imarant, 6-mercaptopurine, chlorobutin) are used.

Sanitation of potential foci of infection( tonsillitis, caries, sinusitis) includes their instrumental and antibacterial treatment.

The use of penicillin antibiotics in the treatment of rheumatism is of an auxiliary nature and is indicated in the presence of an infectious focus or obvious signs of streptococcal infection.

In the remission phase, resort treatment is provided in the sanatoriums of Kislovodsk or the Southern coast of the Crimea. In the future, to prevent recurrence of rheumatism in the autumn-spring period, a monthly preventive course of NSAIDs is carried out.

Forecast for rheumatism

Timely treatment of rheumatism virtually eliminates an immediate threat to life. The severity of the prognosis for rheumatism is determined by the defeat of the heart( the presence and severity of the defect, the degree of myocardiosclerosis).The most unfavorable from a prognostic point of view is the continuously progressing course of rheumatic heart disease.

The risk of formation of heart defects increases with the early occurrence of rheumatism in children, late-onset treatment. In primary rheumatic attacks in patients over 25 years of age, the course is more favorable, valve changes usually do not develop.

Prevention of rheumatism

Measures of primary prevention of rheumatism include the detection and rehabilitation of streptococcal infection, hardening, improvement of social, household, hygienic living and working conditions. Prevention of recurrence of rheumatism( secondary prevention) is carried out in conditions of dispensary control and includes prophylactic intake of anti-inflammatory and antimicrobial agents in the autumn-spring period.

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Rheumatism( rheumatic fever)

Rheumatism( rheumatic fever)

Rheumatism - inflammatory infectious-allergic systemic lesion of connective tissue of various localization, mainly of the heart and blood vessels. A typical rheumatic fever is characterized by an increase in body temperature, multiple symmetrical arthralgia of a volatile nature, polyarthritis. In the future, ring-shaped erythema, rheumatic nodules, rheumatic chorea, rheumatic carditis with damage to the heart valves can be attached. Of the laboratory criteria for rheumatism, the most important are positive CRP, an increase in the titer of streptococcal antibodies. In the treatment of rheumatism, NSAIDs, corticosteroid hormones, immunosuppressants are used.

Rheumatism( rheumatic fever)

Rheumatism( synonyms: rheumatic fever, Sokolsky-Buyo disease) occurs chronically, with a tendency to relapse, exacerbations occur in the spring and autumn. The share of rheumatic heart and vascular lesions account for up to 80% of acquired heart defects. In the rheumatic process, joints, serous membranes, skin, and the central nervous system are often involved. The incidence of rheumatism rises from 0.3% to 3%.Rheumatism usually develops in childhood and adolescence( 7-15 years);children of preschool age and adults get sick much less often;3 times more often rheumatism affects the female.

Causes and mechanism of development of rheumatism

Rheumatic attack is usually preceded by a streptococcal infection caused by group A beta-hemolytic streptococcus: scarlet fever, tonsillitis, maternal fever, acute otitis media, pharyngitis, erysipelas. In 97% of patients who underwent streptococcal infection, a stable immune response is formed. The rest of the people do not develop stable immunity, and with repeated infection with β-hemolytic streptococcus a complex autoimmune inflammatory reaction develops.

The development of rheumatism is promoted by reduced immunity, young age, large collectives( schools, boarding schools, hostels), unsatisfactory social conditions( food, shelter), hypothermia, a burdened family anamnesis.

In response to the introduction of β-hemolytic streptococcus in the body, antistreptococcal antibodies( anti-streptolysin-O, antistreptogyaluronidase, antistreptokinase, antidexoxyribonuclease B) are produced, which together with streptococcal antigens and components of the complement system form immune complexes. Circulating in the blood, they are carried throughout the body and settle in tissues and organs, mainly localized in the cardiovascular system. In the localization of immune complexes, the process of aseptic autoimmune inflammation of connective tissue develops. Streptococcus antigens have pronounced cardiotoxic properties, which leads to the formation of autoantibodies to the myocardium, which further aggravate inflammation. With repeated infection, cooling, stressful effects, the pathological reaction is fixed, contributing to the recurring progressive course of rheumatism.

The processes of connective tissue disorganization in rheumatism go through several stages: mucoid swelling, fibrinoid changes, granulomatosis and sclerosis.

In the early, reversible stage of mucoid swelling develops swelling, swelling and cleavage of collagen fibers. If at this stage the damage is not eliminated, irreversible fibrinoid changes occur, characterized by fibrinoid necrosis of collagen fibers and cellular elements. In the granulomatous stage of the rheumatic process around the necrosis zones, specific rheumatic granulomas are formed. The final stage of sclerosis is the outcome of granulomatous inflammation.

The duration of each stage of the rheumatic process is 1 to 2 months, and the entire cycle - about six months. Relapses of rheumatism promote the occurrence of repeated tissue lesions in the area of ​​already existing scars. The defeat of the tissue of the heart valves with the outcome of sclerosis leads to deformation of the valves, their fusion with each other and is the most common cause of acquired heart defects, and repeated rheumatic attacks only exacerbate destructive changes.

Classification of rheumatism

The clinical classification of rheumatism is made taking into account the following characteristics:

  • Phases of the disease( active, inactive)

Three phases are active in the active phase: I - minimal activity, II activity moderate, III - activity high. In the absence of clinical and laboratory signs of the activity of rheumatism, they speak of its inactive phase.

  • Variant of the course( acute, subacute, prolonged, latent, recurrent rheumatic fever)

In acute course rheumatism attacks suddenly, proceeds with a sharp severity of symptoms, is characterized by polysyndromy of the lesion and a high degree of activity of the process, rapid and effective treatment.

In subacute rheumatism the duration of the attack is 3-6 months, the symptomatology is less pronounced, the activity of the process is moderate, the effectiveness of the treatment is less pronounced.

The protracted variant proceeds with a long, more than half a year's rheumatic attack, with sluggish dynamics, monosyndromic manifestation and low activity of the process.

The latent flow is characterized by the absence of clinical and laboratory data and instrumental data, rheumatism is diagnosed retrospectively, according to the already formed heart disease.

Continuously recurrent variant of development of rheumatism is characterized by a wave-like, with bright exacerbations and incomplete remission of course, polysinomicity of manifestations and rapidly progressive defeat of internal organs.

  • Clinico-anatomical characteristics of lesions:
  1. with involvement of the heart( rheumatic carditis, myocardiosclerosis), with or without heart failure;
  2. with involvement of other systems( rheumatic involvement of joints, lungs, kidneys, skin and subcutaneous tissue, neuro-rheumatism)
  • Clinical manifestations( carditis, polyarthritis, annular erythema, chorea, subcutaneous nodules)
  • Circulatory states( see: degrees of chronic heart failure).

Symptoms of rheumatism

Symptoms of rheumatism are highly polymorphic and depend on the degree of acuity and activity of the process, as well as the involvement of various organs in the process.

A typical clinic of rheumatism has a direct connection to a streptococcal infection( tonsillitis, scarlet fever, pharyngitis) and develops 1-2 weeks after it. The disease begins with acute subfebrile temperature( 38-39 ° C), weakness, fatigue, headaches, sweating. One of the early manifestations of rheumatism is arthralgia - pain in the middle or large joints( ankle, knee, elbow, shoulder, wrist).With rheumatism arthralgia is multiple, symmetrical and volatile( pain disappears in some and appears in other joints) character. There is swelling, puffiness, local redness and fever, a sharp restriction of movements of the affected joints. The course of rheumatic polyarthritis is usually benign: after a few days the acuteness of the phenomena subsides, the joints do not deform, although moderate soreness can persist for a long time.

After 1-3 weeks, rheumatic carditis joins: pain in the heart, palpitations, interruptions, shortness of breath;asthenic syndrome( malaise, lethargy, fatigue).The defeat of the heart for rheumatism is noted in 70-85% of patients.

In rheumatic heart disease, all or individual membranes of the heart become inflamed. More often there is a simultaneous lesion of the endocardium and myocardium( endomyocarditis), sometimes with pericardial involvement( pancarditis), possibly the development of isolated myocardial damage( myocarditis).In all cases with rheumatism, the myocardium is involved in the pathological process.

In case of diffuse myocarditis, shortness of breath, palpitations, irregularities and pains in the heart, coughing with physical exertion, in severe cases - circulatory insufficiency, cardiac asthma or pulmonary edema. Pulse is small, tachyarrhythmic. A favorable outcome of diffuse myocarditis is myocarditis cardiosclerosis.

With endocarditis and endomyocarditis in the rheumatic process, the mitral( left atrial-ventricular) valve is more often involved, less often the aortic and tricuspid( right atrial-ventricular) valves. Clinic of rheumatic pericarditis is similar to pericarditis of another etiology.

In rheumatism, the central nervous system can be affected, the so-called rheumatic or minor chorea serves as a specific sign: hyperkinesis appears - involuntary jerking of muscle groups, emotional and muscle weakness.

Less common skin manifestations of rheumatism: annular erythema( in 7-10% of patients) and rheumatic nodules. Ring-shaped erythema( annular rash) is a ring-shaped, pale pink rash on the trunk and legs;rheumatic subcutaneous nodules - dense, rounded, painless, inactive, single or multiple nodules with localization in the middle and large joints.

The defeat of the kidneys, abdominal cavity, lungs and other organs occurs in severe rheumatism, very rarely at the present time. Rheumatic lung injury occurs in the form of rheumatic pneumonia or pleurisy( dry or exudative).With rheumatic damage of the kidneys in urine, erythrocytes, protein are determined, a jade clinic arises. The defeat of the abdominal cavity in rheumatism is characterized by the development of abdominal syndrome: abdominal pain, vomiting, abdominal tension.

Repeated rheumatic attacks develop under the influence of hypothermia, infections, physical overstrain and occur with a predominance of symptoms of heart damage.

Complications of rheumatism

The development of complications of rheumatism is predetermined by the severity, protracted and continuously recurring nature of the course. In the active phase of rheumatism, circulatory insufficiency and atrial fibrillation may develop.

The outcome of rheumatic myocarditis can be myocardiosclerosis, endocarditis - heart defects( mitral insufficiency, mitral stenosis and aortic insufficiency).When endocarditis is also possible thromboembolic complications( infarction of the kidneys, spleen, retina, cerebral ischemia, etc.).With rheumatic lesions, adhesions of the pleural, pericardial cavities can develop. Mortally dangerous complications of rheumatism are the thromboembolism of the main vessels and decompensated heart defects.

Diagnosis of rheumatism

Objective diagnostic criteria for rheumatism are developed by the WHO( 1988), large and small manifestations, as well as confirmation of a previous streptococcal infection. Great manifestations( criteria) of rheumatism include polyarthritis, carditis, chorea, subcutaneous nodules and annular erythema.

Small criteria for rheumatism are divided into: clinical( fever, arthralgia), laboratory( increase in ESR, leukocytosis, positive C-reactive protein) and instrumental( on ECG - lengthening P-Q interval).

Evidence supporting the previous streptococcal infection is an increase in the levels of streptococcal antibodies( anti-streptolysin, antistreptokinase, anti-hyaluronuridase), bacussis from the throat of β-hemolytic streptococcus group A, recent scarlet fever.

The diagnostic rule states that the presence of 2 large or 1 large and 2 small criteria and evidence of a transferred streptococcal infection confirm rheumatism.

Additionally, the radiograph of the lungs determines the increase in the heart and a decrease in the contractility of the myocardium, a change in the cardiac shadow. By ultrasound of the heart( Echocardiography), signs of acquired defects are revealed.

Treatment of rheumatism

The active phase of rheumatism requires hospitalization of the patient and compliance with bed rest. Treatment is carried out by a rheumatologist and cardiologist. Hypersensitizing and anti-inflammatory drugs, corticosteroid hormones( prednisolone, triamsinolone), nonsteroidal anti-inflammatory drugs( voltaren, indomethacin, butadione, brufen), immunosuppressants( plaquenyl, delagil, imarant, 6-mercaptopurine, chlorobutin) are used.

Sanitation of potential foci of infection( tonsillitis, caries, sinusitis) includes their instrumental and antibacterial treatment.

The use of penicillin antibiotics in the treatment of rheumatism is of an auxiliary nature and is indicated in the presence of an infectious focus or obvious signs of streptococcal infection.

In the remission phase, resort treatment is provided in the sanatoriums of Kislovodsk or the Southern coast of Crimea. In the future, to prevent recurrence of rheumatism in the autumn-spring period, a monthly preventive course of NSAIDs is carried out.

Forecast for rheumatism

Timely treatment of rheumatism virtually eliminates the immediate threat to life. The severity of the prognosis for rheumatism is determined by the defeat of the heart( the presence and severity of the defect, the degree of myocardiosclerosis).The most unfavorable from a prognostic point of view is the continuously progressing course of rheumatic heart disease.

The risk of heart disease is increased with the early onset of rheumatic fever in children, late-onset treatment. In primary rheumatic attacks in persons over 25 years of age, the course is more favorable, valve changes usually do not develop.

Prevention of rheumatism

Measures of primary prevention of rheumatism include the detection and rehabilitation of streptococcal infection, hardening, improvement of social, household, hygienic living and working conditions. Prevention of recurrence of rheumatism( secondary prevention) is carried out in conditions of dispensary control and includes prophylactic intake of anti-inflammatory and antimicrobial agents in the autumn-spring period.

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Rheumatism in children

Rheumatism in children

Rheumatism in children is an infectious and allergic disease that occurs with a systemic lesion of the connective tissue of the cardiovascular system, synovial joints of the joints, serous membranes of the central nervous system, liver, kidneys, lungs, eyes, and skin. With rheumatism, children can develop rheumatic polyarthritis, rheumatic carditis, small chorea, rheumatic nodules, annular erythema, pneumonia, nephritis. Diagnosis of rheumatic fever in children is based on clinical criteria, their connection with a transmitted streptococcal infection, confirmed by laboratory tests and markers. In the treatment of rheumatism in children, glucocorticoids, NSAIDs, preparations of quinoline and penicillin series are used.

Rheumatism in children

Rheumatism in children( rheumatic fever, Sokolsky-Buyo disease) is a systemic inflammatory disease characterized by affection of the connective tissue of various organs and etiologically related to streptococcal infection. In pediatrics, rheumatism is diagnosed mainly in children of school age( 7-15 years).The average population frequency is 0.3 cases of rheumatism per 1000 children. Rheumatism in children is characterized by an acute onset, often prolonged, over the years, with a course with alternating periods of exacerbations and remissions. Rheumatism in children is a common cause of the formation of acquired heart defects and disability.

Causes of rheumatism in children

The experience accumulated in rheumatology allows rheumatism in children to be attributed to an infectious and allergic disease, which is based on infection caused by β-hemolytic streptococcus of group A( M-serotype) and altered organism reactivity. Thus, the incidence of a child with rheumatism is always preceded by a streptococcal infection: tonsillitis, tonsillitis, pharyngitis, scarlet fever. The etiological significance of β-hemolytic streptococcus in the development of rheumatism in children is confirmed by the detection in the blood of the majority of patients of anti-streptococcal antibodies - ASL-O, antistreptokinase, antistreptogialuronidase, antidexoxyribonuclease B, with tropism to the connective tissue.

An important role in the development of rheumatism in children is assigned to hereditary and constitutional predispositions. In a number of cases, a family history of rheumatism can be traced, and the fact that only 1-3% of children and adults who have experienced streptococcal infection get sick with rheumatic fever allows one to talk about the existence of so-called "rheumatic diathesis".

The leading factors in the virulence of β-hemolytic streptococcus are its exotoxins( streptolysin-O, erythrogenic toxin, hyaluronidase, proteinase) that cause pyrogenic, cytotoxic and immune reactions that cause damage to the heart muscle with the development of endomyocarditis, contractility and myocardial conduction.

In addition, the proteins of the cell wall of streptococcus( lipoteichoic acid peptidoglycan, polysaccharide) initiate and support the inflammatory process in the myocardium, liver, synovial membranes. The M-protein of the cell wall suppresses phagocytosis, exerts a nephrotoxic effect, stimulates the formation of anticardium antibodies, etc. The basis of skin and subcutaneous tissue damage in rheumatism in children is vasculitis;Rheumatic chorea is caused by the defeat of subcortical nuclei.

Classification of rheumatism in children

In the development of rheumatism in children, the active and inactive phases are isolated. Criteria for the activity of the rheumatic process are the severity of clinical manifestations and changes in laboratory markers, in connection with which three degrees are distinguished:

  • I( minimal activity) - absence of exudative component of inflammation;weak severity of clinical and laboratory signs of rheumatism in children;
  • II( moderate activity) - all signs of rheumatism in children( clinical, electrocardiographic, radiographic, laboratory) are not pronounced;
  • III( maximum activity) - predominance of the exudative component of inflammation, the presence of high fever, signs of rheumatic carditis, articular syndrome, polyserositis. The presence of distinct X-ray, electro- and phonocardiographic signs of carditis. Sharp changes in laboratory parameters - high neutrophilic leukocytosis. Sharply positive CRP, a high level of serum globulins, a significant increase in anti-streptococcal antibody titres, etc.

The inactive phase of rheumatism in children is noted during the interictal period and is characterized by normalization of the child's well-being, instrumental and laboratory indicators. Sometimes between attacks of rheumatic fever is preserved subfebrile and malaise, there is a progression of carditis with the formation of valvular heart disease or cardiosclerosis. Inactive phase of rheumatism in children can last from several months to several years.

The course of rheumatism in children may be acute( up to 3 months), subacute( 3 to 6 months), prolonged( more than 6 months), continuously-relapsing( without clear periods of remission of up to 1 year or more), latent( secretly leading to the formation of valvular heart disease).

Symptoms of rheumatism in children

Clinical manifestations of rheumatism in children are diverse and variable. The main clinical syndromes include rheumatic carditis, polyarthritis, small chorea, anuricular erythema and rheumatic nodules. For all forms of rheumatism, children manifest a clinical manifestation 1.5-4 weeks after the previous streptococcal infection.

The defeat of the heart with rheumatism in children( rheumatic heart disease) always occurs;in 70-85% of cases - primarily. With rheumatism, children may experience endocarditis, myocarditis, pericarditis, or pancarditis. Rheumatic carditis is accompanied by lethargy, fatigue of the child, subfebrile condition, tachycardia( rarely bradycardia), shortness of breath, pain in the heart.

Repeated attack of rheumatic heart disease usually occurs after 10-12 months and is more severe with symptoms of intoxication, arthritis, uveitis, etc. As a result of repeated attacks of rheumatism, all children are diagnosed with acquired heart defects: mitral insufficiency, mitral stenosis, aortic insufficiency, stenosis of the aortic aorta, mitral valve prolapse, mitral-aortic defect.

In 40-60% of children with rheumatism, polyarthritis develops, both in isolation and in combination with rheumatic carditis. Typical signs of polyarthritis in rheumatism in children are the predominant lesion of medium and large joints( knee, ankle, elbow, shoulder, rarely - wrist);symmetry of arthralgia, migratory nature of pain, rapid and complete reverse development of joint syndrome.

Cerebral form of rheumatism in children( small chorea) accounts for 7-10% of cases. This syndrome, mainly, develops in girls and is manifested by emotional disorders( crying, irritability, mood swings) and gradually increasing motor impairments. First, handwriting and gait change, then there are hyperkinesis, accompanied by a violation of the intelligibility of speech, and sometimes - the inability to eat and self-serve independently. The signs of chorea completely regress after 2-3 months, but tend to recur.

Manifestations of rheumatism in the form of anular( annular) erythema and rheumatic nodules are typical for childhood. Ring-shaped erythema is a kind of rash in the form of rings of pale pink color, localized on the skin of the stomach and chest. Itching, pigmentation and peeling of the skin are absent. Rheumatic nodules can be found in the active phase of rheumatism in children in the occipital region and in the region of the joints, in the places of attachment of tendons. They have the appearance of subcutaneous formations 1-2 mm in diameter.

Visceral lesions in rheumatism in children( rheumatic pneumonia, nephritis, peritonitis, etc.) are practically not found at present.

Diagnosis of rheumatism in children

Rheumatism in a child may be suspected by a pediatrician or a children's rheumatologist on the basis of the following clinical criteria: the presence of one or more clinical syndromes( carditis, polyarthritis, chorea, subcutaneous nodules or annular erythema), the connection of the onset of the disease with streptococcal infection, the presence of a "rheumatic anamnesis" infamily, improvement of the child's well-being after specific treatment.

Reliability of the diagnosis of rheumatic fever in children must be confirmed laboratory. Changes in the hemogram in the acute phase are characterized by neutrophilic leukocytosis, acceleration of ESR, anemia. Biochemical blood analysis demonstrates hyperfibrinogenemia, the emergence of CRP, an increase in the fractions of α2 and γ-globulins and serum mucoproteins. Immunological examination of blood reveals an increase in the levels of ASG, ASL-O, ASA;an increase in the CIC, immunoglobulins A, M, G, anticardial antibodies.

When rheumatic carditis in children, carrying out a chest X-ray reveals cardiomegaly, mitral or aortic configuration of the heart. Electrocardiography with rheumatism in children can detect various arrhythmias and conduction disorders( bradycardia, sinus tachycardia, atrioventricular blockades, atrial fibrillation and flutter).Phonocardiography allows you to record changes in heart sounds and noise, indicating the defeat of the valve apparatus. Echocardiography plays a crucial role in the detection of acquired heart defects in rheumatism in children.

Differential diagnosis of rheumatic carditis is carried out with non-rheumatic carditis in children, congenital heart defects, infective endocarditis. Rheumatic polyarthritis should be distinguished from arthritis of another etiology, hemorrhagic vasculitis, SLE.The presence of a cerebral syndrome in a child requires the involvement of a neurologist and the exclusion of neurosis, Tourette's syndrome, brain tumors, etc.

The treatment of rheumatism in children

Therapy for rheumatism in children should be comprehensive, continuous, long-term and gradual.

The acute phase shows inpatient treatment with physical activity restriction: bed rest( with rheumatic carditis) or sparing regimen for other forms of rheumatism in children. To combat streptococcal infection, antibacterial therapy with penicillin drugs is given for 10-14 days. In order to suppress the active inflammatory process, non-steroid( ibuprofen, diclofenac) and steroidal anti-inflammatory drugs( prednisolone) are prescribed. With a prolonged course of rheumatism in children, complex preparations of quinoline series( plaquenil, delagil) are included in the complex therapy.

In the second stage, the treatment of rheumatism in children continues in the rheumatological sanatorium, where general restorative therapy, exercise therapy, mud therapy, sanitation of foci of infection. At the third stage, the observation of the child by specialists( a pediatric cardiologist, a rheumatologist, a children's dentist, a children's otolaryngologist) is organized in a polyclinic. The most important direction of dispensary observation is the antibiotic prophylaxis of relapses of rheumatism in children.

Prognosis and prevention of rheumatism in children

Primary episode of rheumatic heart disease is accompanied by the formation of heart defects in 20-25% of cases;However, recurrent rheumatic carditis does not leave a chance to avoid damage to the heart valves, which requires subsequent cardiac surgery. Mortality from heart failure, due to heart defects, reaches 0.4-0.1%.The outcome of rheumatism in children is largely determined by the timing of the onset and the adequacy of therapy.

Primary prevention of rheumatic fever in children involves hardening, nutrition, rational physical culture, sanation of chronic foci of infection( in particular, timely tonsillectomy).Secondary prevention measures are aimed at preventing the progression of rheumatic fever in children who have suffered rheumatic fever and include the administration of penicillin prolonged action.

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Rheumatism: symptoms and treatment, prevention. How to treat rheumatism

Mechanism of the development of the disease

The mechanism of the onset and development of the disease is associated with two main factors: the presence of the causative agent of antigenic substances common to the tissue of the heart membranes and cardiotoxic effects of enzymes produced by β-hemolytic streptococcus.

When an infection occurs, the body begins to produce anti-streptococcal antibodies that form immune complexes with antigens of the infectious agent that can circulate in the blood and settle in the microcirculatory bed. However, streptococcal enzymes and toxic products of its vital activity have a damaging effect on connective tissue and cardiac muscle.

The place of localization of the inflammatory process most often becomes the cardiovascular system. Also, a nonspecific inflammatory reaction in joints and serous membranes often develops.

Rheumatism, as well as for any other autoimmune pathology, is characterized by a wavy course, with periods of exacerbations and remissions. Provoke the development of exacerbation of various infectious agents, stress, physical overexertion and hypothermia.

The pathological process can extend to all cardiac membranes( this condition in clinical terminology is called "pancarditis"), or to affect one of them.

In the early stages of the disease, its clinical picture determines myocarditis( it is in the myocardium that the primary morphological disorders are detected).Approximately 1.5-2 months after the onset of painful symptoms, inflammatory changes in the inner layer of the cardiac membrane( endocardium) are observed. As a rule, rheumatism initially affects the mitral valve, then follows the aortic valve, followed by the tricuspid valve.

Note: rheumatism is not characterized by damage to the pulmonary artery valve.

Classification of rheumatism

  1. Cardiac form( rheumatic carditis).In this condition, heart membranes become inflamed( rheumopancarditis), but first of all - myocardium( rheumomyocarditis).
  2. Joint form( rheumatic polyarthritis).There are inflammatory changes in the joints characteristic for rheumatism.
  3. Skin.
  4. Rheumatic chorea( dances of St. Witt).Increased activity of dopaminergic structures.

Symptoms of rheumatism

Rheumatism is a polysymptomatic disease, for which, along with general changes in the state, signs of affection of the heart, joints, nervous and respiratory system, as well as other organic structures are characteristic. Most often, the ailment makes itself felt 1-3 weeks after the infectious disease caused by group A beta-hemolytic streptococcus. In subsequent cases, the incubation period is usually reduced.

In a separate group of patients, primary rheumatism may occur 1-2 days after hypothermia, even without infection.

Rheumatic carditis

From the very beginning of the disease, patients complain of persistent pain in the heart, dyspnoea observed both during exercise and at rest, increased heart rate. Often in the right hypochondrium, due to circulatory failure in a large circle, edema appears, accompanied by a sense of heaviness. This condition is a consequence of the increase in the liver and signals the development of a heavily current diffuse myocarditis.

Pericarditis( rheumatic pericardial damage) is a relatively rare form of pathology. Dry pericarditis is accompanied by constant pain in the heart area, and with exudative pericarditis, as a result of the accumulation in the cardiac bag of the exudate inflammatory fluid that separates the pericardium leaves, the pain disappears.

Rheumatic polyarthritis

With the defeat of the musculoskeletal system, gradually increasing pain in the knee, elbow, wrist, shoulder and ankle joints develops. Articular joints swell, and they restrict active movements. As a rule, with articular rheumatism, after receiving non-steroidal anti-inflammatory drugs, the pains quickly stop.

Skin rheumatism

With the development of cutaneous rheumatism, the permeability of capillaries increases. As a consequence, small hemorrhages( petechiae) occur on the lower extremities( in the area of ​​the extensor surface of the joints).Also, often on the skin of the lower legs and forearms appear dense, painless nodules( their sizes range from a millet grain to a large pea).At the same time, it is possible to form dark red painful large seals( the size of a cherry) penetrating the thickness of the skin and slightly rising above the surface. This pathological condition is called nodal erythema. It can be localized not only in the limb region, but also on the skin of the skull.

Rheumatoid pleurisy

This is a relatively rare form of pathology( found in 5.4% of patients suffering from rheumatism).The development of the pathological process is accompanied by the emergence of intense pains that increase with inspiration, an increase in body temperature to 38-40 C. In patients, there are attacks of dry painful cough, in the affected half of the chest can hear pleural noise. Over time, the pain begins to subside, as well as pleural noise. However, the patient's condition worsens. Shortness of breath, febrile condition, respiratory noises begin to disappear, there is a strong weakness, cyanosis. Sometimes, due to the large amount of inflammatory exudates, there may be a lag in the breathing of one half of the chest, a sharp bulging of the intercostal spaces, very severe shortness of breath. Such patients take a forced semi-sitting position.

It should be noted that severe symptoms in rheumatic pulmonary disease are relatively rare. More often the disease is accompanied by lighter manifestations of rheumatic fever.

Rheumatic disorders of the nervous system

Rheumatism sometimes affects the meninges, subcortical layer and brain substance. One of the manifestations of the disease is rheumachorea( dances of St. Witt).This pathology, characterized by involuntary convulsive contraction of the striated muscles, develops in childhood and adolescence. With a convulsive contraction of the glottis, there may be an attack of suffocation, leading to a sudden fatal outcome.

Abdominal syndrome

Rheumatic peritonitis, a pathological condition that often occurs with acute primary rheumatism, is typical only for all children and adolescents. The disease develops suddenly. The body temperature rises sharply, and signs of dysphagia appear( nausea, vomiting, stool disorders, cramping abdominal pains).

Diagnosis of rheumatism

When diagnosing "primary rheumatism" there are often certain difficulties. This is explained by the fact that rheumatic manifestations are very nonspecific, that is, they can be observed in other pathologies. And only the detection of a prior streptococcal infection and the presence of two or more signs of the disease may indicate a greater likelihood of rheumatic damage. Therefore, the diagnosis is based on the presence of syndromes( syndromic diagnosis of rheumatism stage I).

Clinical and epidemiological syndrome( the presence of data indicating the association of pathology with the infectious process caused by beta-hemolytic streptococcus group A);

Clinical and immunological syndrome( subfebrile, weakness, fatigue and heart rate violation after angina or other nasopharyngeal infection).In 80% of patients the antistreptolysin titer is elevated, in 95% antibodies to cardiovascular antigen are detected. Biochemical signs of inflammation include accelerated ESR, dysproteinemia, detection of C-reactive protein;

Instrumental diagnosis of rheumatism( cardiovascular syndrome).

To instrumental methods of research carry:

  • ECG( cardiogram is infrequently detected violations of the heart rate);
  • heart ultrasound;
  • X-ray examination( allows to determine the increase in the size of the heart, changes in its configuration, as well as a decrease in the contractile function of the myocardium);

Laboratory diagnostics. In the general analysis of blood there is an increase in ESR, shift of the leukocyte formula to the left, anemia. In the immunological analysis, the titer of ASH increases, the number of immunoglobulins of class A, G, M increases, C-reactive protein, anticardial antibodies and circulating immune complexes are detected.

Treatment of rheumatism

The best therapeutic effect is achieved with early diagnosis of rheumatism, which helps prevent the development of heart disease. Treatment is carried out in stages and in a complex. It is aimed at suppressing the activity of β-hemolytic streptococcus and preventing the development of complications.

I stage of treatment of rheumatism

At the first stage the patient is assigned inpatient treatment. It includes medicamental therapy, diet therapy and exercise therapy. Appointments are made taking into account the characteristic features of the disease and the severity of the damage to the heart muscle.

Antibacterial therapy is used to eliminate the infectious agent. The only antibiotic that can cope with pyogenic streptococcus is penicillin. Currently, adults and children over 10 years of age are prescribed phenoxymethylpenicillin. In more severe cases, benzylpenicillin is recommended. As drugs of an alternative action, macrolides and lincosamides are used. The duration of the course of antibiotic therapy is at least 14 days. With frequent colds and exacerbations of chronic tonsillitis, another antibacterial drug( amoxocycline, cephalosporins) may additionally be used.

Antirheumatic therapy includes the use of non-steroidal anti-inflammatory drugs, which, depending on the patient's condition, can be used in isolation, or in combination with hormonal agents( no more than 10-14 days).NSAIDs should be applied until signs of an active pathological process are removed( an average of 1-1.5 months).

With prolonged and latent flow of rheumatism, patients are shown taking quinoline drugs( plaquenil, delagil).They are applied by long courses, from several months, to one or two years.

Also during the period of inpatient treatment, foci of chronic infection are eliminated( 2-3 months after the onset of the disease, with an inactive process, it is recommended to remove the tonsils).

II stage of treatment of rheumatism

The main task of this stage is restoration of normal functioning of cardiovascular system and achievement of complete clinical and biochemical remission. The second stage of treatment is carried out in specialized cardio-rheumatological sanatoriums, where patients are assigned a special health regimen, exercise therapy, hardening procedures, differentiated motor activity. Also, spa treatment of rheumatism includes mud therapy( applications on the affected joints), radon, hydrogen sulphide, chloride sodium, oxygen and carbon dioxide baths.

III stage of treatment of rheumatism

Clinical supervision, prevention of relapses preventing the progression of the disease. At this stage, therapeutic measures are carried out, contributing to the elimination of the active course of the pathological process. Patients with heart disease show symptomatic treatment of circulatory disorders. The issues of rehabilitation, work ability of the patient and his employment are also solved.

Principles of treatment of rheumatism in children

In the treatment of rheumatism in children, effective antibacterial therapy( single-dose intramuscular injection of penicillin G sodium salt) is first of all prescribed. When hemorrhagic manifestations shows the use of oral acid-fast penicillin V. In the presence of allergies to this drug, it can be replaced with erythromycin or azithromycin.

The duration of taking nonsteroidal anti-inflammatory drugs is at least 21 days.

In the case of rheumatic carditis, glucocorticoids are given( 1-2 mg per 1 kg of body weight) for 10-15 days. When leaving hormone therapy, salicylates are prescribed.

Forecasts

Rheumatism is a disease that does not pose an immediate threat to the life of the patient. Exceptions are acute meningoencephalitis and diffuse myocarditis, which occur mainly in childhood. In adults, for which the cutaneous and articular forms of the disease are more characteristic, the course is most favorable. With the development of rheumatic fever, there are minor changes in the heart.

The main prognostic criterion for rheumatism is the degree of reversibility of its symptoms, as well as the presence and severity of heart disease. In this case, the most unfavorable are constantly recurrent rheumatic carditis. However, an important role is played by the start of treatment( the later the therapy is started, the higher the probability of developing a defect).In childhood, rheumatism is much more severe than in adults and often causes permanent valve changes. In the case of the development of the primary pathological process in patients who have reached the age of 25, there is a favorable course of the disease without the formation of a defect.

It should be noted that changes in cardiac structures occur only in the first three years after the onset of initial signs of the disease. If during this time there are no valvular disorders, then the subsequent probability of their occurrence is rather low, even with the preserved activity of rheumatism.

Prevention of rheumatism

  1. Timely isolation of a patient who has a streptococcal infection.
  2. Follow-up monitoring of persons in contact with him( preventive single injection of bicillin).
  3. Hardening of the body.

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Rheumatism in children symptoms and treatment |How to treat rheumatism

Rheumatism( rheumatismus) or Sokolsky-Buoyu's disease of children is a systemic inflammatory disease of the connective tissue with a predominant cardiovascular damage that is etiologically associated with group A P-hemolytic streptococcus.

From this article you will learn the main causes and symptoms of rheumatismin children, about how rheumatism is treated in children and what preventive measures you can take to protect your child from this disease.

Treatment of rheumatism in children

A harmonious system of measures has been developed in our country, including the provision of medical and preventive care to the population at various stages of the pathological process. The key to successful treatment is early diagnosis, which means the recognition of rheumatism in the first 7-10 days from the onset of the attack, as well as the early initiation of therapy( from 10-14 days).The main principles of pathogenetic therapy of rheumatism are the fight against streptococcal infection, active influence on the current inflammatory process and suppression of the hyperimmune reaction of the child's body.

How to treat rheumatism in children?

Rheumatism treatment is carried out in 3 stages:

Each child with active rheumatism is to be treated in a hospital( 1st stage).It is extremely important to properly organize the motor regime. Patients with rheumatic carditis II-III degree of activity should be for 1-2 weeks on strict bed rest, and then 2 - 3 weeks - on bed rest with possible participation in board games in bed. During this period, breathing exercises and passive movements are shown. After 1 - 1/2 months( taking into account the results of functional tests), children are transferred to a sparing regime with permission to use a dining room, a toilet;the complex of therapeutic physical training is expanding. Later in the sanatorium( 2 nd stage) children are transferred to the training regime. The diet should be easily digestible, enriched with protein, vitamins and products containing potassium salts. Limit table salt to 5 -6 g per day and liquid, especially in case of circulatory failure. To treat rheumatism recommended fractional meals( 5 - 6 times a day).Difficult to digest products, pickles, extractives are excluded. Sometimes there are fasting days( with circulatory failure of II - III degree).

Treatment of rheumatism in children

Drug therapy includes antibacterial, aimed at eliminating streptococcal infection, non-steroidal anti-inflammatory and immunosuppressive agents, as well as symptomatic( diuretics, cardiac) and corrective drugs. Assign penicillin or its analogs in the age-appropriate dose for 12 to 15 days. At the same time, use acetylsalicylic acid or preparations of the pyrazolone series. Acetylsalicylic acid is prescribed at the rate of 0.2 g, amidopirin - 0.15-0.2 g for 1 year of life of the child per day.

Corticosteroids have a rapid anti-inflammatory and antiallergic effect, which are especially indicated in primary rheumatic carditis and a pronounced exudative component of inflammation. Usually, prednisolone is used, administered at a dose of about 0.75 to 1 mg / kg per day. The duration of application of the maximum daily dose of prednisone is determined by the results of treatment. Its decrease begins when the patient's condition improves, fever, exudative component is eliminated, ESR normalization. The total duration of the course of treatment is 30-40 days, with a continuously-recurrent course of rheumatism it can be more. In recent years, new anti-inflammatory non-steroidal drugs - voltaren and indomethacin have been used, which are successfully used in the general treatment complex. With prolonged and continuously-recurrent course in children, a long-term use of quinoline-based drugs( delagil, plakvinil) at 5-10 mg / kg per day is shown.

An extract from the hospital is made after 11/2 ~ 2 months, provided that the well-being is improved, the positive dynamics of the pathological process is evident and its activity is reduced.

Aftercare and rehabilitation of patients( stage 2) are performed at the local sanatorium for 2 to 3 months. At this stage, treatment with drugs in a half dose continues, the amount of physical exertion is increased, therapeutic gymnastics, restorative measures, aeration are carried out.children receive high-grade food, vitamins.

Further follow-up( 3rd stage) is carried out by a district( city) rheumatologist who regularly examines every child suffering from rheumatism in order to identify signs of disease activation, and performs secondary all-the-year-round prophylaxis( relapse) with the help of bicillin-5.If necessary, sanitize the foci of chronic infection, determine the conditions of the regime and work of schoolchildren. Clinical follow-up of children with rheumatism is carried out until they are transmitted for observation in the adolescent office.

Complex therapy of rheumatism in children

A complex method of therapy for primary rheumatism involves the simultaneous administration of small doses( 0.5-0.7 mg / kg / day) of glucocorticoids and NSAIDs.

Doses of glucocorticoids to treat rheumatism are selected depending on the severity of the pathological process and the severity of changes in the heart. Usually, prednisolone is used in a dose of 15-25 mg / day, with 1 / 2-1 / 3 of the daily dose prescribed in the morning. The initial dose is gradually reduced to complete cancellation on average after 1.5 months.

Of the NSAIDs most often prescribed indomethacin and diclofenac. NSAIDs are combined with glucocorticoids and one of the basic drugs, especially with a prolonged course of the disease and the formation of heart disease.

  • Indomethacin: 23 mg / kg / day in 2-3 doses for 1-1.5 months.
  • Diclofenac: 23 mg / kg / day in 2-3 doses for 11.5 months.

As a basic therapy, quinoline derivatives are used:

  • Chloroquine( hingamine, delagil) at a dose of 0.060.25 g, depending on the age of 1 times a day after dinner;duration of treatment from several months to several years;
  • Hydroxychloroquine( plakvenil) in a dose of 0.05-0.2 g, depending on the age of 1 times a day after dinner;duration of treatment from several months to several years.

Given the streptococcal nature of rheumatism, during the first 10-14 days of therapy prescribe benzylpenicillin or its analogs at 0.75-1 million units / day. The complex therapy includes also sanation of foci of chronic infection, in particular chronic tonsillitis. With decompensated chronic tonsillitis requires tonsillectomy. After 6-8 months after an acute period, sanatorium treatment is recommended.

Prevention of rheumatism in children

Primary prevention includes a set of measures aimed at preventing the development of rheumatism( improving living conditions and work, eliminating crowding in schools, taking two shifts, etc.) and fighting streptococcal infection( use of antibiotics in anginaand other acute diseases of the nasopharynx with control after 10 days of blood and urine, sanation of foci of infection).

Importance of tempering and improving the children's team.

WHO recommendations( 1989) on the prevention of rheumatic fever and its relapse include the following activities.

1.

Primary prevention - activities that ensure the correct development of the child:

  • hardening from the first months of life;
  • full nutrition with sufficient vitamins;
  • rational physical education and sports;
  • control of infection caused by Group A streptococcus( angina, scarlet fever), including administration of penicillin preparations at a dose of 0.75-1.5 million units per day for 10-14 days. The recommended drug is phenoxymethylpenicillin( ospene).
2.

Secondary prevention is aimed at preventing recurrence and progression of the disease. The most optimal year-round prevention, carried out monthly for at least 5 years. All children who have suffered rheumatism are prescribed:

  • benzathine benzylpenicillin + benzylpenicillin procaine( bicillin5) at a dose of 1.5 million units once every 4 weeks to school-age children;
  • bicillin5 at a dose of 0.75 million units 1 time in 2 weeks of patients of preschool age.

Secondary prevention is aimed at preventing the progression and recurrence of rheumatism. All-the-year-round bicillin prophylaxis is performed for at least 3 years in the absence of relapses. Bicillin-5 is used once every 3 weeks at a dose of 600,000 units for preschool children and at a dose of 1,200,000-1,500,000 units once every 4 weeks for children older than 8 years and for adolescents. In addition, after each intercurrent disease, as well as in spring and autumn for 3 to 4 weeks, acetylsalicylic acid courses are administered at the age-related dosage.

In the following 2 years, only seasonal prophylaxis is performed for 6 to 8 weeks( bicillin-5 and acetylsalicylic acid).Periodically, children are sent to a specialized local sanatorium.

Prognosis of treatment. In recent decades, significantly improved due to effective measures to combat streptococcal infection and effective pathogenetic therapy. Rarely began to occur cases of severe rheumatism accompanied by violent exudation. Lethality decreased from 11 - 12% to 0.4 - 0.1%.It is determined by heart failure, which develops in acute course with high activity as a result of severe myocarditis or with prolonged rheumatism due to a formed heart defect with hemodynamic disorders. Combined defects and combined damage to the heart valves are usually observed as a result of repeated relapses of the disease. Primary rheumatic carditis leads to the formation of valvular heart disease in only 10-15% of patients, whereas recurrent - in 40% of patients.

Symptoms of rheumatism in children

Clinical picture of rheumatism

The disease most often develops in 2 to 4 weeks after suffering angina, scarlet fever or acute nasopharyngitis. Diffuse lesion of connective tissue causes a pronounced polymorphism of the clinical picture. The most typical manifestations of the disease in children are carditis( rheumatic carditis), polyarthritis, chorea.

The onset may be acute or gradual and even inconspicuous( in such cases, the diagnosis is made retrospectively on the basis of carditis or heart disease detected).The first signs of the disease in most children are fever, malaise, joint pain. The examination reveals changes in the heart, leukocytosis, increased ESR, anemia. Sometimes rheumatism in children begins with chorea. The clinical severity of individual symptoms and their combination can be very different, depending on the nature of the course and the degree of activity of rheumatism.

Primary rheumatic carditis - this defeat of the heart determines the severity of the course and the prognosis of the disease. Early manifestations in children are fever and general malaise. Very rarely there are complaints of pain or discomfort in the heart.

Objective symptoms are determined by the primary lesion of the myocardium, endocardium or pericardium. In children, myocarditis is the most frequent, and sometimes the only manifestation of cardiac pathology with rheumatism( 100% of cases).Clinically in 75 - 80% of children moderate and mild rheumatic heart disease predominates, and in 20 - 25% - pronounced( most often in the pubertal period).

With objective examination, tachycardia and bradycardia can be noted, in one third of patients the heart rate is normal. In the majority of patients( up to 85%), cardiac enlargement is noted, mainly to the left( clinically and radiologically), with a weakening of cardiac tones. Almost all listen to systolic noise, often at the V point or at the apex, not conducted beyond the heart area.

With a pronounced myocarditis, the exudative component of inflammation with diffuse changes in myocardial interstitium predominates. The general condition of the child is severe, pallor, dyspnea, cyanosis, a weak pulse, a decrease in blood pressure, and rhythm disturbances are noted. The boundaries of the heart are greatly expanded, the heart tones are sharply weakened. There are also signs of heart failure.

On the ECG the most often observed homotopic rhythm disturbances, retardation of atrioventricular conduction, as well as changes in bioelectric processes in the myocardium( decrease and deformation of the G wave, ST segment down, elongation of the electric systole).The severity of ECG changes corresponds to the severity of rheumatic carditis.

The decrease in the amplitude, expansion and deformation of the I tone is noted at the PCG.Pathological III and IV tones can be determined, the systolic murmur is fixed in the muscle.

Endocarditis almost always combines with myocarditis and is observed in 50 - 55% of sick children. The most frequent development of valvulitis, mainly of the mitral valve, the signs of which often appear from the first days of the disease.

The main clinical symptom is a systolic "blowing" noise in the area of ​​the projection of the mitral valve( apex, V point).With the passage of time, as well as in the prone position, on the left side and under physical exertion, its intensity increases. Noise is well carried out in the armpit.

On the PCG, it is recorded as high- and mid-frequency pasystolic or protosystolic murmur of small or medium amplitude with an epicenter at the apex. On radiographs, in addition to widening the left border, the mitral configuration of the heart is determined.

Approximately 10% of patients are affected by the aortic valve, which is manifested by diastolic noise along the left edge of the sternum with a possible decrease in diastolic pressure. In this case, a high-frequency - proto-diastolic - noise of the same localization is recorded on the PCG.

Echocardiography fixes the thickening of the mitral valve, changes in the nature of echoes( "shaggy") from its valves and chords, signs of mitral and aortic regurgitation, dilatation of the left chambers of the heart.

Pericarditis is always observed simultaneously with endo- and myocarditis and is considered as part of rheumatic polyserositis. Clinically diagnosed rarely( 1 - 1.5%), radiologically - in 40% of cases;In a complex instrumental study, including echocardiography, this percentage is much higher. By nature, it can be dry, fibrinous and effusive - exudative. With fibrinous pericarditis pain syndrome is possible and the pericardial friction noise along the left edge of the sternum is intermittent( not constant), which is compared with the rustling of silk or the crunch of snow underfoot.

Serial ECG examination reveals pointed P-teeth and typical dynamics of ST-interval and T wave changes. Echocardiograms show thickenings and separation of epi- and pericardium sheets.

The exudate serous-fibrinous pericarditis affects the general condition of the patients. It sharply worsens, attention is paid to pallor, and with a large accumulation of exudate - the puffiness of the patient's face, cervical veins swelling, shortness of breath, forced semi-sitting position in bed. There may be retrosternal pains, the signs of hemodynamic disorders rapidly increase, amplifying in the horizontal position of the patient. Pulse is frequent, small filling, blood pressure is lowered. Sometimes the heart region swells, the apical impulse is not determined. The borders of the heart are considerably expanded, the voids are deaf. ECG showed a decrease in myocardial electrical activity. On the roentgenogram, along with the expansion of the boundaries and small amplitude of pulsations, the contours of the heart are smoothed, its shadow often acquires the shape of a ball or trapezium.

The echocardiogram determines the echo-negative space separating the epi- and pericardium, the size of which can be judged by the amount of exudate in the cavity of the hearth.

Thus, primary rheumatic carditis in childhood develops after the transferred beta-streptococcal infection, has moderately or poorly expressed clinical and functional manifestations in most children, is characterized by a common combination of lesions of all three heart membranes.

Recurrent rheumatic carditis. Under unfavorable conditions contributing to the recurrence of the process, it is possible to develop repeated attacks with the formation of recurrent rheumatic carditis. In childhood, it is less common than in adolescents and adults. Recurrent rheumatic carditis is usually characterized by a mild exsudative component of inflammation, proceeds in the form of recurrent myocarditis with progression of valvular lesion. In the clinical picture there is a change in the sonority of cardiac tones, an increase in intensity or the appearance of new noises with the development of signs of heart failure and a possible rhythm disturbance.

Rheumatic polyarthritis. It is characterized by multiple symmetrical lesions of predominantly large joints with severe pain syndrome. At the heart of the joint process - acute or subacute synovitis with unstable, volatile nature, inflammatory changes. However, at present, true polyarthritis with edema, hyperemia and abrupt function disorder is rare. The articular syndrome predominates in the form of polyartralgia, the duration of which is from several days to 2 - 3 weeks;relapses are possible.

Chorea( small). This is a manifestation of rheumatic brain damage, predominantly of the striopallidal region. Developed in 11-13% of children with rheumatic fever. It often takes place in isolation with the subsequent addition of carditis, more often during the first attack. It usually starts gradually: the state of health worsens, sleep, school performance, the child is irritable, tearful, distracted. After 1 - 2 weeks, the main signs of chorea develop:

  • hyperkinesis - involuntary impetuous excess movements of various muscle groups, amplified by emotions, external stimuli and disappearing in sleep;
  • muscle hypotension;
  • movement coordination disorder;
  • disorders of the emotional sphere. The behavior of the child changes, there is grimacing, slovenliness, handwriting changes.

Sometimes the number of hyperkinesis is so great that they speak of a "motor storm".The mass of involuntary movements prevents a child from walking, lying, eating, he can not service himself. Sharp muscle hypotension can lead to a decrease or elimination of hyperkinesis and the development of the so-called paralytic, or "soft", form of chorea, which Filatov described. Characteristic violations of tendon and skin reflexes in the form of asymmetry, unevenness, easy exhaustion, the appearance of Gordon's symptom( the topical contraction of the quadriceps muscle when the knee reflex is called).The period of hyperkinesis can last from several weeks to 2-4 months.

At present, small chorea often has an atypical, prolonged recurrent course, especially at preschool age, with poorly expressed clinical signs, asthenia, and vegetovascular dystonia.

With severe rheumatic damage of the nervous system, acute and chronic meningoencephalitis, arachnoiditis, mental disorders, polyneuritis are possible.

Other annoying manifestations of rheumatism in childhood( which are currently rare and only in the active period of the disease) include annular erythema, rheumatic nodules, rheumatic pneumonia, nephritis, hepatitis, polyserositis. Reflex poliserozita may be abdominal syndrome, characterized by pain in the abdomen, sometimes with signs of irritation of the peritoneum.

Causes of rheumatic fever in children

Most often( 80%) rheumatism develops in childhood( 7-15 years), in 30% of cases is of a family nature. The disease is observed in about 1% of schoolchildren, at an early age( up to 2 years) almost never occurs. Rheumatism is the main cause of acquired heart disease in children. Growth of well-being, improvement of living conditions, as well as organization of a system of specialized care and comprehensive prevention of rheumatism, led to a significant decrease in the incidence - up to 0.18 per 1,000 children.

In the development of the problem of childhood rheumatism, Russian pediatricians - VI Molchanov, AA Kisel, MA Skvortsov, AB Volovik, VP Bisyarina, AV Dolgopolova and others - made a great contribution.

Epidemiology. The relationship between the onset of the disease and the transmitted streptococcal infection was established, mainly in the form of angina( exacerbation of chronic tonsillitis), nasopharyngitis, sinuititis, otitis. Important is the fact that rheumatism in children is more often recorded where there is an increased population density( among urban schoolchildren) and the possibility of transmitting infection from one person to another is great. Various diseases of streptococcal nature( scarlet fever, glomerulonephritis, rheumatism, upper respiratory catarrh, septic foci, etc.) occur in 10-20% of school-age children and more often in closed groups. The source of infection is a patient whose streptococci fall on household items. The greatest infectivity is observed in the first 24-48 hours, but the patient remains dangerous to others for 3 weeks. In the spread of infection, the carriage of virulent strains of group A streptococcus is also important. In the external environment, it is relatively stable: under the influence of appropriate conditions it is possible to transform it into L-forms( non-envelope forms of streptococcus).Infected persons often suffer a streptococcal infection in an erased form or almost asymptomatically( in 20-40% of cases), and they also develop rheumatism.

Etiology. main etiological factor is currently considered beta-hemolytic streptococcus group A. In favor of this concept of indirect evidence of the presence in the serum of most patients with active rheumatic fever( 70%) of streptococcal antigen and elevated titers of antibodies to toxins A streptococcus - antistreptolisin-O( ASL-O) antistreptogialuronidazy( LRA) antistreptokinazy( ACK) and Antideza ksiribonukleazy-B, which can be regarded as streptococcal aggression. A good effect of anti-streptococcal therapy of angina and nasopharyngeal diseases in the prevention of rheumatism also confirms this theory. Insufficient treatment of angina and prolonged carriage of streptococcus are one of the conditions for the development of the disease. Relapses of rheumatism and its prolonged course can be caused by both streptococcal reinfection and activation of persistent L-forms in the body.

Pathogenesis. In the development of rheumatism, the massiveness and duration of the effects of streptococcal infection, as well as the peculiarities of the response of the macroorganism, are important.

The main role in pathogenesis belongs to immune reactions of immediate and delayed type with the subsequent development of immune inflammation. Numerous antigens( shell, membrane, cytoplasmic) and streptococcal enzymes cause the formation of specific antibodies, some of which cross react with tissue antigens of the body. Damage to their antigenic structure myocardial sarcolemma and individual components of connective tissues( fibroblasts, glycoproteins, glycans proteolysis) leads to the formation of autoantibodies. Antibodies circulating in the blood and immune complexes containing antistreptolysin O-and C4-komponent complement damage microvasculature, promote activation of inflammatory mediators.

immunopathological reactions confirmed participation in the pathogenesis of inflammation serve as detection deposits in myocardial tissue( immune complexes of antigen - antibody - complement) as well as the frequency of detectable circulating immune complexes in the development of carditis and chorea. Development

immunopathological process, undoubtedly due to the reactivity of the microorganism, in particular the duration antistreptococcal hyperimmune response and Streptococcus defect elimination from the body. At present, great importance is attached to a genetically determined predisposition to rheumatism, which basically boils down to the inheritance of the characteristics of immune responses. This is confirmed by widely known facts of increased frequency of rheumatic diseases in certain families and observations of identical twins( with the development of rheumatism in one of them, the risk of disease in another is much higher than in the same situation in one of the twins).Apparently, under the influence of the same external factors, the rheumatic process is realized precisely in persons with an immunological predisposition to this.

Pathological anatomy. Morphologically rheumatism in children is characterized by systemic disorganization of connective tissue, including mucoid swelling, fibrinoid changes, up to necrosis, and a proliferative reaction( the formation of the granuloma Ashot-Talalayev).Nonspecific changes of exudative character( mucoid swelling, fibrinoid) develop as manifestations of immediate type hypersensitivity( antigen-antibody reaction) and mainly determine the clinical and laboratory activity of the pathological process. Cellular reactions are a reflection of delayed type hypersensitivity. The formation of granulomas in the interstitium of the myocardium, endocardium, pericardium, periarticularly, under synovia is a specific morphological trait for rheumatism. One and the same patient can meet all three stages of change simultaneously, which indicates the continuity of the process. The development of fibrinoid necrosis ends with sclerosing.

An important link in morphogenesis is the diffuse lesion of the vessels of the microcirculatory bed( destructive-productive vasculitis).

It should be emphasized that in childhood, nonspecific - exudative - components of inflammation are most pronounced, which determines the brightness of the clinic and the greater effectiveness of anti-inflammatory therapy provided that a timely diagnosis is made.

Currently, the following working classification of rheumatism is adopted.

Classification of rheumatism in children

Currently common is the classification and nomenclature of rheumatism A.I.Nesterov( Table).The classification is made taking into account the phase of the disease, clinicoanatomical damage to organs, the nature of the course of the disease and the state of the circulation.

Table. Working classification and nomenclature of rheumatism

Phase and degree of activity of rheumatism

Clinical and anatomical characterization of lesions

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