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.
Causes and mechanism of development of rheumatism
Rheumatic attacks are 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)
In the active phase, three degrees are distinguished: 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, lingering, 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 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 lesion of internal organs.
- Clinical and anatomical characteristics of lesions:
- with involvement of the heart( rheumatic carditis, myocardiosclerosis), with or without heart failure;
- with involvement of other systems( rheumatic involvement of 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, 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, 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, and rarely the aortic and tricuspid( right atrial-ventricular) valves are more often involved. 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 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 drugs in the autumn-spring period.
Rheumatism of the heart
Rheumatism of the heart is a serious chronic disease in which the inflammatory process, which began as a result of infection of the joints, covers the membranes of the heart and entails disorganization of the connective tissue of the heart.
Causes of rheumatism of the heart
There are several reasons for the development of this disease:
- frequent and untreated infectious diseases of the nasopharynx( tonsillitis, chronic tonsillitis, chronic pharyngitis, etc.);
- infection with beta-hemolytic group A streptococcus;
- transferred scarlet fever;
- is a hereditary factor.
Some people have a predisposition of the body in the form of hyperreaction to streptococcal infection, which not only causes rheumatic fever, but also causes its exacerbations. There is the concept of "family" rheumatism of the heart, which is caused by a prolonged stay in the streptococcal environment and unfavorable living conditions, as well as the inherited polygenic predisposition to the disease.
Symptoms of rheumatic heart
Symptoms of rheumatism of the heart appear, as a rule, 1 to 2 weeks after a streptococcal infection. However, in some cases, the disease can take a long time to be practically not noticeable for the patient, progressing at a slow pace.
The most common manifestations of the disease include:
- general weakness, fatigue;
- severe joint pain;
- increased sweating;
- pallor of the skin;
- heart rhythm disturbances;
- nasal bleeding;
- weight loss;
- lack of appetite;
- shortness of breath;
- increased body temperature.
Special attention is paid to such a symptom for rheumatism, as pain in the heart. These pains, as a rule, are pulling, pricking and often combined with rapid heart rate.
Heart defects in rheumatism
If the treatment is not started on time, it can lead to heart disease or articular deformities. Heart disease is a defect in the structure of the heart, leading to a malfunction of its normal functioning. Rheumatic heart defects often develop with repeated rheumatic attacks.
The most common rheumatism of the heart affects the mitral valve - the narrowing of the lumen occurs, or the valve starts to flow the blood in the wrong direction. The aortic and other valvular defects are less common.
It should be borne in mind that heart defects can not give symptoms for a long time and are detected only with thorough diagnosis.
Treatment of rheumatic heart
Rheumatism of the heart requires comprehensive treatment in a hospital environment, the main principles of which are:
- Bed rest - recommended for the entire treatment period. The subsequent restoration of physical activity must be slow.
- Compliance with diet: salt refusal, restriction of liquid and carbohydrates, sufficient intake of protein, potassium-containing products( dried apricots, buckwheat porridge, potatoes, etc.).
- Medical therapy: administration of antibiotics, anti-inflammatory and vitamin preparations. In some cases, cardiac therapy is performed.
- Sanatorium treatment - recommended during the recovery period after treatment and in the future as supporting activities.
Treatment of rheumatic heart folk remedies
Traditional medicine suggests the use of medicinal plants for the treatment of this disease. Here are a few recipes:
- A tablespoon of collection from 10 g of buckthorn bark, 40 g of birch leaves and 50 g of willow bark pour a glass of boiling water. Insist for an hour, strain and take twice a day for a glass of infusion.
- Prepare a tincture of twigs of yellow acacia with leaves, fill 30 g of raw material 200 g of vodka. Infuse in a dark place for 10 days, then strain and take 20 drops three times a day, washing down with water.
- Take on an empty stomach juice from half a lemon, diluted with half hot water.
rheumatic heart disease
Many ignorant people in medicine believe that rheumatism is when the joints hurt. But the real insidiousness of the disease lies in the fact that, first of all, it affects the cardiovascular system, first of all, the heart itself."Rheumatism licks the joints and bites the heart," - so meticulously described it as French doctor Lacega in the 19th century. How does the damage occur, what to expect from the disease and how to cope with it?
If you suffer from rheumatism and your heart has already suffered from the disease, consider, together with your doctor, the possibility of cardiac rehabilitation. We invite patients to effective rehabilitation programs in the sanatorium "Barvikha".Call on the phone.8( 495) 228-90-30, 8( 495) 642-52-86.
Why is the heart affected by rheumatism?
It is now proved that the factor provoking the development of rheumatism is beta-hemolytic streptococcus group A. This microorganism secretes a number of toxins( streptolysins) that disrupt the activity of the heart.
In addition, under the action of streptolysins, the antigenic structure of the surface membrane of endocardial cells( the inner shell of the heart) changes, and the body's immune system begins to perceive them as "strangers."A kind of allergic reaction to one's own cells develops.
There are statistical data that at the first attack of rheumatism the myocardium( cardiac muscle) is affected in 100% of cases, the endocardium( the inner membrane that forms the valves of the heart) - up to 40% of cases. With repeated attacks, due to the increase in sensitivity to streptococcal allergens, the endocardium affects up to 95% of cases.
As a result, recurrent( repeated) rheumatic endocarditis leads to deformation of the heart valves( more often mitral), i.e.to heart disease, and to the onset of heart failure.
How is acute rheumatic heart disease manifested?
Acute rheumatic heart disease is rheumatic heart disease, i.e.inflammation of the heart, which occurs during the primary attack or with the relapse of rheumatism.
In modern medical literature, the name "acute rheumatic fever" is more common, which corresponds to the International Classification of Diseases of the 10th revision( ICD-10).
Symptoms are characterized by:
- onset of the disease 1-3 weeks after catarrh of the nasopharynx or sore throat
- fever, chills with sweating
- sensation of lack of air, fast fatigue
- discomfort or pain in the heart
- heart rhythm disturbance( palpitation,work, acceleration or slowing of the rhythm)
- in severe conditions - swelling, signs of heart failure.
In most cases, rheumatic carditis is combined with rheumatic polyarthritis, when pain and swelling occur in the large and medium joints, their function is impaired. The nervous system, skin and other organs are much less affected.
Such a bright picture of the disease is more common at the age of 7 to 20 years, when the body's immune system reacts violently to streptococcal infection. For the older age is characterized by an "erased", low-symptom flow of the process, because of which it can sometimes not be recognized.
What is chronic rheumatic heart disease?
The effects of acute rheumatic fever, which manifest themselves in the chronic inflammatory process in the heart and its membranes, as well as in the development of defects( deformity, disturbance of function) of the mitral or aortic valves, is called chronic rheumatic heart disease.
Types of Rheumatic Heart Disease:
- Valve Insufficiency
Valves are similar to doors that open when the heart chamber is cut, missing a portion of blood, and close when this portion has already passed. The function of the valves is to prevent the reverse flow of blood. Normally, their shutters close tightly during closing.
Due to the inflammatory process and the destruction of the valves, the correct tight closing of the valve flaps becomes impossible. This condition is called valve failure. As a result, the reverse flow of blood occurs in the phase of myocardial relaxation. The load on the heart increases, which subsequently leads to the development of chronic heart failure.
- Stenosis of the valve
The word "stenosis" is of Greek origin and means "constriction".With stenosis due to rheumatic inflammation, a partial fusion of valve flaps and narrowing of its lumen occurs. This breaks the blood flow and significantly increases the burden on the heart. The result is clear - heart overload, stretching of his chambers and chronic heart failure.
3. Combined defect - valve deformation occurs simultaneously by the type of insufficiency and stenosis.
4. Combined defect - simultaneous damage of several valves in severe course of chronic rheumatic heart disease.
Most often, rheumatism affects the mitral valve, which is located between the left atrium and the left ventricle. The second most frequent lesion is the aortic valve at the border between the left ventricle and the aorta. The remaining valves, as a rule, are not involved in the inflammatory process.
The main symptoms of chronic rheumatic heart disease
Here are the symptoms that can be suspected:
- increased fatigue, weakness
- sensation of air shortage, dyspnoea at physical exertion and even at rest
- choking and coughing attacks at night( and just lying down)
- heartbeatand various heart rhythm disturbances
- discomfort and pain in the heart area
- appearance of edema.
What is the insidiousness of rheumatic heart disease?
It should be remembered that before the era of antibiotics in almost 100% of cases, the disease led to deformation of the valves( heart disease) and the onset of heart failure. Therefore, most patients with rheumatism died at a young age, before reaching the age of 30-40.
Currently, due to bicillin prophylaxis and timely cardiac rehabilitation, heart defects are formed only in 20-25% of cases. This means that any suspicion of heart disease should be confirmed or disproved during the examination, and if the disease does exist, it is very important to conscientiously treat "from" and "before."
Several facts about rheumatism
- primary attack of rheumatic fever occurs more often in children aged 7 to 15 years - according to statistics in 70% of cases of
- after 45 years people do not practically suffer from acute rheumatic fever
- women are more susceptible to the disease than men
- wet climate,work in damp and cold rooms contribute to the onset of the disease
- frequent colds, chronic tonsillitis, decreased immunity also provoke the disease
- revealed hereditary predisposition to rheumatism
- timely diagnosis, treatment and cardio-rehabilitation can prevent the formation of defect of the heart valves and the development of chronic rheumatic heart disease.
If you suffer from rheumatism and your heart has already suffered from the disease, consider, together with your doctor, the possibility of cardiac rehabilitation. We invite patients to effective rehabilitation programs in the sanatorium "Barvikha".Call on the phone. 8( 495) 228-90-30, 8( 495) 642-52-86.
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Rheumatism: symptoms, diagnosis, treatment
Rheumatism is an inflammation of the connective tissue with a predominant localization of the process in the cardiovascular system.
The development of rheumatism is closely related to a previous acute or chronic nasopharyngeal infection caused by streptococcus, directly or indirectly, by the damaging effects of its components and toxins on the body with the development of immune inflammation.
For selective damage to the valves of the heart and myocardium with the development of immune aseptic inflammation, anti-streptococcal antibodies that cross-react with the tissues of the heart( molecular disguise) are responsible.
An important role is assigned to genetic factors, which is confirmed by the more frequent incidence of children from families in which one of the parents suffers from rheumatism.
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Rheumatism is characterized by a variety of manifestations and variability of the flow. As a rule, it occurs at school age, less often in preschool children and practically does not occur in children under 3 years old.
- In typical cases, the first signs of rheumatism in the form of fever, signs of intoxication( fatigue, weakness, headache), joint pain and other manifestations of the disease are detected 2-3 weeks after sore throat or pharyngitis.
- One of the earliest signs of rheumatism is joint pain, detected in 60-100% of cases( rheumatoid arthritis).
- Rheumatoid arthritis is characterized by an acute onset, involvement of large or medium joints( more often knee, ankle, elbow), rapid reverse development of the process.
- Symptoms of heart failure are defined in 70-85% of cases. Complaints of a cardiac nature( pain in the heart, palpitation, dyspnea) are noted with severe cardiac disorders.
- More often, especially at the beginning of the disease, there are various asthenic manifestations( lethargy, malaise, fatigue).
To rarer symptoms of rheumatism is the annular rash and rheumatic nodules.
Annular rash( annular erythema) - pale pink soft rashes in the form of a thin annular rim that does not rise above the surface of the skin and disappear when pressed. The rash is found in 7-10% of patients with rheumatism, mainly at the peak of the disease and is usually unstable.
Subcutaneous rheumatoid nodules are round, dense, inactive, painless, single or multiple formations with localization in the area of large and middle joints, spinous processes of the vertebrae, in the tendons. Currently, there are rare, mainly with severe rheumatism, remaining from a few days to 1-2 months.
Abdominal pain, damage to the lungs, kidneys, liver and other organs with rheumatism is currently very rare, mainly in severe its course.
Photo: ring-shaped eczema as a sign of rheumatism
The ECG often shows irregularities in the rhythm.
Radiographically( in addition to not always expressed increase in the heart), signs of a decrease in the contractile function of the myocardium, a change in the configuration of the heart are determined.
Laboratory indicators in patients with rheumatism reflect the signs of streptococcal infection, the presence of inflammatory reactions and the immunopathological process.
The active phase is determined: leukocytosis with a leftward shift, an increase in ESR, often anemia;increased serumucoid, diphenylamine reaction;disproteinemia with hypergammaglobulinemia;increase of titers of ASG, ASLO, increase in immunoglobulins( Ig) of class A, M and G;C-reactive protein( CRP), circulating immune complexes, anticardial antibodies.
Treatment of rheumatism
Treatment of rheumatism is based on the early appointment of a comprehensive therapy aimed at suppressing streptococcal infection and the activity of the inflammatory process, as well as preventing the development or progression of heart disease.
The implementation of these programs is carried out on the basis of the sequence principle:
- Stage I - inpatient treatment,
- II stage - aftercare at the local cardio-rheumatological sanatorium,
- Stage III - dispensary observation in the polyclinic.
1. At the first stage in the hospital, the patient is prescribed medicinal treatment, correction of nutrition and therapeutic exercise, which are determined individually, taking into account the characteristics of the disease and, above all, the severity of the heart.
In connection with the streptococcal nature of rheumatism, treatment is carried out with penicillin.
- Antirheumatic therapy involves one of the non-steroidal anti-inflammatory drugs( NSAIDs), which is administered alone or in combination with hormones, depending on the indications.
- Antimicrobial therapy with penicillin is carried out for 10-14 days.
- In the presence of chronic tonsillitis, with frequent exacerbations of focal infection, the duration of treatment with penicillin is increased or additionally used by another antibiotic - amoxicillin, macrolides( azithromycin, roxithromycin, clarithromycin), cefuroxime axetil, other cephalosporins in the age-related dosage.
- NSAIDs are used for at least 1-1.5 months until the signs of activity are eliminated.
- Prednisolone in the initial dose is prescribed for 10-14 days before the effect is obtained, then the daily dose is reduced by 2.5 mg every 5-7 days under the control of clinico-laboratory indicators, in the following the drug is canceled.
- Duration of treatment with quinoline preparations for rheumatism is from several months to 1-2 years and more, depending on the course of the disease.
In a hospital environment, the elimination of chronic foci of infection, in particular, the tonsillitis surgery, carried out 2-2.5 months after the onset of the disease, in the absence of signs of activity of the process, is also carried out.
2. The main task at the second stage is to achieve complete remission and restore the functional capacity of the cardiovascular system.
The sanatorium continues the therapy begun in the hospital, treats the foci of chronic infection, implements the appropriate treatment and health regime with differentiated motor activity, therapeutic physical training, hardening procedures.
3. The III stage of complex therapy of rheumatism provides for the prevention of relapse and progression of the disease.
To this end, penicillin preparations of prolonged action, mainly bicillin-5, are used, the first administration of which is carried out even during inpatient treatment, and in the subsequent - once in 2-4 weeks all year round.
Regularly, 2 times a year, an outpatient examination is carried out, including laboratory and instrumental methods;appoint the necessary recreational activities, therapeutic exercise.
For rheumatism without cardiac involvement, bicillin prophylaxis is carried out for 5 years after the last attack.
In the spring-autumn period, along with the introduction of bicillin, a monthly course of NSAIDs is shown.
Prevention of rheumatism is divided into primary and secondary.
Primary prevention is aimed at preventing rheumatism and includes:
1. Enhance immunity( hardening, alternation of exercise and rest, nutrition, etc.).2. Detection and treatment of acute and chronic streptococcal infection.3. Preventive measures in children predisposed to the development of rheumatism: from families in which there are cases of rheumatism or other rheumatic diseases;often with nasopharyngeal infection;having chronic tonsillitis or who underwent an acute streptococcal infection.
Secondary prophylaxis is aimed at preventing recurrences and progression of the disease in patients with rheumatism in conditions of dispensary observation.
Forecast for rheumatism
Currently, with timely treatment, the primary lesion of the heart ends in recovery.
The formation of valvular heart disease, more often with the development of mitral insufficiency, is determined in 15-18% of cases in the first attack, mainly in severe, prolonged or latent course of the disease.
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Rheumatic heart disease
What is it?
Not so long ago, the defeat of the cardiovascular system with rheumatism was considered as a complication of the joint syndrome. Only after the publication of the works of the French doctor Buyo( 1836) and the Russian physician IGSokolsky( 1838), rheumatism was isolated in an independent disease, providing for the defeat of the heart.
Although in the XX century.the incidence of rheumatic fever slowly but surely declined, yet about 10 percent of heart operations are still being done just about his chronic rheumatic fever. In more than half the cases, rheumatoid arthritis causes rheumatic heart disease.
What makes it happen?
Rheumatism itself occurs as a late complication of strep infection( usually the throat), for example, sore throat or pharyngitis. However, do not be scared: only 0.3-3 percent of people who have suffered acute streptococcal infection get rheumatism. For the emergence of rheumatism, first of all, the individual increased immune response of the body to streptococcal antigens and the duration of this response are important.
The intermediate stage between primary rheumatism and heart disease is rheumatic carditis - it is when the heart shells are involved in the inflammatory process. It can occur both against the background of joint disease, and without it. The term "rheumatic carditis" refers to the joint damage of the cardiac muscle - the myocardium( myocarditis) and the inner shell of the heart - endocarditis( endocarditis).It is very difficult to separate these two states, especially at the first attack of rheumatism. Unfortunately, endocarditis can often be referred to when there are signs of heart disease.
The connection between rheumatism and heart damage is most accurately reflected in the aphorism of the French doctor Lacega: "Rheumatism licks the joints and bites the heart."Rheuma? ?in translation means fluidity. And, indeed, rheumatism shows its fluidity, then giving a heavy current with a rapid heart attack, then hiding, and, as if disappearing.
For selective damage to heart valves and myocardium in the process of inflammation development, anti-streptococcal antibodies that cross-react with the heart tissues are responsible, and this situation is a direct consequence of a violation of immunity, or, more accurately, a malfunction of the immune response of the body to streptococcal infection.
Chronic rheumatic heart disease causes severe disruption of its functions, often occurring after a sharp attack of rheumatic fever. Myocarditis is mostly cured, but deformations of valves, especially mitral and aortic, usually remain. In 85 percent of cases with rheumatism the mitral valve is affected, rarely there is a two-valve lesion, and even less often?isolated lesion of the aortic valve. Moreover, aortic heart defects can be asymptomatic for a long time( sometimes for 20-25 years), but further in people with rheumatic heart defects develop the most formidable complications - thromboembolism, arrhythmias and chronic heart failure. Cardiac asthma and pulmonary edema are less common.
In case of rheumatic valvulitis, the valve flaps thicken and become loose on the edge. After 6 months? 1 year, fibrosis of the tissue develops - it is a thickening and the appearance of scar changes in the connective tissue, often resulting from its inflammation or trauma - up to the restriction of the mobility of the posterior sash of the mitral valve.
Symptoms of heart disease are defined in 70 to 85 percent of cases at the onset of the disease and somewhat more often in subsequent attacks, but depend on where the process itself is going-in the myocardium, endocardium, or pericardium.
In rheumatic carditis( inflammatory heart disease) a person complains of weak pains and unpleasant sensations in the region of the heart, shortness of breath due to physical exertion, palpitations, interruptions. However, not all heartbeats and pains in the heart are symptoms of rheumatic heart disease. For example, similar symptoms in adolescence do not necessarily talk about rheumatic heart disease, but are a natural consequence of the difference in the speed of development of the skeleton, muscles and internal organs of the child.
Diagnosis of rheumatic carditis is handled by a cardiologist. The method of echocardiography allows using ultrasound to study the state of the heart muscles and valves and assess the rate of movement of blood in the heart cavities. When examining the activity of the heart, an obligatory method is an electrocardiogram( ECG), a treadmill test-recording of an electrocardiogram under physical exertion and a holter monitoring of an ECG is an ECG recording conducted during the day.
Treatment is reduced to the prevention of repeated infections by antibiotics, the active use of physiotherapy methods for the first symptoms of rheumatism and to the surgical repair or replacement of damaged heart valves. A balloon valvuloplasty is used to treat aortic heart disease. If a person is affected and mitral and aortic valves - the so-called combined mitral-aortic heart disease - the operation of mitral commissurotomy is performed. If it is not possible to cure damage to the heart valves, surgery to replace the heart valves has become very popular in recent years.
Rheumatism( Rheumatic Fever) |Doctor-V.ru
Rheumatism( Rheumatic fever) is a systemic inflammatory disease of connective tissue with a predominant localization of the process in the cardiovascular system, which develops in persons predisposed to it, mainly young people, in connection withinfection( 3-hemolytic group A streptococcus.
This definition of the disease emphasizes:
- predominant cardiovascular disease;
- the role of pathological heredity;
- significance of strepoocox infection
The essence of the disease lies in the defeat of all the membranes of the heart, but mainly the myocardium and endocardium with the appearance of deformation of the valvular apparatus - a heart defect and the subsequent development of heart failure. The defeat of other organs and systems in rheumatism is of secondary importance and does not determine its severity and prognosis
The incidence rate is highest for children and adolescents( 5-15 years) and does not depend on sex. Primary attack of rheumatism can be in people aged 20-30 years, but after 30 years of primary rheumatism is almost not found. After 40 years of rheumatism do not fall ill. Nevertheless, you can meet a patient and over 60 years old, suffering from rheumatic heart disease, but this does not mean that he fell ill for the first time at this age;His rheumatic attack was at a young age.
It is noted that those who developed rheumatism shortly before the onset of the disease suffered angina, exacerbation of chronic tonsillitis, and in their blood they determined an increased amount of streptococcal antigen and anti-streptococcal antibodies. This association with the previous streptococcal infection is especially pronounced in acute rheumatism accompanied by polyarthritis.
In the development of rheumatism, social factors( unfavorable living conditions, malnutrition), as well as genetic predisposition( the existence of "rheumatic" families are well known) are important, which is a hyperimmune response to streptococcus antigens, the tendency of patients to autoimmune and immunocomplex processes.
Classification of .Currently, the classification of rheumatic fever( Association of Rheumatologists of Russia, 2003), reflecting clinical variants, basic and additional clinical manifestations, outcomes and functional state of the cardiovascular system( Table 8) has been adopted.
Table 8. Classification of rheumatic fever
03. Pathogenesis of
In response to ingestion of streptococcal infection, anti-streptococcal antibodies are produced and immune complexes are formed( streptococcus antigens + antibodies to them + complement) circulating in the blood and settling in the microcirculatory bed. The toxins and enzymes of streptococcus also have a detrimental effect on the myocardium and connective tissue( Scheme 8).
Scheme 8. The pathogenesis of rheumatism
Due to the genetic defect of the immune system, the streptococcal antigens and immune complexes are not fully and rapidly eliminated from the body of the patients. The tissues of such patients have an increased tendency to fix these immune complexes. In addition, cross-reacting antibodies are important, which, appearing in response to the presence of streptococcal antigens, are able to react with tissue, including cardiac antigens of the body. In response, inflammation develops on the immune basis( by the type of immediate type hypersensitivity - GNT), while the factors that realize the inflammatory process are the lysosomal enzymes of neutrophils that phagocytize immune complexes and are destroyed in this case. This inflammatory process is localized in the connective tissue of the predominantly cardiovascular system and changes the antigenic properties of her and the myocardium. As a result, autoimmune processes develop according to the type of delayed type hypersensitivity( HRT), and lymphocytes reacting with myocytes are detected in the blood of patients. These cells are given great importance in the origin of organ damage( primarily the heart).Antimyocardial antibodies are also detected in the blood, but they are of less importance in the development of heart damage.
Systemic inflammatory process with rheumatism is manifested by characteristic phase changes in connective tissue( mucoid swelling - fibrinoid changes - fibrinoid necrosis) and cellular reactions( infiltration by lymphocytes and plasmocytes, formation of rheumatic, or Aschoff-talalay, granuloma).These Cell Reactions are the morphological expression of immune disorders. The pathological process ends with sclerosing.
Another morphological substrate of heart failure in rheumatic carditis is a nonspecific inflammatory reaction, essentially similar to that in joints and serous membranes. It is expressed in the edema of the intermuscular connective tissue, sweat of fibrin, infiltration by cellular elements, mainly neutrophils and lymphocytes.
As the pathological process has an autoimmune character, the disease also flows undulating, exacerbated by infection or Nonspecific factors( hypothermia, physical stress, emotional stress, etc.).
When the heart is affected, the inflammatory process spreads to the endocardium and myocardium( endomyocarditis or rheumatic carditis) or to all the heart shells( pancarditis) or affects only the myocardium( at the first, rarely at the second attack).Morphological changes in rheumatism are found primarily in the myocardium, therefore it is myocarditis in the early period that determines the clinical picture. Inflammatory changes in the endocardium( valvulitis, warty endocarditis), lesions of tendon filaments and fibrous rings are clinically detected in later rheumatism attacks - after 6-8 weeks.
There is a definite pattern of damage to the heart valves: most often affects the mitral, then aortic and tricuspid valves. The valve of the pulmonary artery with rheumatism is almost never affected.
Various heart defects occur at different times after the attack of rheumatism: insufficiency of the mitral valve - after 6 months after the onset of the attack( aortic valve insufficiency a little earlier), mitral stenosis - 2 years after the attack;in even later terms, stenosis of the aortic aperture is formed.
04. Clinical picture( Symptoms)
As is known, with rheumatism the cardiovascular system predominantly suffers. Therefore, it is advisable to divide all manifestations of the disease into cardiac and non-cardiac diseases and describe the clinical picture of the disease from these positions.
It should be borne in mind that the clinical picture of rheumatism proper is more distinct at the first attack, while the vice is not yet formed. With relapses of rheumatism, when heart disease has already formed, and even more so in the presence of heart failure, the clinical symptomatology of the active rheumatic process is more difficult to identify, since it is caused by a combination of heart disease and impaired blood circulation. In this regard, the clinical picture of the primary attack of rheumatic fever is discussed below.
Diagnostics of .Recognition of of primary rheumatism presents great difficulties, since its most frequent manifestations, such as polyarthritis and heart damage, are not specific. At present, the largest and smallest criterion of rheumatism of the American Association of Cardiology, which was revised in 1992, has become the most widespread worldwide.
06. Treatment of
Currently, with rheumatism treatment is carried out in 3 stages: 1) treatment in the active phase in the hospital;2) continued treatment of the patient after discharge in the cardiorherapy rooms of the polyclinic;3) the subsequent long-term dispensary supervision and preventive treatment in a polyclinic.
Forecast of .An immediate threat to life with rheumatism is very rare. The prognosis is mainly determined by the severity of the heart defect and the state of the contractile function of the myocardium.
Primary prevention consists of a set of public and individual measures aimed at preventing primary morbidity( improving living standards, promoting healthy lifestyles, in particular tempering, improving living conditions, combating crowding in kindergartens, schools, public institutions).
Important is the early and effective treatment of angina and other acute streptococcal diseases of the upper respiratory tract. This is achieved by the appointment of penicillin during the first 2 days to 1 500 000 units, on the 2nd day bicillin-5 is administered to 1,500,000 units. With intolerance to penicillin, erythromycin can be given for 10 days. Any treatment of angina should last at least 10 days, which leads to a complete cure for streptococcal infection. Prevention of recurrence of rheumatic fever( secondary prevention) is performed in the hospital immediately after the end of a 10-day treatment with penicillins( macrolides).The classic parenteral regimen is benzathine benzylpenicillin( retarpen, extensillin) for 1.2-2.4 million units intramuscularly once every 3-4 weeks. The smaller the patient's age at the first attack, the greater the probability of a relapse. After a five-year follow-up, the frequency of relapse usually decreases with age. Patients without rheumatic heart disease should receive antiretroviral prophylaxis at least 5 years after the last attack, at least up to 21 years of age. Patients who had a heart attack during the previous attack, the prevention is carried out for at least 40 years or more. Patients who underwent heart surgery for rheumatic heart disease, secondary prevention is carried out for life.
what is rheumatism
Rheumatism is a disease that develops imperceptibly and gradually. First of all, it damages our heart, blood vessels and joints. Then he gets to other organs: the liver, kidneys and lungs. This multifaceted manifestation of rheumatism is due to the fact that it does not just destroy any one organ. The disease affects a whole group of cells with specific properties( connective tissue), which are found in our body everywhere.
Rheumatism is an infectious-allergic disease that affects the connective tissue( mainly the cardiovascular system, joints, muscles, internal organs, skin).
Manifestations, symptoms of rheumatism are diverse, the most common lesions of joints( more often - knee, ankle, less often - shoulder, hip).The joint swells, the skin over it blushes, glosses, becomes hot to the touch;the temperature rises( up to 40 °).A few days later, pain and swelling cover a number of joints, not only large, but also small. The patient has to lie motionless, because any movement causes severe pain. With timely and proper treatment after a while, the temperature becomes normal, the pain passes. During an attack, or otherwise called a "rheumatic attack", the muscle and valvular valves( rheumatic heart) are often affected. Rheumatic diseases of the peripheral nervous system include neuritis and radiculitis: the central nervous system can also be affected - chorea occurs( a disease characterized by twitching, involuntary movements).
disease, according to the mound of the loin. .
Rheumatism is a chronic disease characterized by affection of connective tissue with the primary involvement of the cardiovascular system and joints in this process.
Causes of the disease. The main cause of rheumatism - the presence of slag in the blood as a result of malnutrition. The origin of rheumatism can also be caused by streptococcal infections( angina, scarlet fever, pharyngitis) and genetic predisposition of the body. When hypothermia the disease worsens.
Manifestations of rheumatism - pain and stiffness of muscles and( or) joints, reddening and swelling of the joints - elbows, knees, ankles( rheumatic polyarthritis).Rheumatic damage to the heart valves over time can lead to persistent deformation and the formation of heart defects.
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