Many of us have seen old people with twisted fingers and swollen knuckles. It is difficult for such people to perform even very simple actions - fasten a button, hold a spoonful of soup, dial a phone number. These signs of rheumatoid arthritis do not appear immediately, but years after the onset of the disease. The disease affects not only the joints of the hands, but also the legs. If the disease has affected the knees, it is very difficult for a person to move even with a cane. It becomes a problem for him to sit down, climb the stairs. These signs of rheumatoid arthritis also indicate an advanced stage of the disease. Not everyone knows that you can even die from it. Every year, rheumatoid arthritis kills about 50,000 people worldwide. Consider what causes this ailment, what are its signs, how it should be treated.
General information
People have known rheumatoid arthritis for thousands of years. The characteristic signs of this disease are found on the remains of people who lived 4500 years before ours.era. Nowadays, it is spread all over the planet. Rheumatoid arthritis affects people of all nationalities and ethnic groups. It is especially common in South America and Russia. What is the reason, scientists have not yet figured out. But it is already known that women are affected by this disease approximately 3-5 times more often than men.
Rheumatoid arthritis is considered by some to be a disease of the elderly, because it is diagnosed in older people about 5 times more often than in young people. Basically, the first signs of rheumatoid arthritis are observed in people aged 40-50 years.
The disease rarely develops rapidly. Usually it proceeds slowly, the joints are destroyed gradually. In parallel with pathological changes in the musculoskeletal system, the work of many body systems is deteriorating, which, without quality treatment, can lead to death.
Reasons
Many people believe that the development of rheumatoid arthritis (especially in the hands) is affected by professional activities, for example, work that requires a long time to perform manipulations in cold water. This opinion is based on the fact that such workers most often develop symptoms of rheumatoid arthritis on their hands. The causes of the disease, unfortunately, have not yet been precisely established by doctors. Unfavorable working conditions only contribute to its emergence. However, rheumatoid arthritis is not a cold-related disease.
There is a version that it is associated with bacterial orviral infections, but in practice it is not confirmed.
Many scientists suggest that the basis of its appearance is a violation of the immune system. In a he althy person, all of a sudden, lymphocytes, designed to protect against all kinds of infections, begin to consider their own absolutely he althy cells located in the synovial fluid of the joints as foreign agents. This triggers the immune defense mechanism.
This is by far the main version explaining the causes of rheumatoid arthritis. Symptoms of the disease do not appear immediately. For some time, the cells try to work in the same mode, but the running mechanism cannot be stopped. You can only slow down its activity. This is the main task of doctors prescribing a course of therapy for those suffering from rheumatoid arthritis.
Risk factors
The start for the development of the disease can be a variety of conditions and situations. Doctors divided them into three groups:
1. Heredity. It determines the genetic predisposition of a person to autoimmune reactions. It is known that the first visual signs of rheumatoid arthritis are observed in carriers of antigens of the MHC II group, that is, HLA DR4 and HLA DR1. In the future, x-rays, as a rule, confirm the presence of a destructive process in the joints in such patients.
2. Infections. This group includes viruses:
- Hepatitis B.
- Shingles.
- Epstein - Barr.
- Herpes simplex.
- Paramyxoviruses (cause measles, mumps, respiratory sensitial infections).
- Cytomegalovirus.
- Retroviruses.
All of them affect the development of rheumatic ailments, acting as a complication of the underlying disease.
3. Other trigger factors:
- Hypercooling.
- Intoxication.
- Stress.
- Some foods and medicines.
- Hyperinsolation (a condition similar to heat stroke).
- Regular fatigue.
- Other factors leading to malfunction of the immune system.
Scientists have found that prolonged breastfeeding (more than a year) significantly reduces the risk of rheumatoid arthritis.
Structure of the joint
The first symptoms of rheumatoid arthritis usually appear months (or years in some people) after the onset of the disease.
To understand how the pathological process in the joint develops all this time, you need to remember its structure. Without going into details, we can say that the joint is a movable articulation of two bones, the heads of which are covered with a synovial membrane, cartilage and synovial capsule. Between them there is a small gap filled with joint fluid. Its role is to lubricate the cartilage and joint membrane during movement, as well as nourish the cartilage.
Synovial fluid is a complex substance that includes many different components. Up to 40% of its composition falls on synovitis. These are specific cells that perform important functions.
There are synovitistwo types - A and B. Type A cells are macrophage-like. Their role is to absorb unnecessary components in the synovial fluid. B cells are fibroblast-like. They release a number of substances into the synovial fluid that lubricate the articular surfaces and nourish the cartilage.
Pathogenesis
Supposedly, when the immune system malfunctions, synovitis receives the wrong command. B cells stop releasing useful substances and acquire the functions of macrophages. A cells begin to produce cytokines in the synovial fluid, triggering further reactions in B cells. These synovocytes release interleukin 1 and tumor necrosis factors, which leads to the activation of T-helper cells.
The next step in the development of the disease is the accumulation of T-helpers in the synovial membrane and at the same time in the synovial fluid, where they begin to very actively secrete interferons - proteins that should be produced during the invasion of the virus.
That is, the cells behave as if an infection has entered the joint.
At this stage, the first symptoms of rheumatoid arthritis may already appear in the form of pain when moving, a slight swelling of the joint.
The disease continues to progress. T-helper-activated macrophages and monocytes secrete a range of pro-inflammatory cytokines, including IL-8, into the synovial fluid. It causes an increased concentration of neutrophils, which are called upon to destroy foreign microorganisms (viruses, bacteria) by phagocytosis.
The cytokine IL-1, which is an inflammatory mediator, is especially dangerous.
At this stage, there are more pronounced signs of rheumatoid arthritis in women and men, such as fever, significant joint pain.
Tumor necrosis factor promotes the appearance of adhesion molecules, which leads to exudation and weight loss of the patient.
In the future, cytokine I 16 activates B-lymphocytes. In patients, the concentration of IgG and IgM increases in the synovial fluid and in the blood.
As a result of all these complex reactions and interactions, pannus is formed in the joint. This is a tissue with signs of tumor-like growth. It is embedded in the cartilage and in the surface of the bones of the joints, where it forms erosion.
These deformities correspond to stage 3 rheumatoid arthritis. The radiological sign of this condition is perfectly visible on x-rays.
IgG, which is part of the immune complex formed in the blood, interacts with rheumatoid factors. As a result, complement is activated in patients and the microcirculation is damaged. This is the cause of the visceral (manifested in many organs) signs of rheumatoid arthritis.
Classification
There are several types and forms of rheumatoid arthritis, which are based on clinical indicators, laboratory and hardware studies.
According to clinical manifestations, there are four stages:
- Very early (before the onset of the first symptoms, it takes six months or less from the onset of the disease).
- Early (the onset of symptoms from six months to a year).
- Expanded (signs become noticeable throughyear after the onset of the pathological process).
- Late (after 2 years and later, the first signs of the disease begin to appear).
According to the activity of the progression of symptoms, 4 degrees of the disease are distinguished. In this case, the so-called DAS 28 calculator is used. For calculations, the number of swollen and painful joints, the activity of pathology development and the functional capabilities of patients are taken into account. As a result, numbers are obtained in the range from zero to some values. These results determine the degree of rheumatoid arthritis in a patient:
- 0 - remission (according to the DAS 28 calculator, the value is below 2.6).
- 1 - low (value from 2.6 to 3.2).
- 2 – average (calculation result from 3, 2 to 5, 1).
- 3 - high (above 5, 1).
By immunological characteristics:
- Rheumatoid factor is defined as seropositive or seronegative.
- Anti-CCP differentiate between sero-positive and sero-negative.
According to the functionality of the limbs, rheumatoid arthritis is divided into four classes:
- I – professional and non-professional activities are preserved in the patient. Of course, he serves himself.
- II - only non-professional activities are retained. The patient can take care of himself.
- III - All activities are impaired, but the patient is still able to serve himself.
- IV - any activities are violated. The patient cannot take care of himself.
Symptomatics
For unknown reasons, it is from the small joints of the fingers that the vast majorityIn most cases, rheumatoid arthritis begins. The first sign may be pain and swelling of the affected joint, which is caused by swelling of the synovial bags. Some people have redness and fever on the skin at the site of the lesion. Many patients develop articular syndrome, which means stiffness in the morning of the limb in which the joint is affected. Stiffness can last up to half an hour. The duration of such a state depends on how actively the destructive process proceeds.
In most patients, at the onset of the disease, body temperature may rise, symptoms of intoxication are present, fatigue, irritability are observed.
An important sign of rheumatoid arthritis is that the inflammation on both limbs proceeds symmetrically. If, for example, the joint on the index finger of the right hand is affected, then very soon a similar process will develop in the joint of the index finger of the left hand. The reason for this phenomenon has not yet been determined.
As a rule, the development of the destructive process proceeds monotonously, slowly. There are residual effects after treatment.
Only in some patients, rheumatoid arthritis manifests acutely or subacutely, which means the symptoms develop rapidly.
For many people, a painful reaction in the joints to changes in weather conditions (rain, cold snap, and so on) is also one of the signs of rheumatoid arthritis. Symptoms of the disease are not only deformation of the joints, but also violations in many systemsorganism:
- In the cardiovascular. Pericarditis, atherosclerosis, vasculitis, granulomatous lesions of the heart valves may develop. This is manifested by pain in the heart, shortness of breath, dry cough, weight loss, general weakness, damage to the larynx, organs of vision, hearing.
- In the respiratory system. Often pleurisy develops, characterized by pain in the chest when breathing, bending over, coughing.
- Livedo reticularis, rheumatic nodules may appear on the skin.
- The nervous system also suffers if a person has rheumatoid arthritis. What are the signs of this? The patient complains of tingling in the affected limb, numbness, loss of skin sensitivity, difficulty in flexion/extension. In some cases, inflammation of the spinal cord (cervical myelitis) may develop.
- The urinary system. Patients with rheumatoid arthritis often develop nephritis, amyloidosis, NSAID nephropathy. These complications are manifested by edema, dysuria, and back pain. Protein is detected in the urine, and its values in plasma become abnormally low.
- Analysis of the blood of patients reveals that the hemoglobin is greatly reduced, and platelets are significantly increased, which creates a risk of blockage of blood vessels. In addition, there is a reduced content of neutrophilic granulocytes in the blood, which provokes the frequent occurrence of tonsillitis, gingivitis, stomatitis, pneumonia, intermuscular phlegmon and other dangerous diseases.
Signs of rheumatoid arthritis in women and men are almost identical. The difference in the manifestation of the disease inrepresentatives of both sexes may be due to biological nature. So, women are more likely to experience increased fatigue, mood changes. In addition, some have problems with menstruation (they become more abundant). In men, the disease can affect a decrease in physical and sexual activity.
Women are more concerned about the aesthetic problems of finger deformities. For some, this state of affairs can lead to a nervous breakdown. Men (until it hurts a lot) are not very upset due to joint deformities.
Juvenile rheumatoid arthritis
It was noted above that this disease is observed in the vast majority of cases in the adult population. However, rheumatoid arthritis can develop in adolescence and even childhood. In this case, it is called juvenile.
The causes of the disease in children are the same as in adults. The main symptoms are also similar. This is:
- Temperature increase.
- Symptoms of intoxication.
- Swollen joints.
- Difficulties in performing movements.
- Weight loss.
- Symmetry of joint damage (one of the main signs).
However, little patients have a slightly different genetic picture. So, they very rarely have leukocyte antigens HLA Dw 4 and HLA DRw 4, but often antigens HLA TMo, HLA Dw 7 and 8 are detected. This gives scientists the right to assume the nosological independence of the disease.
In most cases, rheumatoid arthritis in children is acute and subacute. However, children rarelycomplain of stiffness in the limbs in the morning and pain in the joints, even if they are swollen. The most typical for young patients are increased fatigue, fever, poor appetite, weight loss.
Children rarely affect the joints of the fingers, but the cervical spine and temporomandibular joints are more commonly affected.
The consequences of this disease in children are stunted growth and physical development, changes in the phalanges of the fingers (shortening or lengthening), underdevelopment of the lower jaw and other parts of the skeleton located near the affected joints.
Diagnosis
Rheumatoid arthritis is diagnosed based on outward symptoms and signs. Based on 11 criteria proposed by the American Rheumatology Association:
1. Stiffness in the morning.
2. Joint swelling.
3. Pain on movement (in at least one joint).
4. Symmetry of deformations.
5. Pain in other joints over time.
6. Radiological signs.
7. Subcutaneous nodules.
8. Serum rheumatoid factors.
9. Changes in joint fluid associated with rheumatoid arthritis.
10. Synovial changes.
11. Rheumatoid nodules.
Probable rheumatoid arthritis is diagnosed if the patient has 3 signs.
Definite – if 5.
Classic - if 7 or more.
Also perform tests:
- Blood.
- Synovial fluid (take a puncture).
- Fragments of the synovium (by biopsy).
- They take x-rays.
Rheumatoid arthritis is diagnosed in 4 stages based on radiological signs:
- First. Signs of osteoporosis are found (the images clearly show the transparency of the bones at the ends). However, this sign is not specific, since such changes are inherent in many diseases of the bones and joints.
- Second. The narrowing of the gap between the bones is added to the sign of osteoporosis.
- Third. The images show bone erosion. This radiological sign of stage 3 rheumatoid arthritis is specific to this disease and indicates that the disease has been developing for a long time.
- Fourth. Ankylosis (this is the immobility of the joints resulting from bone fusion).
Treatment
If there are signs of rheumatoid arthritis, treatment is prescribed according to several schemes, which depends on the degree of manifestation of the disease and the activity of its development. The classic scheme includes:
- Non-steroidal anti-inflammatory drugs (Indomethacin, Butadion, Ibuprofen, Naproxen, Voltaren tablets). These drugs act quickly. After two to three weeks, patients notice significant improvements.
- Injections into the joint (Depomedrol, Kenalog). The drugs have a prolonged action.
- Corticosteroids ("Prednisolone"). They are prescribed only for a period while the patient's pain syndrome is too pronounced.
- Anti-rheumatic basic drugs ("Levamisole", "D-penicillin", gold s alts). They are prescribed if there is no improvement after a course of anti-inflammatory drugs.
- If a positive effect has been achieved, continue to take anti-inflammatory drugs for a long time (sometimes years).
- Cytostatic immunosuppressants ("Azathioprine", "Cyclophosphamide", "Chlorbutin"). They are assigned last. At the same time, a general blood test is performed at least 1 time per week. In some cases, plasmapheresis is performed (blood sampling, purification and return to the bloodstream).
The dosage of all drugs is prescribed by the doctor individually for each patient.
Physiotherapy treatments are of great help in treatment:
- exercise.
- Massage.
- Paraffin applications.
- Electrophoresis.
- UHF.
- Inductothermy.
- Radon baths.
- Phonophoresis.
- Microwave therapy.
For inflammation of the joints, pain-relieving ointments and gels "Voltaren", "Deep Relief" and others are used.
Folk methods are widely used: compresses, rubbing with alcohol tinctures from acacia, lilac, horse chestnut and other plants. Baths with sea s alt, chamomile, nettle are also shown. With their help, you can improve the condition of the skin around the inflamed joint, relieve pain.
At the 4th stage, surgical correction of the joints is performed.
Prevention
It is believed that rheumatoid arthritis shortens a person's life by 3-12 years. Because itthe disease is autoimmune in nature, there are no preventive measures that would prevent its occurrence with a 100% guarantee. However, there are a number of measures that help strengthen bones, which helps to resist the development of osteoporosis. This is the restoration of calcium balance in the body, an increase in calcium absorption in the intestines and a decrease in its excretion from the body. A diet that includes foods rich in calcium and vitamin D (milk, walnuts, cottage cheese, cheese, and others) plays a big role in this case.
To maintain the effect achieved during the treatment, patients are shown sanatorium treatment, where they undergo a course of supporting physiotherapy.
Since there is a version that rheumatoid arthritis is provoked by the introduction of bacteria and viruses into the body, it is very useful to avoid infectious diseases as a preventive measure. If they happen, you must follow all the recommendations of the doctor so that there are no complications.
