It is currently considered one of humanity’s most common and dangerous diseases.
Therefore, despite significant advances in its treatment, it is difficult to overstate the importance of this disease, both medically and socially.
Usually, the disease develops in childhood, but damage to the heart due to latent dominant flow, detected only in adult patients, often results in a temporary loss of work capacity and, in 10% of cases, even a disability.
Rheumatism is a systemic inflammatory disease that occupies a unique position among other connective tissue diseases.
The leading site for the location of this pathology is the cardiovascular system.
Rheumatism affects all the membranes of the heart and leads to deformation of the valve device, which is the cause of the development of heart failure.
The causative agent of rheumatic fever is streptococcal infection.
Pathological inheritance plays a vital role in the development of the disease.
While the infectious agent circulates in the blood, rheumatism cannot be cured.
At present, the human population, for objective reasons, cannot get rid of streptococcus.
Therefore, there is no panacea for rheumatism; that is, it is part of a group of incurable chronic diseases.
Causes and risk factors for the development of rheumatism
Rheumatism is a disease of an infectious nature.
Its pathogen is group A β-hemolytic streptococcus, which affects the upper respiratory tract.
Factors that cause the development of a pathological condition include:
- Exacerbation of chronic tonsillitis.
- Angina pectoris .
- Scarlet fever
- The does nutrition.
- Unfavorable living conditions.
- Genetic predisposition.
Mechanism of disease development
The original mechanism and development of the disease are associated with two main factors: the presence of antigenic substances, an infectious agent, in the heart and joint tissue and the cardiotoxic effects of enzymes produced by β-hemolytic streptococcus.
With the penetration of the infection, the body begins to develop anti-streptococcal antibodies that form immune complexes with the antigens of the infectious agent, capable of circulating in the blood and depositing in the bed of the microcirculation.
However, streptococcal enzymes and the toxic products of their vital activity have a detrimental effect on connective tissue and heart muscle.
The location of the inflammatory process most often becomes the cardiovascular system.
In addition, a nonspecific inflammatory reaction often develops in the joints and serous membranes.
As for any other autoimmune pathology, a wave course is characteristic for rheumatism, with periods of exacerbations and remissions.
It causes the development of an exacerbation of various infectious agents, stress, physical overwork, and hypothermia.
The pathological process can extend to all the cardiac membranes; this condition in clinical terminology is called “pancarditis” or affect one of them.
In the early stages of the disease, its clinical picture determines myocarditis: primary morphological alterations are detected in the myocardium.
About 1.5 to 2 months after the onset of pain symptoms, inflammatory changes are seen in the inner layer of the heart membrane (endocardium).
As a rule, rheumatism affects the mitral valve first, then the aortic valve follows, followed by the tricuspid valve.
Classification of rheumatism
- Cardiac form (rheumatic carditis). In this condition, the membranes of the heart become inflamed (rheumopancarditis), but primarily the myocardium (rheumomyocarditis).
- Joint shape (rheumatic arthritis). There are inflammatory changes in the joints that are characteristic of rheumatism.
- Cutaneous form.
- Pulmonary form (rheumatic fever).
- Rheumatic chorea (dances of Saint Vitus). Increased activity of dopaminergic structures.
Rheumatism is a polysymptomatic disease; therefore, with general changes in the condition, signs of affection of the heart, joints, nervous and respiratory systems, and other organic structures are characteristic.
The disease often occurs 1 to 3 weeks after infectious disease caused by group A beta-hemolytic streptococcus.
In later cases, the incubation period is usually shortened.
In a separate group of patients, primary rheumatism can occur 1 to 2 days after hypothermia, even without an infection.
From the beginning of the disease, patients complain of constant pain in the heart area and dyspnea, observed during exercise and at rest, with an increased heart rate.
Often in the right hypochondrium, due to circulatory insufficiency in a large circle, edema appears accompanied by a feeling of heaviness.
This condition is a consequence of liver enlargement and signals the development of a very common diffuse myocarditis.
Pericarditis (pericardial rheumatic lesion) is a relatively rare form of pathology; dry pericarditis is accompanied by constant pain in the region of the heart and pericardial effusion, resulting from the accumulation in the fluid of the inflammatory exudate bag of the heart that separates the leaves of the pericardium, the pain disappears.
With the defeat of the musculoskeletal system, the pain gradually increases in the knee, elbow, wrist, shoulder, and ankle joints.
The joints swell and limit active movement.
As a general rule, with rheumatoid arthritis, after taking nonsteroidal anti-inflammatory drugs, the pain stops quickly.
With the development of cutaneous rheumatism, the permeability of the capillaries increases.
As a result, small hemorrhages (petechiae) occur in the lower extremities (in the area of the extensible surface of the joints).
In addition, dense, painless nodules often appear on the skin of the lower legs and forearms (their sizes range from a grain of millet to a large pea).
At the same time, sizeable nodal erythema may form.
It can be located not only in the region of the limb but also on the skull’s skin.
It is a relatively rare form of pathology (found in 5.4% of rheumatism patients).
The development of the pathological process is accompanied by the appearance of severe pain that increases with inspiration and an increase in body temperature from 38 to 40 C.
In patients, there are attacks of dry and painful cough; in the middle of the chest, you can hear the pleural sound. Over time, the pain begins to subside, as does the pleural sound.
However, the patient’s condition worsens.
Shortness of breath, feverish state, and breath sounds disappear; muscular weakness and cyanosis are present.
Sometimes, due to many inflammatory exudates, there may be a delay in breathing from the middle of the chest, an apparent swelling of the intercostal spaces, and very severe shortness of breath.
These patients take a semi-forced sitting position. It should be noted that severe symptoms of rheumatic lung disease are relatively rare.
Most often, the disease is accompanied by milder manifestations of rheumatic fever.
Rheumatic disorders of the nervous system
There is sometimes an injury to the meninges, the subcortical layer, and the brain substance with rheumatism.
One of the disease manifestations is the minor chorea or San Vito dance.
This pathology, characterized by an involuntary convulsive contraction of the striated muscles, develops in childhood and adolescence.
There may be an attack of suffocation with a convulsive contraction of the glottis, leading to a sudden fatal outcome.
Rheumatic peritonitis, which often occurs with acute primary rheumatism, is typical only in all children and adolescents.
The disease develops suddenly.
Body temperature rises sharply, and signs of dysphagia appear (nausea, vomiting, abnormal bowel movements, abdominal cramps).
In diagnosing “primary rheumatism,” there are often some difficulties.
This is explained by the fact that rheumatic manifestations are very nonspecific; they can be observed in other pathologies.
And only the detection of previous streptococcal infection and the presence of two or more signs of the disease can indicate a higher probability of rheumatic damage.
Therefore, the diagnosis is based on syndromes (syndromic diagnosis of rheumatism stage I).
- Clinical and epidemiological syndrome: availability of data indicating the association of the pathology with the infectious process caused by group A beta-hemolytic streptococcus.
- Clinical-immune syndrome: subferebrile state, weakness, fatigue, and violation of the heart rhythm after angina or other nasopharyngeal infection. In 80% of patients, the antistreptolysin titer is high, and 95% of the antibodies against the cardiovascular antigen are detected.
Biochemical signs of inflammation include accelerated erythrocyte sedimentation, dysproteinemia, and detection of C-reactive protein.
Research methods for instrumental diagnosis of rheumatism (cardiovascular syndrome) include:
- Electrocardiogram – Heart rhythm disturbances are often shown.
- Ultrasound of the heart.
- Radiological examination: allows for determining the increase in the size of the heart, the change in its configuration, and the decrease in the contractile function of the myocardium.
- Laboratory diagnosis: in the general analysis of the blood, there is an increase in erythrocyte sedimentation, change of a form of leukocyte, and anemia.
The immunoglobulin class number increases in the immunoassay, and C-reactive protein, anti-Ro antibodies, and circulating immune complexes are detected.
The best therapeutic effect is achieved with the early diagnosis of rheumatism, which helps prevent the development of heart disease.
Treatment is carried out in stages and a complex.
Its objective is to suppress the activity of β-hemolytic streptococcus and prevent the development of complications.
The first stage of rheumatism treatment
In the first stage, the patient receives hospital treatment. It includes drug therapy, diet therapy, and exercise therapy.
Appointments are made taking into account the characteristics of the disease and the severity of the damage to the heart muscle.
To eliminate the infectious agent, antibacterial therapy is carried out. The only antibiotic that can cope with pyogenic streptococcus is penicillin.
Currently, adults and children older than ten years are given phenoxymethylpenicillin. In more severe cases, benzylpenicillin is recommended.
As drugs of alternative action, macrolides and lincosamides are used. The duration of antibiotic therapy is at least 14 days.
With frequent colds and exacerbations of chronic tonsillitis, another antibacterial drug (doxycycline, cephalosporins) can also be used.
Antirheumatic therapy includes nonsteroidal anti-inflammatory drugs, which, depending on the patient’s condition, can be used alone, or in combination with hormonal agents (no more than 10-14 days).
Nonsteroidal anti-inflammatory drugs should be applied until signs of an active disease process are eliminated (1 to 1.5 months).
Patients take quinoline medications (Plaquenil, detail) with latent and prolonged rheumatism.
They are applied for long courses, from several months to one or two years.
Also, during the treatment period in the hospital, the foci of chronic infection must be eliminated (2-3 months after the onset of the disease, with an inactive process, it is recommended to remove the tonsils).
The second stage of rheumatism treatment
The main task of this step is to restore the normal functioning of the cardiovascular system and obtain a complete clinical and biochemical remission.
The second stage of treatment can be carried out in specialized cardio-rheumatic sanatoriums, where patients receive a particular health regimen, exercise therapy, hardening procedures, and differentiated motor activity.
In addition, rheumatism treatment may include mud therapy spa (applications to affected joints), radon baths, hydrogen sulfide, sodium chloride, oxygen, and carbon dioxide.
The third stage of rheumatism treatment
Clinical observation, relapse prevention, prevention of disease progression.
At this stage, therapeutic measures are implemented that contribute to eliminating the active course of the pathological process.
Patients with heart disease have symptomatic treatment for circulatory disorders.
Rehabilitation problems, the patient’s work capacity, and employment are also solved.
Principles of treatment of rheumatism in children
In treating rheumatism in children, effective antibacterial treatment is first prescribed (single intramuscular injection of the sodium salt of penicillin G).
When hemorrhagic manifestations show the use of rapidly acidic oral penicillin V.
If you are allergic to this drug, it may be replaced by erythromycin or azithromycin.
The period of taking nonsteroidal anti-inflammatory drugs is at least 21 days.
For rheumatic heart disease, glucocorticoids (1 to 2 mg per 1 kg of body weight) are given for 10 to 15 days.
When they stop hormone therapy, salicylates are prescribed.
Rheumatism is a disease that does not pose an immediate threat to the patient’s life.
The exceptions are acute meningoencephalitis and diffuse myocarditis, mainly in childhood.
The course is the most favorable for adults, for whom the skin and common forms of the disease are more characteristic.
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 and the presence and severity of heart disease.
In this case, the most unfavorable are recurrent rheumatic heart disease.
However, an important role is played at the beginning of treatment; the later the treatment is started, the higher the probability of developing a defect.
In childhood, rheumatism is much more severe than in adults and often causes permanent changes in the valves.
In the case of the development of the primary pathological process in patients who have reached the age of 25 years, there is a favorable course of the disease without forming a defect.
It should be noted that changes in the heart’s structures occur only in the first three years after the appearance of the first signs of the disease.
If during this time there are no valvular disorders, the subsequent probability of their appearance is relatively low, even with the preserved activity of rheumatism.
Primary prevention (disease prevention):
- Appropriate isolation of a patient with streptococcal infection.
- Follow-up of the people in contact with him (single preventive administration of penicillin).
- Balanced nutrition
- Organization of a healthy life.
- A mandatory diagnostic test of a person who has had a strep infection and a two-month follow-up with a doctor.
Secondary prevention of rheumatism (prevention of recurrence):
In this situation, preventive measures are methods used for a long time (several months and even years). They understand:
- Clinical observation.
- Measures to strengthen the body’s resistance (hardening, constant immunity improvement, balanced nutrition, exercise therapy).
- Prophylactic antibacterial treatment.
- Sanitation of chronic infection foci.
- The antirheumatic treatment provides the long-term use of nonsteroidal anti-inflammatory drugs.