Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by synovitis. The persistent and recurrent attacks of synovitis can lead to the destruction of cartilage and bone in the joints, resulting in joint dysfunction. Vasculitis lesions involve all organs of the body, so the disease is also known as rheumatoid disease. The cause of rheumatoid arthritis is not yet known. It is an autoimmune inflammatory disease with chronic, symmetric, multisynovial arthritis and extra-articular lesions as the main clinical manifestations. The disease occurs in the small joints of the hands, wrists and feet, with recurrent attacks and symmetrical distribution.
1.Pathogenesis
From the perspective of pathological changes, rheumatoid arthritis is a widespread inflammatory disease that mainly involves the synovial membrane of the joints (but can also affect the articular cartilage, bone tissue, joint ligaments and muscle bonds), followed by the plasma membrane, heart, lungs and eyes and other connective tissues.
2.Clinical manifestations
Rheumatoid arthritis can occur in all age groups, mostly between the ages of 16-55, more women than men, about 2.5:1. The onset is mostly gradual, and patients are often accompanied by general malaise and low-grade fever, as well as prodromal symptoms such as loss of appetite, weight loss, sweating of the hands and feet, and joint pain.
Most rheumatoid arthritis is symmetric polyarthritis, rarely starting in one joint. The small joints of both hands (the metacarpophalangeal joints of the 2-5 fingers and the interproximal joints are the most frequently affected), knees, wrists and feet are most often involved. The joints begin with pain and stiffness in the early stages, followed by swelling, fluid accumulation and increased local temperature. The joint stiffness is most pronounced after rising in the morning and decreases with activity, called morning stiffness.
Subsequently, due to the swelling and pain of the joint and the limitation of movement, the stiffness and atrophy of the muscles near the joint become more pronounced. Even if the acute inflammation dissipates, the periarticular tissues become stiff due to the proliferation of fibrous tissue in the joint. As the lesion develops, the joint eventually becomes stiff and deformed, with the knee, elbow, fingers, and wrist fixed in flexion. The fingers often become semi-dislocated laterally at the metacarpophalangeal joint, forming a characteristic ulnar deviation deformity, which is called “blowing hand”.
About 10%-30% of patients have subcutaneous nodules, hard as rubber, at the joint’s prominence, such as the eminence of the upper limb, the wrist and the ankle of the lower limb. Subcutaneous nodules are not easily absorbed, and the appearance of subcutaneous nodules often indicates that the disease is in a severe active stage.
In addition, a small number of patients (about 10%) have lymph nodes and splenomegaly during the active phase of the disease. Ocular sclerositis and keratoconjunctivitis may be present. Cardiac involvement with clinical manifestations is less common and is found in about 35% according to autopsy, mainly affecting the mitral valve and causing valvular lesions. Patients with lung disease present in various forms, pleurisy, diffuse interstitial lung fibrosis, rheumatoid pneumoconiosis. Peripheral neuropathy and chronic calvarial ulcers, amyloidosis, etc. are also occasionally found.
3.Diagnosis
Late rheumatoid patients, because there are multi-joint lesions and typical deformities, so the diagnosis is not difficult. But the early stage of the disease and a few cases of joint involvement, diagnosis is often difficult. At present, for the diagnosis of rheumatoid arthritis, different countries have different criteria. 1958, the American College of Rheumatology proposed a modified diagnostic criteria, many countries have adopted this standard.
They are described as follows.
a Morning stiffness.
b Pain or tenderness with movement in at least one joint.
c Swelling of at least one joint (soft tissue hypertrophy or effusion rather than osteophytes, as seen by the physician).
d swelling of at least one other joint (seen by the physician, the time between the two joints involved should be no more than 3 months).
e symmetrical joint swelling (as seen by the physician), invading the same joint on both sides of the body (full symmetry is not required if the proximal interphalangeal, metacarpophalangeal or toe joints are invaded).
f Subcutaneous nodules (seen by the physician) at the bone elevation or on the extensor side near the joint.
g as seen on standard X-rays (in addition to osteophytes, there must be osteoporosis present near the involved joint).
f Positive rheumatoid factor.
h Poor coagulation of mucin in the synovial fluid.
i With three or more of the following synovial pathologic changes: marked villous hyperplasia; superficial synovial cell hyperplasia and fenestrations; marked chronic inflammatory cell (primarily lymphocytes and plasma cells) infiltration and tendency to form lymph nodes; dense fibrin deposition in the superficial or interstitial layers; and focal necrosis.
Histologic changes in j subcutaneous nodes should show foci of cellular necrosis in the central area surrounding fenestrated proliferating macrophages and a chronic inflammatory cell infiltrate in the outermost layer.
Typical rheumatoid arthritis: the diagnostic criteria require 7 of the above items. In items a-e, joint symptoms must persist for at least 6 weeks. Definite rheumatoid arthritis: 5 of the above items are required for the diagnosis. In items a-e, the joint symptoms must last for at least 6 weeks.
Possible rheumatoid arthritis: The diagnosis requires 3 of the above items and at least 1 of items a-e. The joint symptoms must last for at least 6 weeks.
Suspected rheumatoid arthritis: The diagnosis requires 2 of the following items, and the duration of joint symptoms must be at least 3 weeks.
① Morning stiffness.
② pressure pain and pain on movement (seen by the physician), intermittent or lasting for at least 3 weeks.
③History of joint swelling or as seen.
④Subcutaneous nodules (as seen by the physician).
⑤ Increased blood sedimentation and positive C-reactive protein.
⑥Irisitis (unless in childhood rheumatoid arthritis, otherwise of suspicious value).
4.Treatment
Rheumatoid arthritis so far there is no specific treatment, still stay on the treatment of inflammation and sequelae, take a comprehensive treatment, most patients can get a certain degree of effectiveness.
The purpose of the current treatment is to.
① control the inflammation of the joints and other tissues and relieve the symptoms;
② Maintain joint function and prevent deformity;
(3) repair damaged joints to reduce pain and restore function.
(1) General treatment
During acute attack with fever and obvious swelling and pain of the joint, bed rest should be taken until the condition improves for two weeks and then activity should be gradually increased to avoid prolonged bed rest leading to joint disuse and joint ankylosis. The protein and vitamins in the diet should be sufficient.
(2) Drug therapy The drugs used to treat this disease are divided into two categories
The first category is non-specific allopathic drugs, including hormonal drugs such as cortisone and adrenocorticotropic hormone, and non-steroidal drugs such as aspirin and anti-inflammatory pain.
The second category is drugs that alleviate the course of the disease and can affect the activity of the lesion and its development when taken for a longer period of time. There are gold preparations, Kunming Shanhaibang, Zhengqing Fengpao Ning tablets, etc.
(3) Local treatment
In the acute stage to prevent the occurrence of deformity, the affected limb can be treated by applying brace fixation. Various kinds of heat therapy have the effect of improving local blood flow and anti-inflammatory and pain relief. Manual correction and massage can also improve the function of the limb.
(4) Surgical treatment
Synovectomy: In recent years, with the widespread development of knee arthroscopy, minimally invasive synovectomy can reduce joint fluid exudation, prevent the formation of vascular opacities, prophylactically protect joint cartilage and subchondral bone tissue, and improve joint function.
Artificial joint replacement surgery: With the maturity and widespread use of artificial joint replacement surgery, patients with advanced rheumatoid arthritis have been given a boon, solving the difficulties and pain of life due to deformity and stiffness of the joints.
6.Prevention and health care
(1) Strengthen exercise, enhance physical fitness
(2) Prevent cold, rain and moisture, and keep the joints warm
(3) Diet, regular living, work and rest are the main measures to strengthen the body health
(4) Keep your spirit happy
(5) Prevent and control infections.