rheumatoid arthritis



OVERVIEW

Definition.

Rheumatoid arthritis is an inflammatory reactive disease of the joints caused by group A beta-hemolytic streptococci and is a common clinical manifestation of rheumatic fever.

In 75% of patients with rheumatic fever, there are multiple, painful, irregularly located large arthritic joints with recurrent episodes of localized redness, swelling, heat, pain, and limitation of motion, usually without residual deformity.

Morbidity

Rheumatoid arthritis occurs mostly in winter and spring rainy seasons.

Rheumatoid arthritis can occur at any age, the most common population is children and adolescents aged 5 to 15 years old, infants and young children under 3 years old are rare.

There is no gender difference in the incidence of the disease.

The incidence rate is related to the standard of living, overcrowded living room, low nutrition and poor health conditions are easy to epidemic diseases.

The incidence of rheumatic fever and rheumatoid arthritis has rebounded in the past 20 years, and the incidence of the disease in children of more affluent families in urban areas has increased.

Causes

Causes

The causative agent of rheumatoid arthritis is group A beta-hemolytic streptococcus.

Rheumatic fever and rheumatoid arthritis develop when group A beta-hemolytic streptococcus infects the throat.

Predisposing factors

Cold and humidity are important triggers for rheumatoid arthritis.

Pathogenesis

Rheumatoid arthritis is an autoimmune disease caused by infection with group A beta-hemolytic streptococci. The pathogenesis is not completely clear and is related to the special structural components and extracellular products of group A beta-hemolytic streptococci.

Streptococcal antigenic molecules

The pod membrane hyaluronidase of group A type B hemolytic streptococcus has a common antigen with human synovium, and streptococcal infection produces anti-streptococcal antibody, which produces an immune cross-reaction with synovium, leading to joint damage.

Immune complexes cause disease

Streptococcal antigens combine with anti-streptococcal antibodies to form circulating immune complexes, which are deposited on the synovial membrane and activate complement to produce an inflammatory response in the joint.

Cellular immune damage

Through the cellular immune system, an abnormal immune response occurs, damaging the joints.

Hereditary

The incidence of the disease is higher in families with rheumatic fever than in families without a history of rheumatic fever. Among them, human leukocyte antigen (HLA)-B35, HLA-DR2, HLA-DR4, HLA-DRB1, and lymphocyte surface markers D8/17+ are associated with the development of the disease.

Symptoms

Main Symptoms

Prodromal symptoms

Occur 1 to 6 weeks before the onset of typical joint symptoms.

Prodromal symptoms are manifestations of upper respiratory tract streptococcal infections such as pharyngitis or tonsillitis, such as fever, sore throat, submandibular lymph node enlargement, and cough.

Fever is mostly mild to moderate, irregular, or high.

Pulse rate is rapid, profuse sweating, and pulse rate is disproportionate to body temperature.

Typical Joint Symptoms

Joint pain often occurs in multiple joints, such as knees, ankles, elbows, wrists, shoulders and other large joints.

The location is not fixed and is wandering.

The joints are localized with redness, swelling, burning, pain, and tenderness when pressed.

Several joints may develop at the same time.

Joint pain usually subsides within 2 weeks and rarely lasts more than a month.

Exacerbations are often associated with cold and dampness.

After the acute inflammatory phase, the joint function is fully restored without joint ankylosis or deformity, but it is easy to recur.

Typical joint symptoms are rare in recent years.

Atypical joint symptoms

Only a single joint or a few joints have redness, swelling, heat and pain.

Joint symptoms occur in hip joints, interphalangeal joints, mandibular joints, sternoclavicular joints, thoracic intercostal joints and so on.

Other symptoms

Rheumatoid arthritis is often accompanied by other manifestations of rheumatic fever, such as carditis, annular erythema, subcutaneous nodules, chorea, etc. Rheumatoid arthritis, rheumatic carditis, and chorea are more common, and skin damage is relatively rare.

Rheumatic carditis

Rheumatic carditis is the most serious manifestation of rheumatic fever, including myocarditis, endocarditis and pericarditis. Rheumatic endocarditis often invades the mitral valve, aortic valve, etc., causing rheumatic heart valve disease. It can also invade the myocardium and pericardium. The common symptoms are as follows:

Arrhythmia.

Panic, shortness of breath, weakness, and discomfort in the precordial area after activity.

In severe cases, dyspnea, edema and other manifestations, and even heart failure.

The incidence of rheumatic carditis is more than 50%.

Circumscribed erythema

A light-colored circular erythema with obvious boundaries appears on the inner side of the trunk and limbs, the edges are mildly elevated, and the central skin color is normal.

The erythema is not itchy or hard, and the color fades when pressed.

The erythema is transient, appearing and disappearing, lasting for weeks or even months.

Incidence 6%～25%.

Subcutaneous nodules

Nodules appear on the extensor surfaces of elbows, knees, wrists, ankles and other joints, or on the occipital region, forehead scalp, and the protruding parts of thoracic and lumbar vertebral spinous processes.

They are hard and painless and are not adherent to the skin.

Generally pea-sized, the number varies.

It disappears naturally after 2 to 4 weeks, and some last for months, or reappear after disappearing.

Incidence 2%～16%.

Chorea

Facial manifestations are scowling, shaking the head and turning the neck, grinning and sticking out the tongue.

The limbs show purposeless, involuntary trunk or limb movements.

In severe cases, there is unsteadiness in sitting and standing, staggering gait, difficulty in swallowing and chewing, and inability to take care of oneself.

The above excessive movements are aggravated during excitement and disappear after sleep.

It usually lasts for 1 to 3 months, and a few episodes may be recurrent.

It is most common in children aged 4 to 7 years, and is more common in females than males.

The incidence is reported to be around 3% in China.

Consultation

Department of Medicine

Department of Rheumatology and Immunology

If symptoms such as redness, swelling, heat and pain in the joints, subcutaneous nodules, and annular erythema appear 1 to 6 weeks after symptoms such as fever, sore throat, and enlarged submandibular lymph nodes, it is recommended to consult a doctor promptly.

Cardiovascular medicine

If symptoms such as panic, shortness of breath and discomfort in the precordial area after exercise occur, timely consultation is recommended.

Emergency Medicine

Symptoms such as panic, shortness of breath, and chest pain can also be seen at the Emergency Department or by calling the 120 emergency number.

Preparation

Preparing for medical treatment: registration, preparation of documents, and common problems.

Tips for seeking medical treatment

Avoid self-medication before going to the doctor to avoid aggravating the symptoms or masking the condition.

If you have many clinical symptoms, you should try to record the symptoms you have experienced and how they have changed, so that you can give the doctor more reference.

Preparation checklist for medical consultation

Pay special attention to the time of onset of symptoms, special manifestations, etc.

How long has the joint pain lasted? Is the area of pain fixed?

Is there any panic, shortness of breath, chest discomfort?

Are the symptoms more pronounced after exercise?

Are there any subcutaneous nodules or ring-shaped erythema on the skin?

Has anyone in the family had rheumatoid arthritis or rheumatic heart disease?

Is there any history of scarlet fever, tuberculosis, hematologic disorders, etc.?

Test results in the past six months, which can be brought to the doctor’s office.

Laboratory tests: routine blood tests, throat swab culture, serum hemolytic streptococcus antibody measurement, immunological index test

Others: electrocardiogram, color Doppler echocardiogram, myocardial nuclear examination

Medications used in the last 3 months, if available, bring the box or package with you to the doctor’s office.

Analgesic drugs: indomethacin, acetaminophen, diclofenac, ibuprofen

Antibacterials: erythromycin, roxithromycin, cefaclor

Others: prednisone, sodium valproate

Diagnosis

Diagnosis is based on

Medical history

History of scarlet fever, tuberculosis, hematologic diseases.

Family history of rheumatoid arthritis or rheumatic heart disease.

Clinical manifestations

There are symptoms of upper respiratory tract infection such as fever and sore throat caused by pharyngeal infection.

Multiple wandering large arthritis with cold and dampness as the trigger, localized redness, swelling and heat pain in the joints without deformity.

There were also panic, shortness of breath, discomfort in the precordial area, annular erythema, subcutaneous nodules, and chorea.

Physical examination reveals arrhythmia, cardiac enlargement, altered heart sounds, cardiac murmurs, pericardial friction, etc. In severe cases, there is dyspnea, pallor, hepatosplenomegaly and edema.

Laboratory tests

Pharyngeal swab culture is taken from the pharynx and tonsils for bacterial culture or viral isolation, which can clarify the presence or absence of group A beta-hemolytic streptococcus.

Group A beta-hemolytic streptococcus can be found in 20% to 25% of patients.

Pay attention to keep the mouth clean before examination.

Routine blood: mild to moderate increase in white blood cell count, neutrophilia, mildly decreased red blood cell count and hemoglobin level.

Non-specific changes in serum composition: elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP).

Serum hemolytic streptococcal antibodies, anti-streptococcal hemolysin “O” (ASO) >500U.

Immunological indicators

Electrocardiogram (ECG)

Electrocardiogram may show arrhythmias, pericarditis and other manifestations, characterized as follows.

Arrhythmias such as preterm systole, tachycardia, varying degrees of atrioventricular block and paroxysmal atrial fibrillation.

PR interval prolongation is most common, and ST-T wave changes, Q-T interval prolongation and intraventricular conduction block may also be present.

ST-segment elevation in the chest leads.

Color Doppler echocardiography

To assess cardiac morphology, function and the presence or absence of valvular lesions, and to detect manifestations of rheumatic valvulitis and pericarditis.

Myocardial nuclear testing (ECT)

Detects mild and subclinical forms of myocarditis.

Diagnostic criteria

Jones diagnostic criteria as revised by the American Heart Association in 2015

At present, there is no specific diagnostic method for rheumatic fever, and the American Heart Association’s 2015 Revised Jones Diagnostic Criteria is generally used in clinical practice, which mainly relies on clinical manifestations and is supplemented by laboratory tests. However, it is not the “gold standard” and can only guide the diagnosis.

Elevated anti-streptococcal hemolysin or other streptococcal antibody (anti-DNASE B) potency is stronger than a single potency result, as is evidence of a progressive increase in potency.

Group A beta-hemolytic streptococcal pharyngeal swab culture is positive.

Clinical manifestations of streptococcal pharyngitis with a positive streptococcal glycoconjugate antigen test.

The diagnosis of a first episode of acute rheumatic fever requires two major clinical manifestations, or one major + two minor clinical manifestations.

Patients with a history of acute rheumatic fever or rheumatic heart disease are considered at high risk for recurrent attacks if they are reinfected with group A streptococci.

A reliable history of acute rheumatic fever or confirmed rheumatic heart disease and the presence of group A streptococcal infection, two major clinical manifestations, one major and two minor clinical manifestations, or three minor clinical manifestations are sufficient for a preliminary diagnosis of acute rheumatic fever.

If only secondary clinical manifestations are present, exclusion of other more likely causes is recommended before diagnosing a recurrence of acute rheumatic fever.

Primary criteria: carditis (clinical and/or subclinical), typical rheumatoid arthritis manifestations, chorea, annular erythema and subcutaneous nodules.

Secondary criteria: polyarthralgia, fever (≥38.5°C), erythrocyte sedimentation rate Erythrocyte sedimentation rate ≥60 mm/first hour and/or CRP ≥3.0 mg/dl with a prolonged PR interval (unless carditis is a primary criterion).

World Health Organization (WHO) 2002-2003 revised criteria

With regard to the primary and secondary clinical manifestations, the content of the past criteria was followed, but a 45-day antecedent period for streptococcal infection was specified and scarlet fever was added as one of the evidences of streptococcal infection.

The comprehensive judgment is based on the primary manifestations, secondary manifestations and evidence of antecedent streptococcal infection.

Differential Diagnosis

Rheumatoid arthritis

Similarities: redness, swelling, heat, and pain in multiple joints.

Differences: Rheumatoid arthritis is more common in small joints such as interphalangeal joints and metacarpophalangeal joints, accompanied by “morning stiffness” and fusiform swelling of the fingers, with joint deformities in the later stages; concomitant cardiac damage is less common.

Migratory arthritis

Similarities: redness, swelling, heat and pain in the joints.

Differences: migratory arthritis often has symptoms of primary infection, positive blood or bone marrow cultures, and purulent exudate from the joints, where pathogenic bacteria can be found.

Tuberculous arthritis

Similarities: pain in the joints.

Differences: Tuberculous arthritis is mostly inflammation of a single joint, and it occurs in joints that are often active, subject to friction or weight-bearing, such as the hip, thoracic spine, lumbar spine or knee joints; there is no redness or swelling of the joints, and the heart is not diseased, and it is often accompanied by tuberculosis foci in other parts of the body. Anti-rheumatic treatment is ineffective.

Ankylosing spondylitis

Similarities: pain in the sacroiliac joints.

Differences: Ankylosing spondylitis has obvious manifestations of sacroiliac arthritis and tendonitis, is HLA-B27 positive, and has a tendency to develop in families.

Tuberculosis infection allergic arthritis (Poncet’s disease)

Similarities: recurrent arthritis.

Differences: Poncet’s disease patients have tuberculosis foci in non-articular areas, which can be cured by anti-tuberculosis treatment, and anti-rheumatic treatment is ineffective.

Hematologic Tumors

Similarities: fever and acute polyarthritic symptoms.

Differences: arthritic manifestations such as leukemia may precede peripheral blood changes, and similarly in lymphoma.

Lyme arthritis (Lyme disease)

Similarities: fever, chronic wandering skin erythema, recurrent arthritis, heart damage and neurologic symptoms may be present.

Differences: Lyme arthritis tends to be asymmetric arthritis, laboratory tests are positive for circulating immune complexes, and erythrocyte sedimentation rate erythrocyte sedimentation rate is increased. Serum specific anti-Burgdorfer spirochete antibody assay can help diagnosis.　

Treatment

Aims and principles of treatment

Treatment aims: clearing streptococcal infection foci, removing causative factors, antirheumatic therapy, controlling clinical symptoms, and dealing with complications.

Treatment principles: early diagnosis, rational drug therapy, prevention of recurrence, monitoring of adverse drug reactions.

Treatment Methods

General treatment

Pay attention to keep warm, avoid dampness and cold.

Bed rest is necessary during the active period of rheumatic fever.

If arthritis is not manifested with obvious heart damage, after the condition improves, control the activity level until the symptoms disappear and the erythrocyte sedimentation rate is normalized.

If there is heart enlargement, pericarditis, persistent tachycardia and obvious electrocardiographic abnormalities, bed rest is also required for 3 to 4 weeks after the disappearance of symptoms and normalization of erythrocyte sedimentation rate. During the recovery period, activities should be appropriately controlled for 3 to 6 months.

Eat easily digestible and nutritious food.

Medication

Once rheumatoid arthritis is diagnosed, antimicrobial drug therapy is needed in order to remove the hemolytic streptococcal infection foci, and removing the cause of the disease is the key, otherwise the disease will be recurrent or prolonged.

For primary streptococcal infection, benzylpenicillin is preferred for intramuscular injection.

The prophylactic medication for recurrent patients may depend on the condition.

If allergic to penicillin, erythromycin, roxithromycin, lincomycin, cephalosporins or quinolone antibiotics can be used.

Doctors will choose anti-infective drugs based on drug sensitivity tests. Individualized treatment plans are chosen based on the specific condition, drug effectiveness, and other considerations.

The general course of antirheumatic therapy for simple arthritis is 6 to 8 weeks, and for carditis a minimum of 12 weeks. In practice, according to the specific situation, refer to the results of laboratory tests, adjust the anti-rheumatic treatment program until the condition is fully recovered.

Non-steroidal anti-inflammatory drugs

Glucocorticoids

Try to avoid bright light and noise stimuli in a quiet environment.

Sodium valproate is preferred, and risperidone should be applied in cases where this drug is ineffective or in cases of severe chorea such as paralysis.

There is evidence that immunosuppressive therapy, such as intravenous methylprednisolone followed by gradual oral prednisone, is also effective.

Plasma exchange and intravenous gammaglobulin may be used as experimental treatment in those who fail or are intolerant to the above medications.

Chorea is a self-limiting symptom, usually without obvious neurological sequelae, and most of the patient and careful care, appropriate physical activity and drug treatment can achieve good results.

Chinese medicine treatment

Acute rheumatic fever is mostly a kind of heat paralysis, and it is appropriate to dispel wind and clear away heat and dampness.

Chronic rheumatic fever is mostly a cold paralysis, and it is appropriate to dispel wind, cold and dampness treatment. Glucocorticosteroids, salicylic acid preparations, etc. supplemented by traditional Chinese medicine, can achieve better results.

Acupuncture therapy is effective in relieving joint symptoms.

Do not believe in biased prescriptions and special-effect herbs for rheumatoid arthritis; Chinese medicine treatment should be carried out in regular hospitals to identify and treat the symptoms.

Prognosis

Cure

Simple rheumatoid arthritis can be cured without leaving joint deformities and mobility disorders.

Painful symptoms of arthritis subside within 2 weeks and seldom last more than 1 month, but are prone to recurrence.

Acute rheumatic fever simple rheumatoid arthritis for the first time, about 75% of patients in 6 weeks, to 12 weeks 90% of patients can recover, only 5% of patients disease rheumatic activity lasts more than 6 months.

If the heart at the same time, not timely and reasonable treatment, 70% can occur heart valve disease.

Prognostic factors

The younger the age of onset, the more severe the disease is at first onset and the higher the risk of death.

Rheumatoid arthritis alone does not cause death, but those with severe carditis, frequent recurrences, and inappropriate or untimely treatment can die from severe or persistent heart failure, subacute bacterial endocarditis, or the development of chronic rheumatic heart valve disease.

Hazards.

Untimely treatment will result in prolonged and recurrent attacks, and in severe cases, complications of rheumatic heart disease, heart failure and other serious diseases.

Rheumatoid arthritis alone does not affect daily activities, but if it is accompanied by rheumatic heart disease, depending on the severity of the disease, the amount and intensity of daily activities may be limited.

Daily

Daily Management

Living environment management

During the rainy season in winter and spring, pay special attention to weather changes and increase clothing in time.

Avoid living in a damp and cold environment.

Avoid prolonged stay in crowded environments that are prone to cross-infection.

Avoid contact with people with upper respiratory tract infection.

Patients with chorea should avoid bright light and noise stimulation.

Dietary management

Diet should be nutritionally balanced and rich.

Moderately eat more animal blood, eggs, fish, shrimp, snake meat, bean products, potatoes, beef, chicken and other foods rich in histidine, arginine, nucleic acid and collagen.

Eat less food containing tyrosine, phenylalanine and tryptophan such as peanuts, chocolate, millet, cheese and milk sugar.

Eat less food high in animal fat and cholesterol, such as fatty meat.

Exercise and rest management

Bed rest should be given in the acute stage.

In the early stage of acute arthritis, bed rest should be given and activity can be started after the disease is stabilized.

In the acute stage of rheumatic carditis, after the body temperature is normalized, the tachycardia is controlled, and the electrocardiogram improves, then continue bed rest for 3 to 4 weeks before resuming activities.

Avoid staying up late and ensure sufficient sleep.

Adopt a good work routine and avoid exertion.

After the acute phase, you can exercise moderately, and you can do non-weight-bearing exercises, such as slow walking, cycling, swimming or practicing tai chi.

Disease monitoring

Regular outpatient visits and, if necessary, review of routine blood tests, C-reactive protein, anti-streptococcal hemolysin “O”, erythrocyte sedimentation rate and other indicators.

Preventive medication under doctor’s supervision.

If there is rheumatic heart disease, pay attention to testing electrocardiogram, cardiac enzymes, heart function.

Prevent colds and flu. Symptoms such as fever, sore throat or joint pains should be treated promptly in the hospital.

Prevention

Prevention of recurrence

Actively prevent the recurrence of rheumatic fever and rheumatoid arthritis, and take preventive medication under doctor’s guidance. During the preventive medication, pay attention to drinking more water and regularly review the blood routine to prevent leukopenia.

Prevention of illness

Improve the living environment, enhance ventilation and avoid going to crowded places.

Prevent malnutrition, take appropriate physical exercise to strengthen the body and improve the ability to resist diseases.

Take precautions against cold and dampness to prevent upper respiratory tract infections.

Receive anti-streptococcal vaccination in high incidence and susceptible groups.

For acute streptococcal infectious diseases such as scarlet fever, acute tonsillitis, pharyngitis, otitis media and lymph node infections, early, active and thorough anti-infective treatment should be carried out.

For chronic tonsillitis with repeated acute episodes (more than 2 episodes per year), tonsils should be removed on an elective basis.