Rheumatologic diseases are a group of systemic diseases affecting multiple systems and organs, including systemic rheumatologic diseases, various types of arthritis and a variety of rare and uncommon diseases, and rheumatologic diseases are the most common type of difficult diseases in hospital internal medicine.
Rheumatic immune diseases are often misdiagnosed and underdiagnosed, and should be brought to the attention of physicians and patients.
The main categories of rheumatologic diseases
Systemic rheumatic immune diseases: systemic lupus erythematosus, dry syndrome, polymyositis and dermatomyositis, scleroderma, leukodystrophy, rheumatic fever, mixed connective tissue disease, adult Still disease, antiphospholipid syndrome, overlap syndrome, undifferentiated connective tissue disease, and systemic vasculitis.
Various types of arthritis and joint diseases: juvenile arthritis, various types of arthritis of unknown cause, gout and hyperuricemia, osteoarthritis, osteophytes, age-related arthritis, degenerative joint disease, undifferentiated connective tissue disease, reactive arthritis, Wright’s syndrome, post-streptococcal arthritis, seronegative spondyloarthropathy, psoriatic arthritis, ankylosing spondylitis, infectious arthritis, viral arthritis rheumatoid arthritis.
Difficult and rare rheumatic diseases: nodular disease, Charcot arthropathy, POEMS, recurrent rheumatism, Sweet’s disease, allergic granulomatous vasculitis, Wegener’s granulomatosis, neonatal lupus syndrome, Wiber-Christian syndrome.
Soft tissue rheumatic diseases: fibromyalgia syndrome, rheumatic polymyalgia, fibromyositis, hereditary connective tissue disease, etc.
Others: chronic fever of unknown cause, immune deficiency.
Three key points in managing dry syndrome
Misconceptions that need to be corrected
At present, the main misconception of domestic and foreign physicians about dry syndrome is that this disease is untreatable or does not need to be treated. In fact, dry syndrome is not untreatable, and treatment by scientific methods can achieve long-term remission, prevent or reduce the involvement of liver, lung and kidney, and stop the occurrence of complications such as extra-glandular organs. However, due to sitting and waiting for the development of the disease for a long time, the condition of many patients becomes more and more serious, so that they eventually develop interstitial lung fibrosis, hyperglobulinemia, reduction of whole blood cells, as well as impaired liver and kidney function. Therefore, doctors should correct the above-mentioned misconceptions and provide active management and treatment for patients with dry syndrome.
Mastering the main manifestations of patients
When community residents show the following manifestations, community doctors should highly suspect them to be dry syndrome and actively suggest them to go to higher level hospitals for timely consultation and treatment.
Dry mouth Dry mouth, dry tongue, dry and cracked tongue and mirror tongue, need to drink water when talking and eating solid food, recurrent oral ulcers and swelling of parotid and submaxillary glands, etc.
Dry eyes Dry eyes, photophobia, few tears, foreign body sensation, or even no tears, and often filiform discharge from the inner canthus of the eye. Ophthalmia often occurs.
Other manifestations Dryness of nose, throat and trachea; reduced gastric acid, atrophic gastritis, subclinical type of pancreatitis; dry skin and vagina.
Supervise patients for proper treatment
The pathological basis of dry syndrome is B-cell hyperfunction, which leads to excessive antibody production, causing lymphocyte infiltration of various exocrine glands (such as lacrimal gland, sublingual gland, submandibular gland, etc.), damage to lung and liver, and even lymphoma. Therefore, in addition to symptomatic treatment, the key is to suppress the overly hyperactive immune response.
Medication principles That is, follow the principles of individualized treatment: 1. For mild patients, hydroxychloroquine, leucovorin and other mild phytomedicines can be used. 2. Moderately severe patients should be given azathioprine, cyclosporine, leflunomide, etc. Cyclophosphamide can be considered for severe visceral involvement. 3. Standardize the use of hormones. Those with obvious symptoms can be given small doses of hormones (but attention should be paid to timely dose reduction), and add an appropriate amount of immunosuppressants.4. Symptomatic treatment, such as eye drops with sodium glassate, can not only relieve eye discomfort, but also prevent dry keratoconjunctivitis, etc. Immunosorbent plasma replacement may be considered for those with multiple autoantibodies cutting a poor response to medical therapy.
Three steps to managing ankylosing spondylitis
How to recognize ankylosing spondylitis
Recent studies suggest that the ratio of men to women with ankylosing spondylitis is 2:1 to 3:1; women have a slow onset, atypical symptoms, and milder disease. The possibility of compulsory spondylitis should be suspected when the following manifestations occur.
1, intermittent pain and/or stiffness in the low back or sacroiliac region, with stiffness evident in the morning; as the condition develops, the pain increases at night and turning over is difficult. Later it develops into persistent pain and stiffness. 2. asymmetric large arthritis or monoarthritis of the lower extremities, of which the knee, hip, ankle and shoulder joints are common. 3. tendon terminal inflammation is more common, such as plantar fasciitis and Achilles tendonitis, manifested as heel pain or plantar tingling. 4. hip or hip pain. 5. conjunctivitis. 6. positive pressure pain in the sacroiliac joint and paravertebral muscles, with limited motion in one direction of the spine. 7. thoracic extension Reduction in range and posterior cervical protrusion.
Community residents with the above symptoms should be urged to go to the rheumatology department of a higher level hospital for timely treatment.
How to achieve early diagnosis
Compulsive spondylitis is often diagnosed 5 to 10 years after the onset of clinical symptoms. The main reason for this is the late appearance of inflammation of the sacroiliac joint, which is a key condition for diagnostic criteria. Therefore, it is essential to obtain an early diagnosis before the radiological sacroiliac arthritis is present.
According to the criteria proposed in 2005, more than 90% of patients are likely to have obligatory spondylitis if they meet the criteria of inflammatory back pain and 3 of the following: 1. anterior uveitis. 2. tendon telangiectasia. 3. peripheral arthritis. 4. good response to treatment with multiple NSAIDs. 5. increased acute phase reactants (CRP). 6. positive family history of SpA. 7. positive for HLA-B27. 8. MRI showing acute inflammatory injury of the sacroiliac joint.
Inflammatory back pain is the main symptom in the diagnosis of ankylosing spondylitis and can be considered if 4 of the following 5 criteria are present: 1. back pain occurs before the age of 40. 2. insidious onset. 3. lasts at least 3 months. 4. morning stiffness is present. 5. improves with exercise.
Supervise the patient to adhere to the correct treatment
The main drugs used to treat ankylosing spondylitis include.
1. non-steroidal anti-inflammatory drugs. These drugs have anti-inflammatory and pain-relieving effects, reduce morning stiffness and tendon spasm. They are fast-acting and are mainly used to relieve symptoms. The application of such drugs should emphasize individualization and avoid the combination of more than two drugs to reduce adverse reactions. At present, the commonly used drugs are diclofenac, sulforaphane and celecoxib, etc. The common adverse reactions are gastrointestinal reactions, rash and kidney damage, etc.
2, slow-acting drugs. Mainly used to control the activity and development of the disease. Commonly used drugs include salazosulfapyridine, methotrexate, leflunomide, hydroxychloroquine, etc. Other drugs are gold preparations, penicillamine, cyclophosphamide, azathioprine, reaction stop, etc. At present, the combination of slow-acting drugs is advocated, and its effect is better. Common adverse reactions are gastrointestinal reactions, bone marrow suppression, hair loss, stomatitis, blood changes, liver and kidney function damage, etc.
3. Adrenocorticotropic hormone. They are generally considered in the following cases: ① Combined with acute eye lesions, such as iritis and uveitis, they can be used in eye drops and orally. ② When treatment with non-steroidal anti-inflammatory drugs is ineffective, small doses of oral or local injections of glucocorticoids can be used.
Focus on the systematic prevention and treatment of osteoarthritis
Osteoarthritis is a chronic, degenerative joint disease, mostly manifested as pain, restricted movement and joint deformation in finger joints, knees, hips, and cervical and lumbar joints. In China, there are currently about 30 million middle-aged and elderly people with osteoarthritis, which is almost equivalent to the population of two Beijing cities. This shows how important it is to prevent and treat osteoarthritis.
Understanding the causes of osteoarthritis
Age Factors As the population ages, the prevalence of osteoarthritis increases significantly, with the incidence increasing with age, from about 10% in people over 45 years of age to 40% – 60% in people over 60 years of age.
Weight factors Osteoarthritis is also closely related to weight, with the fatter the person, the more likely they are to develop the disease.
Weight factors Certain occupational tasks and long-term joint weight imbalance may trigger osteoarthritis.
Endocrine factors The decrease in estrogen levels in women during menopause is also an important factor in the development of the disease.
How to detect patients with osteoarthritis
Symptoms 1. Patients are mostly middle-aged and elderly people over 45 years old, and osteoarthritis is more common in the knee and hip joints. 2. Joint pain is characterized by mild to moderate intermittent dull pain in the early stages, aggravated by activity, and relieved by rest. Patients may suffer from transient synovitis resulting in joint swelling, short morning stiffness, and also nerve and vascular compression such as hand numbness, sciatica, and dizziness. Later, the pain may develop into persistent, or even tearing or pinprick-like pain. In severe cases, the pain cannot be relieved even after rest, and the pain increases at night. The joint often feels uncomfortable and relatively stiff after rising in the morning or sitting for a long time, as if it is stuck together, or are thick can recover quickly, usually no more than 30 minutes.
Signs Bony hypertrophy (such as Hebden’s nodes, Bouchard’s nodes, etc.), joint movement disorders and deformities can be seen, bone rubbing sounds and bone rubbing sensation can be heard.
Master the key points of prevention and treatment
1.Educate and guide the residents and patients to reduce weight in order to reduce the burden on the joints.
2.Educate and guide patients to avoid excessive activities and joint weight bearing. Because excessive exercise can aggravate joint damage, patients should: ① Reduce walking appropriately, to the extent that no pain is not felt after activity. Those with significant joint pain should reduce the intensity of exercise and shorten the duration of exercise. ② Pay attention to joint warmth.
3, treatment needs to be different from person to person. ①For those with mild symptoms, topical medication and physical therapy can be used to eliminate pain and restore joint function. ②For those with more severe symptoms, physiotherapy and massage are needed in addition to physical therapy, and medication can be used (mainly two types of drugs for symptom control and condition improvement). ③For those with obvious joint dysfunction and obvious joint deformity, surgical treatment can be taken if it cannot be improved even after standardized and correct medical treatment.
Rheumatoid arthritis is managed in this way
Recognize the risks and characteristics of the disease
Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic progressive joint lesions, most commonly occurring in the small joints of the fingers, wrists, elbows, knees, ankles and feet. Patients may have extra-articular manifestations such as fever, anemia, subcutaneous nodules, vasculitis, pericarditis, and lymph node enlargement, and multiple autoantibodies may be present in the serum. If left untreated, repeated attacks and prolongation of the disease may lead to joint deformity and loss of function.
The onset of the disease is characterized by.
1. It occurs in 20-60 years old, and is more common in women during their reproductive years.
2, the course of the disease is chronic.
3, . There is symmetrical swelling and pain in the wrist, metacarpophalangeal and proximal joints.
4. There is morning stiffness.
5. Subcutaneous nodules may appear.
6.Blood test for rheumatoid factor is positive.
7.Hand x-ray has arthropathy.
Master the key to treatment
1, the diagnosis is clear on the use of drugs. Practice has proved that the treatment of RA should adhere to the early treatment. the principles of RA treatment are: early treatment, combination of drugs and individualized program.
2. Combined medication is effective. Combination medication refers to both giving NSAIDs and other drugs to relieve joint swelling and pain and systemic symptoms, and adding slow-acting anti-rheumatic drugs in time so as to fundamentally slow down or stop the patient’s joint lesions. Although a few patients with mild disease may be effective with one slow-acting antirheumatic drug alone, most rheumatoid arthritis requires two or more slow-acting antirheumatic drugs to bring the disease under control. Moreover, studies have confirmed that the therapeutic effect of combination drugs is significantly better than that of single drugs, and their incidence of adverse drug effects is not significantly increased. Therefore, in this avoidance of adverse drug reactions, patients should receive a sufficient amount, a full course of slow-acting anti-rheumatic drugs combined therapy.
3, adhere to the principle of individualization. In drug therapy, special attention should be paid to the individual differences of patients; for severe RA or serum with high titer autoantibodies and multiple autoantibodies positive, duplex or triplex slow-acting anti-rheumatic drugs should be given; for young patients should avoid the use of tretinoin; for refractory patients who are not treated with regular slow-acting anti-rheumatic drugs, immunopurification (such as immunosorbent) and other treatments can be taken; for joint cavity effusion should be promptly For joint cavity effusion, puncture aspiration and intra-articular injection should be given, but care should be taken not to use too many drugs.
In the treatment, NSAIDs such as diclofenac, nimesulide or celecoxib should be selected according to the degree of the patient’s condition, the presence of concomitant diseases and liver and kidney function, and not the same drug should be used for every patient. When the patient’s condition improves, the drug should be reduced to a smaller dose. At the same time, attention should be paid to the characteristics of each NSAID and the individual differences of the patient’s medication.
Slow-acting antirheumatic drugs can stop the progression of synovial lesions in patients with RA and, if used properly, can lead to complete remission in most patients. These drugs include methotrexate, hydroxychloroquine, salazosulfapyridine, leflunomide, and penicillamine. A large number of clinical studies have demonstrated that the combination of slow-acting antirheumatic drugs can bring most patients with severe disease under control. For mild or early patients, you can consider the use of a slow-acting anti-rheumatic drugs alone.
4, do not use hormones indiscriminately. Hormone is not the drug of choice for RA, and most patients with RA do not need hormone therapy. In general, the correct use of non-steroidal anti-inflammatory drugs and the combination of slow-acting anti-rheumatic drugs, can make most patients’ disease under control. Only a minority of patients need to consider hormones when NSAIDs are ineffective or intolerable as a transitional treatment. And even if a patient has an indication for hormone use, the dose should be as small as possible and reduced or discontinued as soon as possible. In some patients with recurrent joint cavity effusion, intra-articular injection of tretinoin, etc. can be used in principle, but the interval between two injections should not be less than 3 months.
Prevention and treatment of SLE should be regulated
Understanding SLE
Hazards of SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can involve all systems and organs of the body, and renal failure, infection and central nervous system damage are the main causes of death in this disease.
Common symptoms 1. fever, fatigue, weight loss. 2. facial erythema and various rashes, skin irritation after sun exposure. 3. hair loss. 4. recurrent oral ulcers. 5. arthralgia, myalgia, muscle weakness. 6. chest tightness, shortness of breath, dry cough. 7. mental disorders, seizures, hemiplegia, etc. 8. extremities turn from white to purple and then red when exposed to cold. 9. epistaxis, gum bleeding, skin purpura, etc. 10. liver and spleen lymph nodes enlargement. Enlarged lymph nodes of spleen.
Related tests 1. routine blood and urine tests. 2. positive for multiple autoantibodies (ANA, dsDNA, ENA, AnuA, AHA, mDNA, ACL, RF, anti-Hu, PCNA, etc.). 3. decreased complement and increased immunoglobulin. 4. positive lupus band test. 5. lupus-like lesions on renal biopsy. 6. x-ray, CT and ultrasound.
Treatment goals Philosophy and principles
Treatment goals The long-term remission of clinical symptoms in SLE, long-term stabilization or maintenance of all laboratory indicators in the normal range, and maintenance of hormones and immunosuppressive drugs at minimal doses or complete discontinuation are the treatment goals of rheumatologists. Community physicians should also be aware of this so that they can promptly supervise patients upon their return to the community.
Treatment philosophy Regardless of the severity of the patient’s condition, treatment should be based on a holistic philosophy, with attention to both pharmacological and non-pharmacological treatment. Pharmacological treatment should address the primary disease, comorbidities and drug-induced adverse reactions, while non-pharmacological treatment should be emphasized.
Treatment principles, i.e., selection of treatment plan according to the condition
SLE has different forms of onset and various clinical manifestations, therefore, there are differences in the choice of medication for different patients. Severe patients need to apply immunosuppressants or HCQ and other drugs, and follow up regularly. Because long-term use of immunosuppressive drugs may have adverse reactions such as blood, liver function and kidney function. Those who have mild adverse reactions can continue to receive treatment while closely monitoring and protecting the liver and kidney, and those with progressive aggravation or severe adverse reactions should immediately stop the drug and change the treatment plan.
2, pay attention to the role of topical drugs. Topical drugs such as tacrolimus ointment and pimecrolimus cream have entered the clinical application or clinical research stage respectively, which have not only achieved better efficacy, but also have not seen any special adverse reactions reported, and are the drugs of choice for the treatment of SLE local rash. And glucocorticoid ointment or double strike can cause skin atrophy, color group deposition and capillary dilation and other adverse reactions, is gradually replaced by new drugs.
3.Reducing adverse reactions. SLE patients (especially postmenopausal patients) who receive long-term glucocorticoid therapy need long-term calcium supplementation and VD, and oral alun phosphate to prevent osteoporosis. According to research, estrogen replacement therapy can significantly improve postmenopausal SLE patients with concomitant osteoporosis, but there is a lack of international standards.
4. The principles of medication in remission and stabilization. Gradually reducing the dose of hormone or immunosuppressant or extending the interval of medication according to the disease is the principle of medication for disease remission and long-term stability. Therefore, SLE patients who have achieved clinical remission should pay more attention to regular review, in addition to insisting on taking medication.
Three key points of gout management
Identify and urge patients to seek timely medical treatment
Physicians should urge community residents to seek timely medical care when they notice the following symptoms.
1. 45 pairs of men or more (less women).
2. Drinking alcohol and eating meat and seafood.
3. The first painful site is mostly the first metatarsophalangeal joint, and the lower limb joints are involved in excess of the upper limb.
4. The pain is often sudden and severe at night.
5. The second attack is mostly single joint or multi-joint alternating attacks.
6. The pain may be self-limiting. Even without treatment, the pain can be relieved on its own after about 1 week, but repeated attacks can be completely restored to normal during the interval.