Rheumatic diseases are a group of diseases that mainly affect joints, bones, muscles, blood vessels and related soft or connective tissues, most of which are autoimmune diseases. Most of them are autoimmune diseases. The onset of disease is insidious and slow, with a long course, and most of them have a genetic predisposition. Diagnosis and treatment are difficult; different autoantibodies can be detected in the blood, which may be related to different HLA subtypes; good short-term or long-term remission response to non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and immunosuppressive drugs.
Disease description
All diseases that cause bone, joint and muscle pain are broadly considered to be rheumatic diseases. In the broad sense, more than 100 diseases have been classified as rheumatic diseases, including infectious, immune, metabolic, endocrine, genetic, degenerative, neoplastic, endemic, toxic and other diseases. In a narrow sense, it should be limited to a few dozen diseases in the immune-related category of internal medicine. Some of these diseases are still interdisciplinary, such as gout, osteoarthropathy, infectious arthritis, etc.
Disease classification
Arthritis-based: e.g. rheumatoid arthritis (RA), Stigers disease divided into juvenile and adult forms, ankylosing spondylitis (AS), psoriatic arthritis.
Infection-related: e.g., rheumatic fever, Lyme disease, Wright’s syndrome, reactive arthritis.
Diffuse connective tissue diseases: systemic lupus erythematosus (SLE), primary dry syndrome (pSS), systemic sclerosis (SSc), polymyositis (PM), dermatomyositis (DM), mixed connective tissue disease (MCTD), vasculitis.
Causes of morbidity
1, immune response: the body to exogenous or endogenous antigenic substances directly or through the macrophage presentation of the stimulus, so that the corresponding T-cell activation, part of the T-cell production of a large number of a variety of inflammatory cytokines caused by various types of tissues and organs of different degrees of damage or destruction; part of the T-cell reactivation B-cells, the production of a large number of antibodies, directly or combined with the antigen to form immune complexes, so that the tissue or organ by Some T-cells then activate B-cells to produce a large number of antibodies, which directly or in combination with antigens form immune complexes, causing damage or destruction to tissues or organs. In addition, monocyte chemotactic proteins (e.g., MCP-1) produced by monocytes can also be involved in the inflammatory response. Most rheumatic diseases, either due to exogenous antigenic substances produced by infection, or due to endogenous antigenic substances produced in the body, can initiate or intensify this autoimmune response, and a variety of antibodies can appear in the serum.
2, genetic background: recent studies have proved that some rheumatic diseases, especially connective tissue diseases, genetics and patient susceptibility and disease expression are closely related, and have a certain significance to the early or atypical cases and prognosis of the disease; among them, HLA (human tissue leukocyte antigen) is the most important.
3, infection factors: according to years of research clarified that a variety of infection factors, antigens or superantigens produced by microorganisms, can directly or indirectly stimulate or initiate the immune response.
4, endocrine factors: research has proved that the imbalance of estrogen and progesterone, and the occurrence of a variety of rheumatic diseases.
5, environmental and physical factors: such as ultraviolet light can induce SLE .
6, other: some drugs such as procainamide, some oral contraceptives can induce SLE and ANCA-positive small vasculitis.
Clinical manifestations
Most rheumatic diseases have joint lesions and symptoms, up to 70-80%, about 50% only have pain, heavy redness, swelling, heat, pain and impaired function and other comprehensive inflammatory manifestations; mostly multi-joint involvement. The size of the affected joints varies depending on the type of disease.
Heterogeneity, that is, the same disease, there are different subtypes, due to the genetic background, different causes of pathogenesis, and different mechanisms, and therefore the type of clinical manifestations, symptoms, severity and response to treatment are not the same.
Rheumatic diseases are mostly multi-system invasive diseases, many of which have overlapping pathologies and similar symptoms, such as MCTD as a typical example of such manifestations.
Multiple antibodies and immune complexes (CIC) appear in the serum and can be deposited in tissues (skin, synovium) or organs (kidney, liver) causing disease.
Raynaud’s phenomenon is often seen in this group of diseases, such as SLE, MCTD.
Disease diagnosis
Disease history
Because rheumatic diseases are diverse, a detailed medical history should be taken, including family history in addition to personal history; a thorough physical examination, with special attention to joint symptoms, skin and mucosal lesions, the presence of Raynaud’s phenomenon, and vasculitis lesions. Based on the history, a preliminary diagnosis of different diseases can be made.
Laboratory tests
Routine tests: rheumatic diseases are diseases that affect multiple systems and organs of the body, so a comprehensive examination of the patient is required, including blood, urine, stool, blood sedimentation, CRP, and comprehensive biochemical tests (liver function, kidney function, muscle enzyme profile, etc.).
Serological examination: ①General: RF, C3, C4, CH50, CIC, IgG, IgA, IgM, IgE. ②Specific: a. Antinuclear antibody profile is very important for the diagnosis and differential diagnosis of rheumatic diseases. ANA is usually done first, and if the titer > 1:40, other items should be further examined. b. HLA: Although HLA has a close correlation with rheumatic diseases, not much is known about it. commonly used, more specific ones such as HLA B-27 can have a positive rate of up to 81.8% for AS and 40% for Wright’s syndrome, and only 10% in psoriasis; DR4/DR1 has a positive rate of 49-79% for The positive rate for RA was 49-79% and 7% for JRA, but Dw4 was 26% and Dw14 was 47% for JRA, and DR3 was only 2.7% in SLE and 5.6% in pSS. Behcet’s disease is positive for HLA B5 in only 3.3%. c. Other: such as anti-keratin antibody (AKA), anti-histone antibody (Anti-histone antibody), antiphospholipid antibody, anti-perinuclear factor (ANCA), etc. have diagnostic reference value for some diseases.
Joint fluid examination: fresh joint fluid is important and should be examined routinely, cultured, serologically and immunologically.
Imaging
Radiographs: Generally, frontal and lateral views of all joints, large and small, extremities, shoulders, spine, and sacroiliac joints are commonly used; depending on the disease and location, different requirements may apply.
Computed tomography (CT): It can accurately show the small differences in density of different tissues in one cross-section, and is an ideal method to observe small lesions of bone, joint and soft tissue. It is mostly used for the sacroiliac joint and spine of AS; cartilage and meniscal lesions of the knee joint, brain changes of SLE; early interstitial lung changes, etc.
Magnetic resonance imaging (MRI): For bone, joint and soft tissue lesions, it has higher resolution than X-ray and CT, and is better than CT for soft tissue visualization. it is mostly used to observe the diagnosis of bone, cartilage, meniscus and fascia; it is also helpful for brain tissue and spinal cord disease.
Arthrography: 1) Arthrography: generally using filtered air or organic iodine solution, or both, called double contrast imaging. It can show the cartilage, meniscus, synovium and ligaments of the joint. It is useful for the diagnosis of intra-articular lesions and is mostly used for large joints of the extremities, but is now less commonly used. ②Angiography: divided into arteriography and venography, which is useful for the diagnosis of aortitis or vasculitis.
Arthroscopy: It can directly observe the lesions of various tissues in the joint, especially for the diagnosis and differential diagnosis of synovitis, which has great significance. Synovial biopsy and surgical treatment can be taken if necessary.
Biopsy: In cases where diagnosis is difficult, this type of examination can assist in confirming the diagnosis. Such as skin, lip mucosa, kidney, liver, synovial membrane, blood vessels, muscle, bone, cartilage, etc.. Sometimes immunohistochemical staining is also performed.
Isotope bone scan: It is very helpful to identify osteoma (primary or secondary), myeloma.
Ultrasound examination: It can determine the thickness of joint capsule, cartilage, synovial membrane and fluid accumulation.
Disease treatment
Rheumatic diseases are a group of autoimmune diseases that invade multiple tissues, systems and internal organs. Different degrees of immune inflammatory reactions can cause damage to various tissues and organs and seriously affect their normal functions. It can even cause fatal damage. In addition, most rheumatic diseases have joint symptoms; each patient, with the same disease, has its own specificity in different disease courses. They should be carefully evaluated to develop their individual treatment plan. Treatment goals should include relief of symptoms, improvement of the disease, restoration of function, improvement of quality of life, and extension of the patient’s life as long as possible. Since most rheumatic diseases cannot be cured at this time, it is important to gain the patient’s cooperation and persevere with treatment over time. Treatment methods include medication, physical therapy, rest and exercise, orthopedics and surgery. It is important to educate the patient about his or her condition and to cooperate with treatment.
The following is a discussion of the medications used to treat rheumatic diseases.
Medications
Medications used to treat rheumatic diseases can be divided into the following categories.
Non-steroidal anti-inflammatory drugs (NSAIDs): The role of these drugs is mainly to relieve fever, anti-inflammation and analgesia, while achieving the purpose of reducing the inflammatory response and. The earliest is aspirin (acetylsalicylic acid) is still an effective drug for the treatment of acute rheumatic fever and rheumatoid arthritis. Later, various salicylic acid drugs were produced, commonly used are ibuprofen, diclofenac, indomethacin, piroxicam, naproxen, etc. However, the pharmacokinetics and adverse reactions of various drugs are different, mainly to the gastrointestinal, renal, hepatic and hematological systems.
Adrenocorticotropic hormone: mainly refers to glucocorticosteroids, because these drugs have anti-inflammatory and immunosuppressive effects, and have a strong and rapid elimination of inflammation and various symptoms brought about by inflammatory reactions, such as fever, joint swelling and pain. Therefore, they are often used as the first-line drugs for various rheumatic diseases. There are short-acting, medium-acting and long-acting preparations used in clinical practice. The methods of administration are oral, intramuscular or intra-articular injection, intravenous injection, which can be chosen according to the type of disease and condition. However, since it is not a curative drug, long-term use of large amounts may induce infections, osteoporosis, femoral head necrosis, diabetes, peptic ulcers, hypertension, mental abnormalities, etc.; and if the drug is stopped too quickly, it is easy to produce a rebound phenomenon. Except for patients with severe diseases, in principle, small doses and short courses of treatment are appropriate.
DMARDs are also known as slow-acting antirheumatic drugs. These drugs include many different types of drugs with different structures and different effects. Their commonality is that they have a slow onset of action and a certain accumulation effect, so after stopping the drug, the effect also disappears slowly and can still be maintained for a period of time. They do not have direct anti-inflammatory and pain-relieving effects, but can have anti-inflammatory and immune or immunosuppressive effects through different mechanisms. Thus, they can also improve joint swelling, pain, stiffness and alleviate systemic symptoms, reduce acute reactive protein and blood sedimentation. If used for a longer period of time, it may also improve other immune indicators such as RF, ANA, etc. DMARDs include antimalarials – chloroquine, hydroxychloroquine, salazosulfapyridine, methotrexate, azathioprine, cyclophosphamide, penicillamine, gold, cyclosporine A and leflunomide.
Each of these drugs has different toxic effects on important organs (liver, kidney, bladder, lung, gastrointestinal, gonad) and tissues (bone marrow) of the body, and attention should be paid to the selection of indications.
Others: Other treatments include rehmannia polysaccharide, pavoline, etc.
Yunque: Inhibits prostaglandin synthesis, inhibits collagenase activity, prevents cartilage breakdown and destruction, and inhibits osteoclasts. It can be anti-inflammatory and analgesic.
Lei Gong Deng total glucoside: Inhibits T and B cell proliferation, inhibits IL-2 production by T-cells and immunoglobulin production by B-cells. Inhibits the production of prostaglandins. Has strong anti-inflammatory and immunosuppressive effects.
Other measures
In patients with rheumatic diseases, in addition to drug therapy, immunosorbent and plasma clearance therapy is available for patients with many circulating immune complexes in the blood with high immunoglobulins; removal of immune complexes and excessive immunoglobulins in the plasma, RF, etc. If there are too many immunoreactive lymphocytes, single nucleated cell clearance therapy is also used. This improves the function of T and B cells and macrophages and natural killer cells, reduces blood viscosity, and unblocks microcirculation, which can improve the symptoms.
Surgical treatment
For patients with rheumatoid arthritis, synovectomy can be performed in the early stage, and joint replacement, or tendon repair or transfer can be performed in the late stage. Improve the quality of life of patients.