Rheumatism is also known as connective tissue disease.
One of the common clinical manifestations of rheumatic diseases, also known as connective tissue diseases, is anemia, with half of the patients experiencing mild or moderate anemia during the course of the disease. The majority of these patients have anemia of chronic disease, and a few have autoimmune hemolytic anemia (AIHA).
Causes
1. Shortened red blood cell life span
In rheumatoid arthritis (RA), the life span of red blood cells is shortened from the normal 100-120 days to 80-90 days. When normal red blood cells are transfused to RA patients, their life span is mildly shortened, whereas when the patients’ red blood cells are transfused to normal people, their survival time is normal. The above results of cross-transfusion suggest that the shortening of erythrocyte lifespan is due to factors other than erythrocytes, and that chronic inflammatory stimulation with proliferation and increased activity of the monocyte macrophage system (MMS) may lead to increased destruction of erythrocytes and shortening of their lifespan.Anemia in patients with RA with Felty’s syndrome (Felty’s syndrome) with marked splenomegaly may be associated with hypersplenism as well.
2. Impaired erythropoiesis
Normal people have several times the usual ability to produce red blood cells, so when the life span of red blood cells is mildly shortened, anemia does not usually occur clinically, but anemia of chronic disease (ACD) in addition to the shortening of the life span of red blood cells, there is still a significant shortage of red blood cell production. The causes are: ① abnormal iron metabolism; ② relative reduction of erythropoietin (EPO); ③ cellular immunity disorders; ④ renal function renal insufficiency.
3. Treatment-related anemia
A considerable part of patients with rheumatic disease long-term application of adrenocorticotropic hormone, such as improper application can be complicated by peptic ulcer, some of which can lead to long-term chronic small amount of bleeding or acute upper gastrointestinal hemorrhage, which can lead to anemia. Cyclophosphamide, methotrexate and azathioprine and other immunosuppressive drugs have been used very commonly, such as improper use can lead to bone marrow suppression, anemia.
Symptoms
Since the anemia is mild to moderate and occurs slowly, most patients do not have obvious symptoms, and only a few have weakness, shortness of breath, palpitations, pallor, etc., and usually do not have jaundice. More patients are masked by the various symptoms of rheumatism, and ACD itself has no characteristic positive signs.
Examination
1. Peripheral blood
Hemoglobin is mostly 80-100g/L, hematocrit is decreased to 30%-35%, mild microcytic hypochromic anemia or normocytic normochromic anemia, mean cell volume (MCV) and mean hemoglobin concentration of erythrocytes (MCHC) are normal or mildly decreased.
2. Erythrocytes
Reticulocytes are normal or mildly decreased and sometimes mildly increased.
3. Bone marrow
Iron staining shows normal or increased iron stores, increased iron content in macrophages, but decreased ferritic erythrocytes.
4. Serum iron, total iron binding capacity and iron saturation.
Serum iron, total iron binding capacity and iron saturation are reduced. Serum ferritin is normal or elevated, indicating a decrease in circulating free iron and an increase in total body iron stores.
5. Iron kinetic assay
The uptake of ferrous sulfate (59Fe) in MMS is increased, while the disappearance time of 59Fe from the blood is shortened, and the mixing of 59Fe in erythrocytes is reduced.
In addition, X-ray, electrocardiogram, ultrasound, biochemistry and other tests can be chosen according to the condition, clinical manifestations, symptoms and signs.
Diagnosis
Rheumatic anemia can be diagnosed with a history of rheumatic disease accompanied by anemia, combining peripheral blood, bone marrow picture and iron staining, serum iron and ferritin, and excluding other types of anemia such as autoimmune hemolytic anemia (AIHA) and iron deficiency. Reduced serum iron is a necessary condition for rheumatic anemia, and sometimes anemia can be the first symptom or manifestation of rheumatic disease, which often brings great difficulties to the diagnosis. Therefore, clinicians must consider the possibility of rheumatism in the differential diagnosis of anemia, especially in young and middle-aged women.
Treatment
1. Treatment of primary disease
2. Erythropoietin (erythropoietin)
Genetically recombinant EPO, more severe anemia and low endogenous EPO levels are more effective. Inject subcutaneously 3 times a week. Dosage is then adjusted according to hemoglobin and hematocrit (HCT) levels. Effective individuals need to be aware of complications such as hypertension and thrombosis. Erythropoietin may provide temporary relief for some people with anemia for at least 1 to 2 months. Mild anemia may be left untreated as the general symptoms are not obvious.