rheumatic disease



OVERVIEW

Definition

Rheumatic diseases are a group of chronic diseases that involve the bones and joints and their surrounding soft tissues (e.g., muscles, tendons, synovium, bursae, ligaments, and cartilage) as well as other related tissues and organs. It mainly includes rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, primary dry syndrome, vasculitis and so on.

The etiology of this group of diseases is complex, and the mechanism is still unclear. Different rheumatic diseases involve different target organs, often involving the joints, blood vessels, heart, kidneys and so on.

Classification

According to the classification of the American Rheumatism Association in 1983, the diseases are divided into 10 categories, including more than 100 types of diseases.

Diffuse connective tissue diseases

Including systemic lupus erythematosus, rheumatoid arthritis, polymyositis/dermatomyositis, systemic sclerosis, necrotizing vasculitis and other vasculitides, desiccation syndrome, overlapping syndromes, mixed connective tissue disorders, and others, such as rheumatic polymyalgia, seborrheic membrane inflammation, and polychondritis.

Spinal arthritis

Including ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, inflammatory bowel disease arthritis, etc.

Degenerative changes

Includes primary and secondary osteoarthritis.

Infectious Related Rheumatic Diseases

Includes rheumatic fever and reactive arthritis.

Rheumatic diseases associated with genetic, metabolic and endocrine diseases

Including gout, acromegaly, congenital or acquired immunodeficiency diseases, hyperparathyroidism, hypothyroidism, etc. .

Tumor-related rheumatic diseases

Including synovial tumor, synovial sarcoma, chondrosarcoma, metastatic tumor, etc.

Bone and cartilage diseases

Including osteoporosis, osteochondrosis, hypertrophic osteoarthropathy, diffuse primary bone hypertrophy, osteitis, etc.

Neurovascular disease

Including neuroarthropathy, compressive neuropathy (peripheral nerve compression, nerve root compression, etc.), reflex sympathetic dystrophy, etc.

Non-articular rheumatic diseases

Including myofascial pain syndrome, tenosynovitis, bursitis, intervertebral disc pathology, idiopathic low back pain, etc.

Other diseases with joint symptoms

Including intermittent joint effusion, drug-related rheumatic syndrome, chronic hepatitis, and cyclic rheumatism.

Morbidity

The global average prevalence of SLE is (12-39)/100,000, and the prevalence in China is (30.13-70.41)/100,000. The prevalence of SLE in women is significantly higher than that of men, and it is more common in women of childbearing age between 20 and 40 years old, 9:1 in the pre-menopausal stage, and 3:1 in children and the elderly, and the prevalence of SLE in Han Chinese is the second highest among the races in the world.

The prevalence of ankylosing spondylitis in China is about 0.25%, and the phenomenon of family aggregation is more common.

The prevalence of dry syndrome in China is 0.29% to 0.77%, and the prevalence in the elderly is 2% to 4.8%. The prevalence of dry syndrome in China is 0.29%～0.77%, and the prevalence of the elderly is 2%～4.8%.

Rheumatoid arthritis can occur at any age, 80% of the incidence of 35 to 50 years of age, the ratio of female to male incidence of about 2 to 3:1. the prevalence of rheumatoid arthritis in China is 0.32% to 0.36%.

The prevalence of rheumatoid arthritis in China is 0.32% to 0.36%. Rheumatic fever occurs most often in winter and spring rainy seasons, and it is common in children and adolescents aged 5 to 15 years old, and is rare in infants and young children aged less than 3 years.

Causes

Causes

There are many types of rheumatic diseases, and the causes of most rheumatic diseases are not yet fully understood. Generally speaking, there are two main categories: genetic factors and non-genetic factors.

Genetic factors

Some rheumatic diseases (systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, etc.) have a clear tendency to clustering in the family, and the probability of the disease is higher in people with a family history than in the general population.

Non-genetic factors

Group A beta-hemolytic streptococcal infections cause pharyngitis or tonsillitis, leading to an immune response to such bacteria or its metabolites, and a non-suppurative inflammatory reaction in areas such as the joints and heart, and rheumatic fever.

The cause of infectious arthritis is related to the infection of the joints by some pathogen.

Gouty arthritis is associated with elevated blood uric acid.

Altered function of immune cells can cause autoantibody cross-reactivity, leading to systemic lupus erythematosus and rheumatoid arthritis.

Risk Factors

Lifestyle

Long-term alcohol consumption, unbalanced diet, smoking, and strenuous exercise can lead to an increased risk of gout and rheumatoid arthritis.

Environmental factors

Living in humid areas for a long time, ultraviolet radiation and other environmental factors can trigger some rheumatic diseases.

Symptoms

Main Symptoms

Rheumatic diseases have their own specific clinical manifestations, but usually have the following common symptoms.

Swelling and pain in the joints

Mostly occurring in the finger and knee joints, can be caused by synovitis, synovial effusion or inflammation of the surrounding soft tissues, but also due to synovial membrane, bone hyperplasia.

It is characterized by swelling and distension of the joints, and the pain is aggravated by physical exertion.

Skin lesions

Rheumatic diseases involving the skin can occur Raynaud’s phenomenon (manifested as pale, cyanosis and flushing of the skin on the fingers, toes and other parts of the skin, accompanied by pain and unusual sensation), reticular cyanosis, subcutaneous nodules, purpura and other skin lesions.

Butterfly-shaped erythema of systemic lupus erythematosus and edematous erythema around the eyes of dermatomyositis may occur on the face.

Cutaneous rheumatoid nodules may occur on the extensor surfaces of the forearms, Achilles tendon, etc., which are of different sizes, hard and only slightly tender, usually several millimeters to several centimeters in diameter.

Joint deformity

Due to the serious damage of articular cartilage and bones, the shape of joints will be changed abnormally and the range of motion will be restricted, such as the knee joint cannot be completely straightened, the metacarpophalangeal joints of fingers will be skewed in the ulnar side, and the joints will be semi-dislocated.

The affected joints may be accompanied by functional disorders.

Other symptoms

Fever, fatigue

Rheumatic diseases have inflammatory lesions, which may cause systemic symptoms such as fever, fatigue, night sweats, loss of appetite and weight loss.

Dry throat and tongue

Salivary gland lesions can occur in dry syndrome, resulting in dry throat and tongue.

Myalgia

Patients with inflammatory myopathies may present with proximal myalgia of the extremities and muscle weakness. Patients with rheumatic polymyalgia tend to present with pain, stiffness and limitation of movement in the scapular and upper arm muscles, hip and thigh muscles.

Consultation

Department of Medicine

Rheumatology

It is recommended to consult the Rheumatology and Immunology Department when you experience pain and tenderness in the joints and muscles of your body, or when you wake up in the morning with stiffness in your joints.

Dermatology

When symptoms such as dry, itchy skin and rashes appear, you should consult the Department of Dermatology promptly.

Endocrinology

If uric acid is found to be elevated during physical examination, you should go to the Department of Endocrinology for timely consultation.

Orthopedics

If you experience pain in the joints of the hip, knee or ankle, you should consult an orthopedic surgeon.

Preparation for medical treatment

Consultation: registration, preparation of information, common problems

Tips for medical treatment

Keep the area of joint pain clean.

Take a picture of your cell phone to record any changes in the shape of the joint.

Do not do a lot of physical work before the consultation.

Have an empty stomach before your visit.

Preparation Checklist

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

Is the joint swollen and painful?

Is there persistent stiffness in the joints?

Is there dry mouth and eyes?

Is there a family history of rheumatic diseases such as systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, etc.?

Is there a history of joint trauma, meniscal tears?

Any history of pathogenic infections?

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

Laboratory tests: blood test, urine test, liver and kidney function, blood sedimentation and C-reactive protein, salivary secretion flow rate test, autoantibody test, synovial fluid test, etc.

Imaging tests: musculoskeletal ultrasound, bone and joint X-ray, CT & MRI, etc.

Medication used in the last 3 months, if there is a box or package of medication, you can bring it with you to the doctor’s office

Anti-rheumatic drugs: methotrexate, hydroxychloroquine, leflunomide, etc.

Non-steroidal anti-inflammatory drugs: celecoxib, loxoprofen, etc.

Glucocorticoids: prednisone, cortisone, etc.

Biological agents: anti-tumor necrosis factor agents, IL-6 receptor antagonists, anti-IL-17A monoclonal antibody, belimumab, etc.

Diagnosis

Diagnostic basis

Rheumatic diseases are very diverse and can involve multiple systems and organs. Age of onset, gender, and family history have reference value for diagnosis.

Medical history

History of joint trauma, meniscus tear.

Family history of systemic lupus erythematosus, dry syndrome, ankylosing spondylitis, rheumatoid arthritis.

History of pathogen infection.

Clinical manifestations

There are many types of rheumatic diseases, and common symptoms such as pain and swelling in the joints, as well as impaired mobility and myalgia, can be used as diagnostic references. In addition, different diseases have different clinical manifestations.

Rheumatoid arthritis, in addition to joint manifestations, may also be manifested by subcutaneous nodules on the skin, which may be accompanied by generalized symptoms such as fatigue, low-grade fever, muscle aches and pains, and weight loss.

In addition to arthritis symptoms, SLE can also have rash (erythema with butterfly-shaped distribution on the face, discoid erythema, etc.), alopecia, oral ulcers, hematopenia (thrombocytopenic purpura, autoimmune hemolytic anemia and leukopenia), plasma membrane inflammation (pleuritis/pleural effusion, pericarditis/pericardial effusion), renal damage (proteinuria, hematuria, renal insufficiency), neuropsychiatric manifestations ( epilepsy, stroke, psychosis, etc.), prolonged fever and other manifestations.

Ankylosing spondylitis may manifest as hip area pain, low back pain, knee swelling and pain, heel pain, etc. Some patients are accompanied by extra-articular symptoms such as cough, dyspnea and uveitis.

In addition to joint pain, dry syndrome may manifest as dry mouth, dry eyes, dry tongue, dry skin, dry cough, diarrhea, anemia and other symptoms.

Rheumatic fever can be preceded by fever, sore throat, enlarged submandibular lymph nodes, cough, etc. Typical manifestations are redness, swelling, burning, pain in the joints, reddish spots with obvious borders, and hard, painless subcutaneous nodules, palpitations, shortness of breath, precordial discomfort after exercise in those who involve the heart.

Laboratory Tests

To understand the hemoglobin concentration and the changes in the number of various types of blood cells and other changes, to understand whether there is any occurrence of blood system damage.

If there is a decrease or increase in white blood cells, red blood cells and platelets, it suggests that hematologic damage may occur, which can assist in the diagnosis of active systemic lupus erythematosus, vasculitis and other rheumatic diseases.

To find out the electrolyte levels and pH changes in the urine.

Test results that show the presence of blood cells, proteins, or pathogenic infections in the urine can help diagnose rheumatic diseases such as SLE.

Include liver and kidney function, blood sedimentation, and C-reactive protein.

Find out if the patient has inflammation, liver damage, kidney injury, etc.

If serum aminotransferase is elevated, it may suggest the presence of liver lesions or damage; if blood sedimentation is elevated or C-reactive protein is elevated, it may suggest the occurrence of inflammatory diseases, which helps to diagnose rheumatoid arthritis, vasculitis and other rheumatic diseases.

If blood creatinine, urea nitrogen, uric acid and other indicators are abnormal, it may suggest kidney damage, and may assist in the diagnosis of systemic lupus erythematosus and other diseases.

It is used to see if salivary secretion is abnormal.

When the patient is sitting still, the patient will absorb the saliva for 10 minutes, centrifuge the saliva to remove the slag, and then calculate the average amount of saliva per minute. If the result of the examination shows that the saliva secretion is less than 0.6 ml/min, it may suggest that there is an abnormality in saliva secretion, which can help to diagnose primary or secondary desiccation syndrome.

It can be used to understand the changes in cell distribution within the joint fluid.

If a significant increase in leukocytes can be observed under the light microscope, a leukocyte count of 2×109/L or less can suggest the occurrence of non-inflammatory arthritis; leukocytes more than 3×109/L or more, and neutrophils up to 50% or more, suggesting inflammatory arthritis; the leukocyte count in the inflammatory synovial fluid is more often (1-75)×109/L, and when the leukocyte count is >100×109/L can be The diagnosis is purulent synovial fluid.

It can be used to detect changes in relevant antibodies in the body.

Positive antinuclear antibodies (ANAs) can aid in the diagnosis of SLE, dry syndrome, systemic sclerosis, and inflammatory myopathies (polymyositis/dermatomyositis).

Anti-ds-DNA is a highly specific antibody for SLE, anti-Sm antibody is a marker antibody for SLE, anti-Scl-70 antibody is highly specific for systemic sclerosis, and anti-Jo-1 antibody is highly specific for inflammatory myopathies.

Rheumatoid factor (RF) positivity and anti-CCP antibody positivity can aid in the diagnosis of rheumatoid arthritis.

Positive anti-neutrophil cytoplasmic antibodies (ANCA) may aid in the diagnosis of granulomatous polyangiitis, microscopic polyangiitis, and eosinophilic granuloma with polyangiitis.

Positive antiphospholipid antibodies (APL) may assist in the diagnosis of antiphospholipid syndrome, systemic lupus erythematosus, etc.

Positive anti-SS-A antibody can assist in the diagnosis of dry syndrome, systemic lupus erythematosus, etc.

Imaging examination

Tissue or lesion changes can be observed. Musculoskeletal ultrasound can also be used with muscle and tendon activities to observe their dynamic changes.

Examination results show the presence of abnormal hypoechoic structures in synovial membrane, bursa, joint cavity effusion, thickness and morphology of articular cartilage, which can indicate rheumatic diseases.

It can be used to examine the changes of bones and joints.

The findings suggest soft tissue swelling and calcification, osteoporosis, narrowing of the joint space, joint erosion and dislocation, subchondral cystic changes and other changes, which can help to diagnose rheumatic diseases.

It can be used to find out whether there are lesions in bones, joints and various organs.

If the examination reveals thickening of the synovium, bone marrow edema and slight joint surface erosion, or damage to some organs, it may indicate the occurrence of rheumatoid arthritis, systemic lupus erythematosus and other rheumatic immune diseases.

It can be used to visualize joint and bone as well as organ involvement.

If the test result shows joint soft tissue lesions, synovial edema, hyperplasia and vascular cataract formation, bone marrow edema, etc., or lesions in some organs, it may suggest rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus and other rheumatic diseases.

Differential Diagnosis

Rheumatoid arthritis

Similarity: joint swelling, morning stiffness, deformity and other manifestations.

Differences: Laboratory findings of rheumatoid arthritis show positive serum rheumatoid factor and increased immunoglobulin IgG, IgM and IgA.

Migratory arthritis caused by septicemia

Similarities: both have joint swelling and pain.

Differences: Blood and bone marrow cultures are positive in septicemia-induced migratory arthritis, and pathogenic bacteria can be found in intra-articular exudate.

Tuberculous arthritis

Similarity: both have joint pain and other manifestations.

Differences: Tuberculous arthritis patients do not have symptoms of redness and swelling in the joints, mostly a single joint is involved, X-ray shows bone destruction, and nodular erythema may appear.

Treatment

Aim of treatment: to improve the prognosis of the disease, to maintain the function of joints and organs, and to relieve the symptoms.

Treatment principle: The etiology and pathogenesis of rheumatic diseases are very complex. Control of inflammation, joints to restore or maintain normal function.

General treatment

Appropriate exercise

Choose appropriate exercise and regulate the intensity of exercise.

Avoid triggers

Avoid prolonged work in wet places and add clothing in cold weather. Avoid excessive fatigue.

Activity training

Daily life activity training should emphasize the functional activities of the joints.

Adjustment of diet

Gout patients should avoid eating seafood and animal offal, and eat more fruits.

Medication

Non-steroidal anti-inflammatory drugs

Applicable to rheumatoid arthritis, dry syndrome, ankylosing spondylitis, etc., can inhibit the conversion of arachidonic acid into prostaglandins, with antipyretic, analgesic, anti-inflammatory effect, improve joints, muscle discomfort symptoms.

Commonly used drugs are celecoxib, lorsolophane and so on.

Adverse reactions include nausea, vomiting, and epigastric discomfort. It is contraindicated in patients with severe heart failure and infants under 3 months of age.

Glucocorticoids

It is suitable for dermatomyositis, extra-articular manifestations of rheumatoid arthritis, systemic lupus erythematosus, dry syndrome, etc. It has the ability to reduce and prevent the tissue response to inflammation.

Commonly used drugs include prednisone and cortisone.

Adverse reactions include edema, hypokalemia, and hypertension. It is contraindicated in people with viral infections (e.g. herpes, chickenpox), and those who are allergic to steroid hormones.

Anti-rheumatic drugs

Applicable to dry syndrome, systemic lupus erythematosus, rheumatoid arthritis, etc. It has the effect of improving the condition and slowing down the progress of the disease, and it can prevent and delay the destruction of the bone structure of the joints.

Commonly used drugs include methotrexate, hydroxychloroquine, leflunomide and so on.

Adverse reactions include nausea, vomiting abdominal pain, diarrhea, etc. Patients are advised to use them under medical supervision.

Biological agents

Applicable to rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, with the effect of controlling disease activity, reducing recurrence, and improving the function of the body.

Commonly used drugs include anti-tumor necrosis factor agents, IL-6 receptor antagonists, anti-IL-17A monoclonal antibody, belimumab and so on.

Adverse reactions include infection, allergic reaction, etc. They should be used under the guidance of specialized physicians and are contraindicated in patients with uncontrolled chronic infections (hepatitis B, tuberculosis, etc.).

Surgical treatment

Suitable for patients with damaged joints.

The function can be improved or restored through synovectomy, orthopedic surgery and other measures.

After surgery, bed rest is required to avoid wound infection.

Prognosis

Cure

Rheumatic diseases are generally not curable. Rheumatic fever, rheumatoid arthritis, systemic lupus erythematosus and dry syndrome can be controlled with standardized treatment.

About 70% of patients with acute rheumatic fever can recover within 2 to 3 months. Without timely and rational treatment, heart valve disease can occur in some patients. Those whose first attack involves the heart have a poorer prognosis.

After early diagnosis and standardized treatment, more than 80% of rheumatoid arthritis conditions can be relieved, and the prognosis is significantly improved.

The 10-year survival rate of patients with systemic lupus erythematosus reaches more than 90%, and the 15-year survival rate is 80%. Dry syndrome can be controlled by timely treatment, and the prognosis is good for those whose lesions are limited to salivary glands, lacrimal glands, skin and mucous membranes, and other exocrine glands.

Prognostic factors

Factors affecting the prognosis of patients include: chronic diseases, malignant tumors, and secondary infections.

Daily

Daily management

Dietary management

Eating more fresh seasonal vegetables is recommended.

Gout patients should eat less or no animal offal and avoid drinking alcohol or alcoholic beverages.

Avoid eating spicy and irritating foods, such as chili peppers and mace.

Life management

Patients with rheumatic diseases are most afraid of dampness and coldness, it is recommended to choose sunny and ventilated rooms as much as possible.

Patients can participate in outdoor exercise appropriately to enhance their resistance, which is conducive to inhibiting the deterioration of the disease.

Psychological support

Rheumatic diseases have a relatively long course and slow remission, and patients are prone to anxiety. When the patient is anxious or depressed, family members should provide more guidance and communication, and if necessary, they can consult the doctor for psychological counseling, so as not to affect the therapeutic effect due to psychological problems.

Follow-up and review

Rheumatic diseases have a long course, and regular follow-up examinations should be conducted during and after treatment to observe the progress of the disease, treatment effects, adverse drug reactions, and whether the disease recurs.

When the disease is active, follow-up should be done once a month; for stable disease, follow-up can be done every 3 to 6 months.

Routine tests such as blood, urine and stool, as well as liver and kidney function tests may be required.

Prevention

Prevent the occurrence of the disease through timely treatment and good living habits.

Strengthen physical exercise to enhance the body’s resistance.

Avoid exposure to wind and cold in your life, and avoid contact with chemical products.

Change dietary habits, eat more vegetables and less animal offal.