Internal illnesses. Rheumatism (Sokolsky-Buyo disease) (lecture notes)

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Internal illnesses. Rheumatism (Sokolsky-Buyo disease) (lecture notes)

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LECTURE No. 7. Rheumatism (Sokolsky-Buyo disease)

Rheumatism is a systemic toxic-immunological inflammatory disease of the connective tissue with a predominant localization of the process in the cardiovascular system. The disease develops at any age, mainly among adolescents and children (7-15 years). Women get sick more often than men.

Etiology. The disease is caused by group A β-hemolytic streptococcus.

Pathogenesis. The secreted streptococcal antigens (streptolysin-O, streptokinase, streptohyaluronidase) lead to the development of an acute phase of inflammation with cell exudation and phagocytosis. In the connective tissue, reparative processes develop: cell proliferation, stimulation of the formation of mucopolysaccharides. The work of the immune system is activated through the enhancement of the functioning of the complement system, lysosomal enzymes. Gradually, chronic inflammation is formed with the transfer of activity to immune mechanisms, collagen formation with the formation of fibrosis processes.

Pathological anatomy. There are 4 phases of development of morphological changes, the duration of each is 1-2 months.

Phase I - mucoid swelling of the interstitial tissue and collagen fibers.

Phase II - fibrinoid changes with disorganization of collagen fibers, formation of structureless fields impregnated with fibrin.

Phase III - the formation of Ashoftallaev granulomas with the appearance of perivascular accumulations of lymphocytes and other cells.

Phase IV - sclerosis (fibrosis) with the transformation of cells in granulomas into fibroblasts and the gradual formation of a scar.

The heart is the main target organ in rheumatic fever. Deformation of the heart valves leads to the formation of their insufficiency, then to the narrowing and deformation of the atrioventricular orifices.

The development of heart defects often occurs in the form of combined and combined forms.

Classification. The clinical classification according to A. I. Nesterov (1990) takes into account:

1) the phase of the disease (active or inactive, specifying the degree of activity of the process - minimal, medium, high);

2) clinical and anatomical characteristics of damage to the heart and other organs;

3) the nature of the course of the disease (acute, subacute, protracted, continuously relapsing, latent);

4) the state of blood circulation (0, I, IIa, IIb, III degree of violations).

Clinic. The first period is called prerheumatism. It lasts 2-4 weeks from the end of the streptococcal infection to the onset of the manifestations of the disease. Rheumatism never begins at the height of infection.

Appear: malaise, fatigue, loss of appetite, palpitations, tingling in the joints, hyperhidrosis, pallor of the skin. The second period represents a rheumatic attack. Fever with syndromes of damage to the joints, heart (primary rheumatic heart disease) and other organs may appear. The third period represents a long period of clinical manifestations. There is recurrent rheumatic heart disease with progressive heart damage, the formation of complex heart defects.

Primary rheumatic heart disease

Inflammation of all membranes of the heart (pancarditis) is possible, the endocardium and myocardium are most often affected. There is tachycardia, rarely bradycardia. The borders of the heart are normal or moderately enlarged. On auscultation, a muffled I tone is heard, a soft systolic murmur at the apex (associated with myocarditis). Sometimes a third tone may appear. With an increase in the intensity of the noise, the formation of mitral valve insufficiency is possible (not earlier than 6 months from the onset of the attack).

Recurrent rheumatic heart disease

There is a formation of new defects of the valvular endocardium in the form of combined and combined heart defects.

Diagnostic criteria for rheumatism according to Kisel-Jones (modified by the American Rheumatological Association, 1982). There are major and minor criteria for the course of the disease.

Major criteria include: carditis, polyarthritis, chorea, erythema annulare, subcutaneous rheumatic nodules. Minor criteria include: previous rheumatism, arthralgia, fever, elevated ESR, increased C-reactive protein, leukocytosis, prolongation of the PQ interval on the ECG, increased titer of antistreptococcal antibodies in the blood, detection of streptococcal antigen.

In the presence of two major and one or two minor criteria, the diagnosis is considered reliable, in the presence of one major and two minor - probable.

Additional diagnostic study. Of the laboratory parameters, the study of a complete blood count (hypochromic anemia, leukocytosis with a shift to the left, an increase in ESR), a biochemical blood test (the appearance of C-reactive protein, an increase in fibrinogen, dysproteinemia, α₂ hyperglobulinemia, increased content of haptoglobin, ceruloplasmin, acid phosphatase).

An immunological study should be carried out to determine the increase in the titer of antibodies ASH, ASL-O, ASA, myocardial antibodies.

Of the instrumental research methods, an ECG is taken (determination of various arrhythmias, conduction), Doppler echocardiography.

X-ray examination is informative in severe process, when there is an increase in the left heart. At the first attack, changes in the heart are not detected.

Differential diagnostics. Should be done with infectious myocarditis. The disease develops at the height of the infection, it is not characterized by progression, signs of valvulitis.

Of the connective tissue diseases, it is necessary to take into account periarteritis nodosa, systemic lupus erythematosus, scleroderma.

With neurocircular dystonia of the cardiac type, there are diverse complaints, there are no objective signs of the disease.

In the syndrome of primary tuberculosis, there are no radiographic symptoms of the primary complex, antistreptococcal antibodies. Mantoux and Pirquet tests are carried out, tuberculosis mycobacteria in sputum are examined.

Treatment. With active rheumatism, mandatory hospitalization is carried out up to 40-60 days or more.

An appropriate regimen is assigned: in the absence of carditis - half-bed for 7-10 days, then free; in the presence of carditis - strict bed rest for 2-3 weeks, then semi-bed and free.

From nutrition, table No. 10 is prescribed with a protein content of at least 1 g / kg, limiting salt to 6 g / day.

Mandatory early prescription of antibiotics is carried out: benzylpenicillin 1,5-4 million units per day (depending on the degree of activity) for 2 weeks. Then they switch to a prolonged form: bicillin-5, 1,5 million units every 2 weeks for 2 months. After this, antibiotic therapy is carried out every 3 weeks every month for at least 3 years in patients without a history of carditis and for at least 5 years in patients with a history of carditis. If you are allergic to penicillin, antibacterial drugs of other groups are used - macrolides, oral cephalosporins.

Glucocorticoid drugs are prescribed only for severe carditis, acute (less often subacute) course of the disease: prednisolone 20-30 mg / day for 2-3 weeks, then the dose is reduced until the drug is completely discontinued, the course of treatment is 1,5-2 months.

NSAIDs are used as monotherapy, in case of recurrent or prolonged course they are combined with quinoline drugs (delagil, plaquenil for many months).

Of the metabolic drugs, phosphalene, cocarboxylase, a polarizing mixture and antiarrhythmic drugs (for arrhythmias) are used.

With the development of circulatory failure, saluretics are used: hypothiazide, furosemide, uregit, ACE antagonists in a short course.

Flow. If the duration of the disease is up to 6 months, it is considered as acute, more than 6 months - chronic.

Forecast. determined by the condition of the heart. The absence of signs of clinical formation of defects within 6 months is a good prognostic indicator. The formation of a defect within 6 months refers to prognostically unfavorable signs.

Prevention. Primary prevention includes hardening of children from the first months of life, good nutrition, physical education and sports, improvement of living conditions, timely treatment and sanitation of foci of streptococcal infection.

Secondary prevention in patients who have had the first rheumatic attack without carditis is more effective until the age of 18, in patients with carditis with the first attack of rheumatism it is more effective until the age of 25.

In patients with valvular disease, bicillin prophylaxis can be carried out throughout life.

Author: Myshkina A.A.

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