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LECTURE № 16. Rheumatism in children and adolescents. Clinic, diagnosis, treatment



Rheumatism is a systemic inflammatory disease of the connective tissue with a characteristic lesion of the heart.

Etiology, pathogenesis. The main etiological factor in acute forms of the disease is b-hemolytic streptococcus group A. In patients with prolonged and continuously recurring forms of rheumatic heart disease, it is often not possible to establish the relationship of the disease with streptococcus. In the development of rheumatism, special importance is attached to immune disorders.

In the body, sensitizing agents (streptococcus, viruses, nonspecific antigens, etc.) are believed to lead to the development of immune inflammations in the heart, and then to a violation of the antigenic properties of its components with their transformation into autoantigens and the development of the autoimmune process. A special role in the development of rheumatism is played by a genetic predisposition.

Classification. It is necessary to identify the previously inactive or active phase of the disease.

Activity can be minimal (I degree), medium (II degree) and maximum (III degree). To determine the degree of activity used severity of clinical manifestations, as well as changes in laboratory parameters.

Classification according to the localization of the activity of the rheumatic process (carditis, arthritis, chorea, etc.), the state of the blood circulation and the course of the disease.

There is an acute course of rheumatism, a subacute course, a protracted course, a continuously relapsing course and a latent course of the disease. The selection of latent flow is justified only for retrospective characteristics of rheumatism: latent formation of heart disease, etc.

Clinic. The disease most often develops 1–3 weeks after a sore throat, sometimes another infection. When relapses, this period may be less. Disease relapses often develop after any intercurrent diseases, surgical interventions, physical overloads. A manifestation of rheumatism is a combination of acute migratory and fully reversible polyarthritis of large joints with a moderately severe carditis. The onset of the disease is acute, rapid, rarely subacute. Polyarthritis develops rapidly, accompanied by a remitting fever up to 38-40 C with daily fluctuations of 1-2 C, with sweating, but more often without chills.

The first symptom of rheumatic polyarthritis is acute pain in the joints, increasing and aggravating with the slightest passive and active movements. The swelling of the soft tissues in the area of ​​the joints joins the pain and an effusion in the articular cavity appears at the same time. The skin over the affected joint is hot, with sharp pain on palpation of the joint, the range of motion is limited due to pain.

A characteristic feature is the symmetrical lesion of large joints - most often the knee, wrist, ankle, elbow. Typical "volatility" of inflammatory changes, manifested in the rapid and reverse development of arthritic manifestations in some joints and the same rapid increase in other joints. All articular changes disappear without a trace, even without treatment, they last no more than 2-4 weeks.

Rheumatic myocarditis, if there is no accompanying defect, proceeds lightly, with complaints of light pain or unpleasant, vague sensations in the heart area, slight shortness of breath during exertion, rarely - complaints of interruptions in heart function, palpitations. With percussion, the heart is of normal size or moderately enlarged to the left, with auscultation and on PCG, satisfactory sonority of tones, slight muting of 1 tone, sometimes 3 tones are recorded, rarely 4 tones, soft muscular systolic murmur at the apex of the heart and mitral valve projections. Blood pressure is normal or moderately reduced. On ECG - flattening, broadening and serration of the P wave and QRS complex, rarely can the PQ interval be longer than 0.2 s, in some patients a slight shift of the S-T interval downward from the isoelectric line and the change of the T wave becomes, becomes low, negative, Rarely two-phase (primarily in leads V1 — V3). Rarely appear extrasystoles, atrioventricular block, grade 2–3, intraventricular block, nodal rhythm.

Diffuse rheumatic myocarditis is manifested by a significant inflammation of the myocardium with its pronounced edema and, consequently, dysfunction. From the onset of the disease, the patient is worried about severe shortness of breath, which causes him to take the position of orthopnea, there is constant pain in the heart region, rapid heart beat. Characterized by "pale cyanosis", swelling of the neck veins. The heart is diffusely dilated, weak apical impulse. The tones are sharply muffled, very often a clear III tone is heard (the protodiastolic gallop rhythm) and a distinct, but significantly soft systolic murmur. Pulse quickens, weak filling. Blood pressure lowered. Venous pressure rises rapidly, but in combination with collapse also decreases. On the ECG, a decrease in the voltage of all teeth, a flattening of the T wave, a change in the S – T interval, an atrioventricular block are recorded. The outcome of rheumatic myocarditis in the absence of adequate treatment may be myocardial cardiosclerosis, which often characterizes the degree of prevalence of myocarditis. With focal cardiosclerosis, myocardial functions are not impaired. Diffuse myocardial cardiosclerosis is characterized by signs of a decrease in the contractile function of the myocardium, which is manifested by a weakening of the apical impulse, by muffling tones (especially I), by systolic noise. Rheumatic endocarditis, which is the cause of the development of rheumatic heart disease, is manifested very little by clinical symptoms.

A significant symptom during auscultation is a clear systolic murmur with sufficient tonal sound and no signs of pronounced myocardial damage. In contrast to the noise associated with myocarditis, endocarditic noise is rough, but can sometimes have a musical connotation. The sound of endocarditis noise increases with a change in posture of the patient or after exercise.

Reliable signs of endocarditis are the variability of already existing noises and especially the emergence of new ones with unchanging borders of the heart. Diastolic murmurs disappear easily and quickly, sometimes heard at the very beginning of a rheumatic attack on the projections of the mitral valve, as well as on the vessels, and in part also may be associated with endocarditis. Deep endocarditis of the valves or aortic valve in some patients has a reflection on the echocardiogram: thickening of the valves, their “shaggy”, multiple echoes from them.
Pericarditis in the rheumatism clinic is rare.

Dry pericarditis is clinically manifested by constant pain in the region of the heart and pericardial rubbing noise, which is often heard along the left edge of the sternum. The intensity of the noise during auscultation is different, it is often determined in both phases of the cardiac cycle. On an electrocardiogram shift of an interval S - T up in all assignments at the very beginning of a disease comes to light. With further development, these intervals return to the isoelectric line, and two-phase or negative teeth T are simultaneously formed. Dry pericarditis itself is not capable of causing heart enlargement.

Exudative pericarditis is a further stage of development of dry pericarditis. The main first clinical sign of effusion is the disappearance of pain in connection with the separation of inflammatory pericardial sheets, accumulating exudate.

Clinical manifestations in the form of shortness of breath, which increases when the patient lies down. With a large amount of exudate, the heart area swells, the intercostal space is smoothed, the apical impulse is not palpable. The heart is greatly enlarged and takes the form of a trapezoid or circular graphite. The pulsation of the contours during fluoroscopy is small. When auscultation tones and noises are deaf (as there is effusion). Pulse frequent, small filling; blood pressure lowered. Venous pressure is always elevated, swelling of the cervical and peripheral veins appears. The electrocardiogram is the same as with dry pericarditis, an additional symptom may be a noticeable decrease in the voltage of the QRS complex. Of particular diagnostic importance is echocardiography, which establishes the presence of fluid in the cardiac pouch. With the defeat of the skin is almost characteristic ring erythema, which is a pink ring-shaped elements that never itch and are located mainly on the skin of the inner surface of the arms and legs, as well as the abdomen, neck, torso. It is found only in 1-2% of patients. The “rheumatic nodules” described in the old manuals are practically not found now. Also not characterized by nodular erythema, hemorrhage, urticaria. With kidney damage, mild proteinuria and hematuria are detected (due to generalized vasculitis and damage to the glomeruli and tubules). Damage to the nervous system and sensory organs. Small chorea, the most typical "nervous form" of rheumatism, is observed mainly in children, especially girls. Small chorea is characterized by a combination of emotional lability with muscular hypotension and violent movements of the body, facial muscles and limbs. Small chorea occurs with relapses, but by the age of 17–18 almost always ends. A feature of this form may be a relatively small heart damage, as well as slightly pronounced laboratory indicators of rheumatism activity.

Diagnosis: based on medical history, clinical and laboratory data. In the analysis of blood, neutrophilic leukocytosis with a shift to the left, thrombocytosis, an increase in ESR up to 40-60 mm / h. An increase in anti-streptococcal antibody titers is characteristic: anti-streptogy apuronidase and anti-streptokinase more than 1: 300, anti-streptolysin more than 1: 250. The height of anti-streptococcal antibody titers and their dynamics does not show the degree of rheumatic activity. In a biochemical study, an increase in plasma fibrinogen level is above 4 g / l, globulins above 10%, y-globulins - above 20%, seromucoid - above 0.16 g / l, the appearance of C-reactive protein in the blood test. In many cases, biochemical activity indicators are parallel to the ESR value. High diagnostic criteria for rheumatism are distinguished: polyarthritis, carditis, ring erythema, chorea, rheumatic nodules. There are small diagnostic criteria for rheumatism: fever, arthralgia, past rheumatism, the presence of rheumatic heart disease, increased ESR, a positive reaction to C-reactive protein, prolonged P-Q interval on the ECG.

The diagnosis can be considered reliable if the patient has two large diagnostic criteria and one small diagnostic criterion, or one large and two small diagnostic criteria, but only if both of the following proofs simultaneously exist, can a person be judged of a previous streptococcal infection: recently transferred scarlet fever (which is an undisputed streptococcal disease); seeding group A streptococcus from the pharyngeal mucosa; increased antistreptolysin O titer or other streptococcal antibodies.

Treatment. Stay in bed for 3 weeks or more. The diet shows the restriction of salt, carbohydrates, sufficient introduction of proteins and vitamins. The exclusion of products that cause allergies. Antibacterial therapy of benzylpenicillin, sodium salt is used for 2 weeks, then long-acting drugs - bicillin-5, with penicillin intolerance - replacement with cephalosporins, macrolides. Assign vitamin therapy, potassium drugs. Pathogenetic therapy: glucocorticoids, prednisone. Nonsteroidal anti-inflammatory drugs (indomethacin, voltaren). Aminoquinoline preparations (rezokhin, delagil) - with sluggish, prolonged and chronic course. Immunosuppressants are rarely used. Symptomatic therapy of heart failure. When indicated, prescribe diuretic therapy. Antirheumatic drugs have practically no effect on the manifestation of minor chorea. In these cases, it is recommended to add luminal or other psychotropic drugs such as aminazine or seduxen to the therapy. Of great importance for the management of patients with small chorea has a calm atmosphere, a positive attitude of others, suggestion to the patient confidence in full recovery. In necessary cases it is required to take measures to prevent self-harm to the patient due to violent movements.

Inpatient treatment - 1.5-2 months, then treatment in a local sanatorium for 2-3 months, where the treatment of chronic foci of infection and follow-up care at the district pediatrician and cardiac rheumatologist.

Prevention: the primary correct treatment of streptococcal infection, rehabilitation of foci of chronic infection, a balanced diet. Secondary prophylaxis includes carrying out Bicillin-drug prophylaxis to all patients, regardless of age and the presence or absence of a heart disease, who have undergone a reliable rheumatic process. The prognosis is favorable.

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LECTURE № 16. Rheumatism in children and adolescents. Clinic, diagnosis, treatment

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