Pathology of ankylosing spondylitis

2021-01-26 12:00 AM

Often taking fluid in the knee, fluid and pale, the amount of Mucin decreases, the number of cells increases, especially neutrophilic nuclei, Joint fluid only shows nonspecific inflammation.

Outline

Define

Ankylosing spondylitis (VCSDK) is chronic, unexplained arthritis, mainly found in young men, causing damage to the joints of the base of the limbs and spine, leading to joint adhesion and deformity and disabled.

Epidemiology

Found all over the world, but the incidence varies due to factor HLA - B27.

In Vietnam: OI accounts for about 20% of joint patients treated at Bach Mai Hospital, about 1.5 / 1000 people over 16 years old.

Men account for about 90-95%, under 30 years old accounts for 80%, 3-10% is of a family nature.

Clinical symptoms

Onset

Age: Around 70% of the world before the age of 30.

Vietnam: 80% before age 30, 60% before age 20

70% begin slowly, 30% begin suddenly, 75% begin at the hip joint 25% begin at the spine.

Initial signs: Pain in the hip, sciatica, Achille tendonitis ... in our country often begins with inflammation of the joints in the lower extremities (ankles, knees, groin) and lumbar spine pain. These symptoms lasted for months and years.

Sicked

Painful swelling, mobility restriction, muscle atrophy, rapid deformity. Arthritis is usually of asymmetrical nature, with increased pain at night.

Joints in the extremities:

Groin: 90% usually start one side, then both sides.

Pillows: 80% may contain water.

Ankle joints: 30%, may leave no sequelae.

Shoulder joints: 30%, usually no longer leaves any sequelae.

Other joints: Rarely, such as elbow, brisket, wrist, little joint damage to hand is never seen.

Spine:

Usually, appear later than joints in the extremities.

Lumbar spine: 100% continuous pain and dullness, limited movement, atrophy of the paranasal muscles.

Spine: usually later than the lumbar region, dull pain, limited movement, deformation (hunchback) or stiffness, muscle atrophy.

Neck spine: maybe later or earlier than other segments, the deformation limited movement.

Pelvic joints:

A specific early sign (mainly on radiographs).

Pain in the same pot spread down the thighs.

Gluteus muscle atrophy.

The solution to relax the pelvis (+).

Other manifestations:

Fever, thinness shot.

Eyes: Iritis, iritis of the eyelids.

Foreigners: This accounts for 20-30% of cases.

Vietnam: About 3%.

Heart: 5% have conduction disorders, aortic valve opening.

Other rare manifestations:

Atrophy of the skin.

Pulmonary fibrosis.

Spinal nerve root compression.

Inguinal and umbilical hernia.

Evolution

General trend: Gradual progression, leading to joint and deformation. Without early, correct treatment, the patient has many poor, handicapped positions.

Complications: respiratory failure, chronic heart-lung, tuberculosis, paralysis of two limbs due to compression of the marrow and nerve roots.

Prognosis:

Bad: Young, peripheral arthritis, fever, weight loss.

Better: Diseased after 30 years of age, the main form of the spine.

50% continuous progression, 10% rapid progression.

Subclinical

Test

General test: It has diagnostic value:

Heal increased (90%).

Increased blood fibres (80%).

Protein Electrophoresis: Albumin decreased; Globulin increased.

Immunological tests: Waaler Rose, antinuclear antibodies, Hargraves cells are mostly negative and have no diagnostic value.

Other XN little changed.

Joint fluid: T usually take fluid and pale knee fluid, Mucin content decreases, the number of cells increases, especially neutrophilic nucleus. Joint fluid only shows nonspecific inflammation.

HLA-B27 (1973): Brewerton (UK) and Schlosstein (USA) found a close relationship between HLA B27 and ERB. It was found that in the VSDK, 75-95% of patients carry this factor (Vietnam: 87%), while in normal people only 4-8% carry HLA B27 (Vietnam 4%).

X-ray

Early signs: Bilateral pelvic arthritis stage 3 (much narrow, with sticky places) and stage 4 (completely boundless)

Late-stage:

Arthralgias: Joint cleft, blurred joint, bone defect, sticky

Spine: Bone bridge (bamboo trunk), fibre strip (rail)

Clinical forms

According to symptoms

Root type: 40%, poor prognosis, a manifestation of early and severe inflammation of the hip and knee joints.

Spine: Progressive slowly, starting after age 30, mild sequelae.

Painless: Gradual adhesion of the spine, no pain and no inflammation.

Combination with rheumatoid arthritis: There is additional inflammation of the hand joints.

Body-based

Women: Light, discreet.

Children under 15 years of age: Progressing rapidly, with poor prognosis, and severe joint and joint deformity.

Elderly: Mild, easily confused with the degenerative spine.

Disease form according to an X-ray image

May not show signs of pelvic arthritis.

You may have a bridge in the front of your spine.

Image of destruction, bone defect.

Causes and anatomy of the disease

Reason

The cause is unknown, there is no evidence of immunity but there is evidence of the role of the infection.

Pathology

Synovial membrane & articular cartilage:

The first stage: synovial membrane proliferates, penetrates cells (lymphocytes, plasmocytes).

Later stage: ulcerated cartilage, endocarditis.

Late-stage: synovial membrane, synovial membrane atrophy, calcification, reinforcement leading to joint adhesion.

Spine:

Buffer organization between the long anterior ligament and vertebral body inflamed, calcified, reinforced, formed a bridge.

The spinal ligaments fibrosis, calcification under the ligaments causing the spinal cord.

Diagnose

Implementing the quadrants

Standards of the New York Rheumatism Association, 1966 a. Clinical:

History or current lumbar or lumbar pain.

Limit movement of the lumbar region in all 3 postures.

Reduced chest stretches.

X-ray: Bilateral pelvic arthritis stage 3, 4.

Diagnosis is determined when there is a clinical standard and a standard X-ray.

Practical application in Vietnam:

Men, young people.

Pain and limited movement of the hip joints.

Pain and limited movement of the lumbar spine.

High blood sedimentation rate.

X-ray: Arthritis of the same pelvis stage 2 or more.

Differential diagnosis

With genital arthritis:

Tuberculosis of the hip joints.

Bleeding joints in Haemophilia.

Rheumatoid arthritis.

Drop.

The main form of the spine is:

Bacterial spondylitis (tuberculosis, staphylococcus ...).

Injury to the spine in Scheuermann's disease: pain, hunchback, no inflammatory manifestation.

Malformations, traumatic sequelae cause pain and limited movement.

Parenchymal muscle diseases: inflammation, trauma, bleeding

Relationship between ED and joint diseases with HLA - B27 (+):

Reiter's Syndrome, HLA B27 (+) 80%.

Psoriatic arthritis: HLA B27 (+) is high with spinal form.

Chronic spondylolisthesis: HLA B27 (+) high.

Treatment

Internally medical treatment

Medicines that work well:

Phenylbutazone:

The first phase is 600 mg/day intramuscularly, then switch to 150-200 mg/day. Note the side effects of the drug: Blood, digestion, skin, saltwater retention, heart disease.

Salazopyrine:

Inflammation 500mg, 2-4 tablets/day, the drug is used according to the mechanism of fighting against potential infections (digestive, genital), good effect in 50-70% of cases, taken for several months.

Other anti-inflammatory drugs: Indomethacin, diclofenac, Profaned, Naprosyn.

Less effective drugs:

Aspirin: Relieves pain but does not limit inflammation.

Steroid: Systemic and topical use is less effective, should not be used in the medical examination.

Chloroquine: No effect.

Immunosuppressants: Not for use.

Other methods

The method of using radiation has brought many positive results.

Using X-rays to illuminate the spine and inflamed joints, each 100r, total dose 400-800r.

Using radioactive isotopes: Radium 224 intravenous injection each time from 50-200 micrograms, the total dose from 1000-1500 micrograms.

Stage level:

Rested.

Put your limbs in a functional position.

Anti-inflammatory non-stéroid injections, oral: Phenylbutazone, Diclofenac, Profenid.

Muscle relaxants: Mydocalin, coltramyl.

Post-acute period:

Practice increasing movement gradually, without exertion to avoid secondary spasticity.

Non-Stéroid anti-inflammatory: Phenylbutazone, Diclofenac, Profenid.

Muscle relaxants.

Antibiotics: Salazopyrine 0.5g 2-4 tablets / day or Tetracycline 0.25g 2-4vs / day, not for patients under 15 years old.

Physical therapy

Measures against sticking joints and bad posture:

When the disease is progressing, the pain is much, so the joint should be in a functional position: lying on his back on a hard floor, with low knees, legs stretched slightly. With this position, if there is joint attachment, the patient can still walk. However, it is only allowed to be fixed for a short time, when the acute phase has passed, it must be immediately mobilized.

Exercising as soon as possible, moving in all positions and all the time, this is the best way to prevent joint adhesion.

Methods of rehabilitation of motor function:

Heat treatment prevents muscle contraction.

Using water (swimming pool), mineral water: exercise patients, especially swimming, bring many results.

Massage, continuous pull, gymnastics therapy.

Surgery

Surgical treatment is indicated to restore motor function in the presence of joint attachment with poor posture.

Bone cutting or bone grafting to adjust the axis of the spine, limbs.

Replace prosthetic joints with plastic or metal: hip joint, knee joint.