Pathology of rheumatism

2021-01-28 12:00 AM

Not clear, inclined too autoimmune. There is a similarity between streptococcal antigens and cardiac antigens

Outline

Rheumatic heart disease is a general inflammatory disease, manifested in many organs, but mainly in the joints and heart, the disease has the following characteristics:

A slow consequence of inflammation of the upper respiratory tract due to group A haemolytic leucocytosis

Appeared in waves monthly, sometimes even decades.

The pathogenesis is inclined too autoimmune.

Heart valve damage can be chronic, progressing to heart failure.

 Effective disease prevention.

 Epidemiology

Youth: 5 -15 years old.

The cold season makes sore throat easy.

Material activities: the disease of the third underdeveloped world, of the crowded groups.

The disease occurs after severe strep throat, sometimes after strep throat is unknown, easy to recur in old rheumatic patients when streptococcal re-infection.

Causes and mechanisms of pathogenesis

Reason

Group A haemolytic streptococci are bacteria that cause disease due to hypersensitivity phenomenon after streptococcal infection. If based on Protein M, there are about 60 different types, strep throat causes pharyngitis of types 1, 2, 4, 12. The rate of disease is about 30%.

Mechanism of pathogenesis

Not clear, inclined to autoimmune. There is a similarity between streptococcal antigens and cardiac antigens (carrying anti-platelet and cardiac antibodies, protein M, and a special glycoprotein antigen that resembles heart valve proteins).

Specific antibodies (KT): Anti-heart antibodies, anti-brain cells, anti-KT

The glycoprotein, Antistreptolysin O. These antibodies increase from week 1 to week 4 of illness.

Genetic site: Easy to get sick, in danger of recurrence lasting for life.

Pathology

Progressive injury.

First stage: C รณ proper connective tissue, degenerative cell infiltrates form fibrin, may necrosis (heart muscle).

Later stage:

Aschoff seeds are located near blood vessels, this seed is composed of:

Central is a region of fibrinolytic necrosis, followed by an epithelial cell area with giant cells with the outermost nuclei of the most diverse cells, lymphocytes and cytoplasm.

These nodules exist most often in the endocardium that causes scars in the heart valves and the muscle columns of the heart valves.

Damage to the heart: It is possible that all 3 layers of heart structure and connective tissue.

Endocardium: Permanent damage to mitral valve 40%. Mitral valve + aortic valve 40%. Pure aortic valve 10-15%. The thick and hard valve is rolled up causing the opening, the valve sticking to the edges causes narrow.

Cardiomyopathy: Dilatation of myocardial fibers, fibrosis inflammation, Aschoff polymorphic cell infiltration.

Pericardium: Lesions have nonspecific fibrous morphology or inflammatory reactions like fibrin and usually have yellow fluid about 200ml, sometimes red, cloudy.

Connective tissue damage: Degenerative fibrinitis.

Injury to joints: Fibrin exudate, sterile, not erosive.

Brain damage: encountered in the striatum causing jerky dance.

Skin lesions: Meynet particles also known as skinless Aschoffs.

Symptom

clinical

Varies widely depending on organ damage and severity.

Onset: A high fever is suddenly toxic if the manifestation of arthritis is primary. Fever slowly, low-grade fever unknown if heart infection is primary.

Joints: Typically, inflammation of the major joints is the main inflammation - hot - red - pain that limits movement, recovers quickly within 2-3 weeks, especially with treatment, completely heals without leaving complications. In joints, the common joints are: shoulder joints, knee joints, elbows, wrists, ankles, sometimes no typical inflammation, some cases do not manifest in joints.

Heart: Inflammation of the heart is the most severe manifestation of low heart, is the only manifestation that has left behind important permanent damage and death. Heart inflammation can cause all 3 layers of the heart's structure:

Pericarditis:

Potentially pre-heart pain.

Sometimes you can hear the pericardial rub

Myocarditis:

Blurred heart sound.

Tachycardia, horse racing, extrasystole, sometimes very slow heart rate, arrhythmia. Atrioventricular bloc levels.

Endocarditis:

Commonly seen are systolic murmurs in the muzzle, the sound of RTC at the apex, diastolic blowing at the base of the heart due to aortic valve opening.

Other manifestations:

Nerve:  

Jerking dance: is involuntary, fast-amplified movements in the limbs, neck, face. Muscle tone decreased, appeared late and is common in women.

Encephalitis and neuritis are also possible.

Skin:

Subcutaneous nodules (Meynet seeds), a few millimetres to 1 cm in diameter, are usually found on extensor surfaces of large, painless density, with no signs of inflammation often appearing late.

Cyclic erythema: non-infiltrating arc, rapidly changing, and occurs in the body and base of the limb.

Kidney: Acute nephritis: mild proteinuria, microscopic haematuria. There is also a case of diffuse acute glomerulonephritis.

Lungs and pleura: Pleural effusion, congestive pulmonary oedema one or two sides.

Abdominal pain: Abdominal pain is sometimes confused with inflammatory appendix

Subclinical

Manifestations of an acute inflammatory reaction in the blood:

Increased blood sedimentation usually> 100 mm in the first hour.

Leukocytes increased from 10,000 to 15,000 / mm3, mainly neutrophils.

Fibrinogen increases 6 - 8 g / l; Increase (2 and gamma Globulin.

Creative Protein (CRP) is positive.

Symptoms of streptococcal infection:

Streptococcus pharyngeal culture: Out of the inflammatory phase, only 10% were positive.

Anti-streptococcal antibodies increased in blood> 500 units Todd / ml.

Antistreptokinase increased 6 times normal.

ECG:

Disorders of atrioventricular conduction, PR prolongation. There are arrhythmia: NTT, atrioventricular block at all levels.

X-ray:

Heart shadow may be larger than normal.

Progression and complications

Conventional form:

Clinical improvement very quickly.

Symptoms of joints decrease after 24 hours, PR prolongs after a few days, VS increases after 2-3 weeks.

All symptoms disappeared after 2 months

Heavy form:

Malignant rheumatism:

Meet children <7 years old.

Whole heart inflammation, especially acute myocardium or in the brain, kidneys, lungs.

Fever discreetly with little joint pain.

Treatment with little results.

Progressive form:

Progressing more slowly.

There was a continuation of exacerbations and remission.

Always have serious sequelae in the heart.

Sequelae:

Usually in the endocardium:

Mitral valve: Most damage causes mitral stenosis after 2 years. Aortic valve: Aortic stenosis, simple aortic stenosis is rare.

Tricuspid valve: rare, often combined with other valves.

Infection of the endocarditis:

The most frightening thing, Osler is more common in open valves than stenosis.

Occur again periodically:

Common in patients with no good prophylaxis.

Diagnose

Implementing the quadrants

Difficulty in the first low, based on Jones' standards.

Main standard:

Heart inflammation.

Round board.

Arthritis.

Subcutaneous nodules.

Dance.

Substandard:

Fever.

Arthritis

Prolonged PR.

Blood sedimentation increased, leukocytes increased, C Reactive Protein (+)

Low history of heart disease following streptococcal infection.

New evidence of streptococcal infection:

The increased concentration of anti-streptococcal antibodies.

Just had scarlet fever (Scarlatine).

When a diagnosis of low heart rate must have 2 main criteria, or 1 primary criterion + 2 secondary criteria and new streptococcal infection.

New techniques:

2-plane ultrasound can see pericardial effusion, changes in heart valves, degree of cardiac dysfunction.

Doppler ultrasound: Detect a mitral valve, aortic valve, assess the degree of openness.

Differential diagnosis

Rheumatoid arthritis: Inflammation of many small joints, deformed joints, muscle atrophy, stiffness, prolonged progression.

Arthritis caused by gonorrhoeal: Inflammation of the knee joint, joint fluid with bacteria.

Tuberculosis: Body exhaustion, persistent fever, usually after tuberculosis, common joints: hip joints, spine.

Lupus erythema: Butterfly-shaped rash on the skin, skin discoloration, joint pain, severe kidney damage, pleural damage, abdomen.

Pericarditis, myocardium due to viruses: Diseases of the heart, acute, high fever, pericardial scrubbing, completely without leaving sequelae.

Prognosis

Depends on heart damage.

If there is no heart injury or heart attack but the heart is not enlarged, early diagnosis and treatment, adequate prevention, no recurrence, a good prognosis of 90% of heart complications can be prevented.

If the first phase of heart injury is not fully preventive according to the regimen, the prognosis is much worse.

According to Friedberg and Jones: 10 - 20% of diseases after the first rheumatic episode will become disabled children. Death after 2 - 6 years.

The remainder survived to adulthood:

65% of patients have normal activities.

25% of living health has decreased significantly and is a burden on the family and society.

Conclude

A disease found in young people, caused by streptococcus.

Variety of medical conditions.

Initial diagnosis is difficult, when diagnosing including new technology, the heart is inflamed.

Unpredictable developments, lifelong prevention speak of the importance of impacting the heart, especially the left heart chamber.