What is Rheumatology?

In a broad sense, rheumatism can be attributed to any disease that causes bones and joints and muscle pain. Continuing, so far in the classification of rheumatism, there have been more than 100 diseases in a broad sense, including infectious, immune, metabolic, endocrine, hereditary, degenerative, tumorous, endemic, and toxic Caused by illness. In a narrow sense, it should be limited to dozens of diseases in the fields of internal medicine and immunity. Some of these diseases are interdisciplinary, such as gout, osteoarthritis, and infectious arthritis. ^[1] ^[2]

Li Zhanguo

(Chief physician)

Department of Rheumatology and Immunology, Peking University People's Hospital

Rheumatism is a group of diseases that invade joints, bones, muscles, blood vessels and related soft tissues or connective tissues. Most of them are autoimmune diseases. The onset is more subtle and slow, the course is longer, and most of them have genetic predisposition. Difficulty in diagnosis and treatment; different autoantibodies can be detected in the blood, which may be related to different HLA subtypes; good short-term effects on nonsteroidal anti-inflammatory drugs (NSAID), glucocorticoids and immunosuppressants Or long-term remission.

Western Medicine Name: Rheumatism
Affiliated Department: Internal Medicine-Department of Immunology

Disease site: whole body
The main symptoms: joint pain
Main cause: Immune response, genetic factors, infections, endocrine factors

Rheumatism disease introduction

In a broad sense, rheumatism can be attributed to any disease that causes bones and joints and muscle pain. Continuing, so far in the classification of rheumatism, there have been more than 100 diseases in a broad sense, including infectious, immune, metabolic, endocrine, hereditary, degenerative, tumorous, endemic, and toxic. Caused by illness. In a narrow sense, it should be limited to dozens of diseases in the fields of internal medicine and immunity. Some of these diseases are interdisciplinary, such as gout, osteoarthritis, and infectious arthritis. ^[1] ^[2]

Classification of rheumatic diseases

1. Mainly arthritis: such as rheumatoid arthritis (RA), Steyr disease is divided into juvenile and adult, ankylosing spondylitis (AS), psoriatic arthritis.

2. Infection-related: such as rheumatic fever, Lyme disease, Wright syndrome, reactive arthritis.

3. Diffuse connective tissue disease: Systemic Lupus Erythematosus (SLE), Primary Sjogren's Syndrome (pSS), Systemic Sclerosis (SSc), Polymyositis (PM), Dermatomyositis (DM), Mixed Connective tissue disease (MCTD), vasculitis. ^[1] ^[3]

Causes of rheumatism

1. Immune response: The body stimulates exogenous or endogenous antigens directly or through macrophages to activate the corresponding T-cells, and some T-cells produce a large number of various inflammatory cytokines causing various tissues and organs to varying degrees Some T-cells reactivate B-cells, produce a large number of antibodies, and directly or in combination with antigens form immune complexes, causing tissues or organs to be damaged or destroyed. In addition, monocyte chemotactic proteins (such as MCP-1) produced by monocytes can also participate in the inflammatory response. Most rheumatic diseases, or exogenous antigenic substances produced by infection, or endogenous antigenic substances produced in the body, can initiate or exacerbate this autoimmune response, and a variety of antibodies can appear in the serum.

2. Genetic background: Recent studies have shown that some rheumatic diseases, especially connective tissue diseases, are closely related to heredity and patient susceptibility and disease expression, and have certain significance for the early or atypical cases and prognosis of the disease; Among them, HLA (Human Tissue Leukocyte Antigen) is the most important.

3. Infectious factors: According to years of research, it has been stated that a variety of infectious factors, antigens or superantigens produced by microorganisms, can directly or indirectly stimulate or initiate an immune response.

4. Endocrine factors: Studies have shown that the imbalance of estrogen and progesterone is related to the occurrence of various rheumatic diseases.

5. Environmental and physical factors: such as ultraviolet rays can induce SLE.

6. Others: Some drugs such as procainamide, and some oral contraceptives can induce SLE and ANCA-positive small vasculitis. ^[4] ^[2]

Clinical manifestations of rheumatism

1. Rheumatism mostly has joint lesions and symptoms, which can be as high as 70-80%, and about 50% only have pain, and in general, redness, swelling, heat, pain, and impaired function are all manifestations; most of them involve multiple joints. Invasion and joint size vary depending on the disease.

2. Heterogeneity, that is, there are different subtypes of the same disease. Due to genetic background, different causes, and different mechanisms, the types of clinical manifestations, symptoms, severity and treatment response are also different.

3. Rheumatism is a disease that invades multiple systems. Many diseases have overlapping pathologies and similar symptoms. For example, MCTD is typical of this manifestation.

4. A variety of antibodies and immune complexes (CIC) appear in the serum and can be deposited in tissues (skin, synovium) or organs (kidney, liver) to cause disease.

5. Raynaud phenomenon often occurs in this type of disease, such as SLE, MCTD. ^[1]

Rheumatism disease diagnosis

History of rheumatic diseases

Because rheumatism is diverse, detailed medical history should be collected in addition to personal history, including family history; comprehensive physical examination, special attention should be paid to joint symptoms, skin and mucosal lesions, whether there is Raynaud phenomenon, vasculitis lesions. According to the medical history, different diseases can be preliminarily planned to be diagnosed.

Rheumatism laboratory examination

(1) Routine examination: Rheumatism is a disease that affects multiple systems and multiple organs throughout the body, so a comprehensive examination of the patient, blood, urine, stool, erythrocyte sedimentation, CRP, and comprehensive biochemical examination (liver function, kidney function, muscle enzymes) Spectrum, etc.).

(2) Serological examination: General: RF, C3, C4, CH50, CIC, IgG, IgA, IgM, IgE. Specificity: a. Antinuclear antibody spectrum is of great significance for the diagnosis and differential diagnosis of rheumatic diseases. Generally do ANA first, if titer> 1:40, other items should be further checked. b. HLA: Although HLA is closely related to rheumatism, it is not well understood at present. Commonly used, more specific, such as HLA B-27 positive rate of AS up to 81.8%, Wright comprehensive It can also reach 40%, only 10% in psoriasis; DR4 / DR1 positive rate for RA is 49-79%, JRA is 7%, but Dw4 of JRA is 26%, Dw14 is 47%, DR3 is in SLE Only 2.7% and 5.6% at pSS. Behcet's disease is only 3.3% HLA B5 positive. c. Others: such as anti-keratin antibody (AKA), anti-histone antibody (anti-histone antibody), anti-phospholipid antibody, anti-perinuclear factor (ANCA), etc. have diagnostic reference value for some diseases.

(3) Joint fluid examination: Fresh joint fluid is very important, and routine, culture, serological, and immunological examinations should be performed.

Rheumatology Imaging

(1) X-ray plain film: Ortho, lateral, large and small joints are commonly used, limbs, shoulders, spine, sacroiliac joints; according to different diseases and parts, there may be different requirements for bone damage or Proliferative lesions are generally displayed clearly, but due to overlapping images, early small lesions are not easy to see; the synovium, joint capsule, cartilage, meniscus, and ligaments are not displayed.

(2) Computerized tomography (CT): It can accurately display small differences in different tissue densities on a cross-section, and is an ideal inspection method for observing small lesions of bone joints and soft tissues. It is mostly used for sacroiliac joints and spine of AS; cartilage and meniscal lesions of knee joint, brain changes of SLE; early pulmonary interstitial changes, etc.

(3) Magnetic resonance imaging (MRI): for bone, joint and soft tissue lesions, it has a higher resolution than X-ray and CT, and is better than CT for soft tissue imaging. It is mostly used to diagnose bone, cartilage, meniscus, and fascia; it is also helpful for brain tissue and myelopathy.

(4) Contrast: Arthrography: Generally, filtered air or organic iodine solution can be used at the same time. Can show articular cartilage, meniscus, synovium and ligaments. It is very helpful for the diagnosis of intra-articular lesions. It is mostly used for large joints of the extremities, but it is now less used. Angiography: divided into angiography and venography, which is very helpful for the diagnosis of arteritis or vasculitis.

(5) Arthroscopy: It can directly observe the lesions of various tissues in the joint, especially for the diagnosis and differential diagnosis of synovitis. Synovial biopsy and surgical treatment can be taken if necessary.

(6) Biopsy: For cases that are difficult to diagnose, this kind of examination can help confirm the diagnosis. Such as skin, labial mucosa, kidney, liver, joint synovium, blood vessels, muscles, bone, cartilage and so on. Sometimes also immunohistochemical staining.

(7) Isotope bone scan: It is very helpful for identifying osteoma (primary or secondary) and myeloma.

(8) Ultrasound examination: the joint capsule, cartilage, synovial thickness, and effusion can be judged. ^[1] ^[4]

Rheumatic Diseases Treatment

Rheumatic diseases are a class of autoimmune diseases that invade multiple tissues, multiple systems, and internal organs. Different degrees of immune inflammatory reactions can cause damage to various tissues and organs, seriously affecting their normal functions. It can even cause fatal damage. In addition, most rheumatic diseases have joint symptoms; each patient, with the same disease, has a specific course of disease. It should be carefully evaluated to develop a personal treatment plan. The goals of treatment should include alleviating symptoms, improving the condition, restoring function, improving the quality of life, and extending the patient's life as much as possible. As most rheumatic diseases cannot be cured at present, we must seek the cooperation of patients and insist on long-term treatment. Treatment methods include medicine, physical therapy, rest and exercise, orthopedics and surgery. Patients should be educated to understand their condition and cooperate with treatment.

The following only discusses drugs for treating rheumatic diseases.

Rheumatism Drug Treatment

Drugs for treating rheumatic diseases can be divided into the following categories:

1. Non-steroidal anti-inflammatory drugs (NSAIDs): The effects of these drugs are mainly antipyretic, anti-inflammatory and analgesic, and to reduce the inflammatory response and purpose. The earliest aspirin (acetylsalicylic acid) is still an effective drug for treating acute rheumatic fever and rheumatoid arthritis. Later, various salicylic acid drugs were produced. Ibuprofen, diclofenac, indomethacin, piroxicam, naproxen, etc. were commonly used, but the pharmacokinetics and adverse reactions of various drugs were different. For the gastrointestinal, renal, liver and blood systems, be sure to pay attention to dosage, usage, side effects, etc. when using it.

2. Adrenocortical hormone: mainly refers to glucocorticoids, because these drugs have anti-inflammatory and immunosuppressive effects, and have a strong and rapid elimination of various symptoms caused by inflammation and inflammation, such as fever, joint swelling and pain . Therefore, various rheumatic diseases are often used as first-line drugs. Clinical applications include short-acting, medium-acting and long-acting preparations. Usage includes oral, intramuscular or intra-articular injection, and intravenous injection. Different choices can be made according to the disease and condition. However, since it is not a curative drug, long-term large-scale use can induce infection, osteoporosis, femoral head necrosis, diabetes, peptic ulcer, hypertension, and mental disorders; and if the drug is stopped too quickly, the disease will rebound. Pay attention to adjust the type and dosage of the drug used according to the disease type and condition. Except for critically ill patients, in principle, a small dose and a short course of treatment are appropriate.

3. Anti-rheumatic drugs (DMARDs) that improve the condition are also called slow-acting anti-rheumatic drugs. Such drugs include many types of drugs with different structures and different effects. Their common feature is relatively slow onset and a certain accumulation effect, so after stopping the drug, the effect disappears slowly, and it can be maintained for a period of time. They do not have direct anti-inflammatory and analgesic effects, but they can play anti-inflammatory and immune or immunosuppressive effects through different mechanisms. Therefore, it can also improve joint swelling, pain, stiffness and reduce systemic symptoms, reduce acute response protein and erythrocyte sedimentation. If it is used for a long time, it can also improve other immune indicators, such as RF, ANA, etc. Some can still improve the radiological image. DMARDs include antimalarials-chloroquine, hydroxychloroquine, sulfasalazine, methotrexate, azathioprine, cyclophosphamide, penicillamine, gold preparations, cyclosporine A and leflunomide .

The above various drugs have different toxic effects on the vital organs (liver, kidney, bladder, lung, gastrointestinal, gonad) and tissues (bone marrow) of the human body. Attention should be paid to the choice of indications.

4. Other: Other treatments include triptolide, Pavlin, Yunke, etc.

(1) Yunke: inhibits prostaglandin synthesis, inhibits collagenase activity, prevents cartilage breakdown and destruction, and inhibits osteoclasts. Anti-inflammatory and analgesic.

(2) Tripterygium wilfordii: inhibits T and B cell proliferation, inhibits T-cell production of IL-2 and B-cell production of immunoglobulin. Inhibits prostaglandin production. Has strong anti-inflammatory and immunosuppressive effects.

Other measures for rheumatism

In patients with rheumatism, in addition to drug treatment, there are many circulating immune complexes in the blood. There are high immunoglobulins. Immunoadsorption and plasma clearance therapy can be selected. Remove immune complexes and excessively high immunoglobulins in plasma. RF ,Wait. If there are too many immune-active lymphocytes, mononuclear cell removal therapy can also be used. So as to improve the function of T, B cells and macrophages and natural killer cells, reduce blood viscosity, and unblock microcirculation, the purpose of improving symptoms can be achieved.

Rheumatism surgery

In patients with rheumatoid arthritis, synovectomy can be performed at an early stage, joint replacement can be performed at a later stage, or tendon repair or transfer can be performed. Improve patients' quality of life. ^[1] ^[3] ^[4] ^[2]