Rheumatoid arthritis is a pathology that affects mainly small peripheral joints. The resulting erosive and destructive tissue changes provoke severe clinical manifestations of the disease. During the initial diagnosis of rheumatoid arthritis, articular and intraarticular signs are taken into account, indicating the involvement of peripheral nerves and muscle tissues in the pathology.
A number of instrumental studies help to detect the disease, radiography is the most informative. The resulting images visualize damaged bone and cartilage, narrowing of the joint spaces, edge erosion. With the help of MRI, the condition of the ligament-tendon apparatus and the muscles located next to the joint are assessed. In the laboratory, a study of the joint fluid is carried out to establish non-specific inflammatory signs. Identification of typical immunological markers of the disease helps to make a final diagnosis: rheumatoid factor, T-lymphocyte concentration, cryoglobulin content.
Key diagnostic criteria
A few years ago, the American College of Rheumatologists made proposals that significantly simplified the diagnosis of rheumatoid arthritis. Seven key features were identified, the identification of which should be carried out during an external examination, laboratory or instrumental measures. These criteria are characterized by high sensitivity and specificity.
If the examination revealed four or more signs that persist for a month and a half, then the patient is given the final diagnosis – rheumatoid arthritis. Chronic recurrent pathology is detected by the following criteria:
- in the morning, a person suffers from stiffness of the joints, which does not disappear for an hour;
- three or more joints are affected by arthritis, which is clinically manifested by swelling of adjacent soft tissues, accumulation of pathological exudate in the joint cavity;
- acute or chronic inflammatory process has affected the proximal, interphalangeal, metatarsophalangeal, wrist joints of the fingers or most of them;
- Symmetric arthritis was diagnosed, that is, the pathology affects interphalangeal, metacarpophalangeal or metatarsophalangeal joints on both hands;
- typical signs of arthritis are revealed – subcutaneous nodules from connective tissue. They are round in shape, of dense consistency, mobile, with their palpation there are no painless sensations;
- when conducting a laboratory study by any method, the presence of rheumato >
All these signs correspond to the clinical picture of the pathology of moderate and high severity.
The main task and at the same time the problem of diagnosing arthritis is its detection in the early stages, when using a long course of taking pharmacological drugs, you can achieve a stable remission, to avoid the development of serious complications.
Early diagnosis opportunity
According to the results of clinical studies, at an early stage of the disease there is a certain time interval lasting only a few months. During this period, active anti-inflammatory and immunosuppressive (correcting the functioning of the immune system) therapy would stop inflammation and prevent joint destruction. Early diagnosis of arthritis is difficult for several reasons:
- Rheumatoid arthritis makes its debut with nonspecific symptoms, which is also characteristic of degenerative-dystrophic pathologies. And generally accepted signs of diagnosing the disease can occur only after a few months, and sometimes years.
- The absence of specific laboratory tests to detect systemic pathology at an early stage when tissue destruction is not yet available on x-ray images. The latest diagnostic method is actively introduced – the detection of antibodies to the cyclic citrulline peptide. But the study is still inaccessible, and some scientists have doubts about its reliability.
- Appeal of patients with joint pain to general practitioners who do not have the proper diagnostic skills. In such cases, rheumatoid arthritis is detected by the already formed specific picture, when therapy with basic drugs is not so effective.
During the first few months of the development of pathology, a third of patients establish destructive changes in the joints of the fingers and toes, but they are considered seronegative, since rheumatoid factor was not detected in laboratory studies. And such a clinical picture is characteristic of gouty, psoriatic arthritis, osteoarthritis. Rheumatologists compiled a list of specific criteria that make it possible to set the correct diagnosis with a high degree of accuracy:
- the presence of an inflammatory process in 3 joints;
- edematous proximal interphalangeal or metacarpophalangeal joints;
- stiffness of movements in the morning for half an hour;
- erythrocyte sedimentation rate> 25 mm / h.
An external examination of the patient determines the presence of inflammation with the “compression” test. The doctor squeezes the patient’s hand for a minute. An alarming factor is the appearance of persistent painful sensations.
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Most often, differential diagnosis of rheumatoid arthritis is carried out at its debut, when the symptoms are similar to other joint diseases:
- reactive arthritis, provoked by the penetration of pathogenic microorganisms into the joint cavity;
- Whipple’s disease, which is characterized by severe arthropathy, manifested in non-destructive poly- and oligoarthritis of large joints;
- gout, chondrocalcinosis – a group of microcrystalline arthritis with an acute onset, a sharp pain syndrome, accumulation of calcium pyrophosphate or tofus in the joint bag, formed during the crystallization of uric acid salts.
The clinical picture of rheumatoid arthritis resembles the symptoms of hemochromatosis, pigmentary synovitis, neutrophilic dermatosis. Differentiation of osteoarthritis is indicated for complications of rheumatoid arthritis with secondary arthrosis.
Conducting a laboratory diagnosis of rheumatoid arthritis is necessary to identify developed complications, determine the stage of the course and degree of damage to the joint structures, exclude pathologies with similar symptoms. Biochemical analyzes of blood and synovial fluid are subsequently shown to patients to evaluate the effectiveness of the therapy and determine the possible progression of the disease. What laboratory indicators help diagnose the disease:
anemia – a decrease in the concentration of hemoglobin in the blood (130 g / l in men and 120 g / l in women). This criterion helps to evaluate the activity of rheumato >
- increased amount of anti-PCP antibodies. High specificity marker. In combination with the high value of the rheumatoid factor, the probability of diagnosing arthritis is more than 90%;
- establishment of NIA CD4. The identification of a quantitative indicator of monomeric transmembrane glycoproteins, or T-lymphocytes, is necessary to assess the likelihood of patients achieving stable remission.
Patients are shown a study of synovial fluid. With arthritis, its viscosity decreases, mucinous clots form, the level of leukocytes and neutrophils rises. This laboratory study plays only a supporting role and is used for differential diagnostics of rheumatoid arthritis from microcrystalline and septic inflammatory processes.
Dominant in the diagnosis are the results of x-ray studies. On the images obtained, signs of swelling of the soft tissues, periarticular spotted or diffuse osteoporosis, cystic bone remodeling are clearly visible. With loss of bone mass, the pineal gland of the affected joint becomes more transparent. On radiographs, narrowed articular cracks, fuzzy and uneven surfaces of hyaline cartilage are clearly visible. If the cortical layer has undergone significant destruction, the bone surfaces are in contact with each other. If some sections of the radiographs are uninformative, then additional instrumental studies are prescribed:
- computed tomography (CT) or nuclear magnetic resonance imaging (NMR). Allow to identify degenerative-dystrophic changes in bone, cartilage, ligament-tendon apparatus even at an early stage of development of pathology;
- Ultrasound The study is conducted to assess the dynamics of the state of the inner shell of the synovial capsule, cartilage located near the joint of the muscles. The study helps to establish the presence of articular effusion and aseptic necrosis of the femoral bone heads.
In diagnostics, the use of minimally invasive surgical manipulation – arthroscopy is practiced. A miniature video camera is inserted into the joint cavity, transmitting to the monitor an image of its inner surface. Arthroscopy reveals the presence and nature of the course of inflammatory and (or) degenerative changes in the cartilage, assesses the condition of the synovial membrane.
Shishkevich Vladimir, orthopedic and traumatologist, project editor-in-chief ExpertNews.
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