Reactive arthritis is an inflammatory disease that affects the joints after an infectious disease - urogenital, intestinal; ICD-10 code – M02 “Reactive arthropathy”. The incubation period for reactive arthritis is 2-4 weeks from the moment of infection with microbial pathogens.
Reactive arthritis is often confused with infectious arthritis. The mechanism of development of the disease is somewhat different: inflammatory processes in the joints are not associated with the direct penetration of infection into the joint tissue.
Arthritis develops as a result of an atypical reaction of the immune system to microbes entering the body.
If there is a tendency to autoimmune processes, as well as if there is a certain link in the human genotype, the cells of the immune system try to destroy the antigens of microorganisms and their own antigens contained in the tissues of the joint. The result is non-purulent aseptic inflammation of large joints (hip, knee, ankle), as well as small joints (mainly the big toe) and periarticular tissues.
Most often the disease occurs in people in the age group of 20-40 years. Men suffer from reactive arthritis much more often. In women, the predominant variant of the development of the disease is after intestinal infections, in men - after genitourinary infections. Reactive arthritis in children is the most common rheumatic disease, especially at the age of 9-14 years.
There is a group of reactive arthropathies of post-infectious origin (seronegative spondyloarthritis), which manifests itself in the form of allergic aseptic inflammation in the joints and is supplemented by conjunctivitis and urethritis (in some cases, cervicitis, colitis). This condition is called Reiter's syndrome.
Presumably, the main cause of the development of the disease is the presence of an abnormal antigen in the DNA, which becomes histocompatible with antigens in the cells of pathogenic microorganisms. As a result, gastrointestinal or urogenital infections activate T-lymphocytes of the immune system, which attack their own tissues.
Food poisoning caused by:
However, the most common causes of reactive arthritis are genitourinary infections:
Arthritis can begin to develop, both as a result of the acute phase of an infectious disease, and due to long-term persistence of pathogens in the body. The most common cause of reactive arthritis is chlamydial infection (up to 80% of cases). Sometimes the disease can develop after a person has been immunized.
The main routes of infection with urogenital diseases are sexual, contact and household, infection of the child during childbirth. Microorganisms that lead to the development of intestinal diseases can penetrate through airborne droplets, dust or with incoming food.
The classification of types of reactive arthritis is based on grouping according to the cause that caused them:
The course of the disease may vary in symptoms and duration:
The clinical picture of the disease develops simultaneously or after a certain period of time after an infectious disease.
Symptoms of joint damage are most often localized in large joints (elbow, shoulder, knee, hip, ankle.
The predominant nature of joint inflammation is one-sided. Sometimes the pathological process involves the lumbosacral and cervical spine, small joints, collarbone and sternum, as well as ligaments and tendons.
Main symptoms of the disease:
Often the patient notes discomfort in the heel area,
Systemic manifestations of reactive arthritis are reduced to:
The symptom complex, as a rule, is supplemented by signs of the underlying disease (prostatitis, cystitis, urethritis, vaginitis, conjunctivitis, iridocyclitis, intestinal disorders, ARVI). Ulcerative lesions of the mucous membranes, psoriatic rashes and nail separation are often observed.
With the development of reactive arthritis in children, there is a risk of juvenile spondyloarthritis. Some patients develop deformation of the joints, especially often the feet; If left untreated, reactive arthritis can lead to ankylosis of the joints. Complications that can cause death can include myocarditis and glomerulonephritis.
The main confirmatory criteria noted in the patient’s medical history are:
Laboratory tests include detection of antibodies to the pathogen (smear from the urethra, vagina, eyelid, blood test, bacteriological examination of stool, blood, urine). Additionally, a general urine test, clinical blood test, and blood biochemistry (to assess rheumatoid factor) are performed. To exclude infectious arthritis, a joint puncture is performed to take a sample of synovial fluid.
X-ray examination is indicated for protracted reactive arthritis, since early treatment usually prevents the development of deforming signs in the joints. If pain occurs in the heart area, echocardiography is performed.
The differential diagnosis is made in comparison with juvenile arthritis, rheumatoid and infectious arthritis, Lyme disease, complications of syphilis and tuberculosis, ankylosing spondylitis.
Drug therapy is aimed at eliminating articular syndrome and treating infectious diseases:
The prognosis for the patient's health and life is favorable. Among the negative signs are frequent exacerbations of the disease and its transition to a recurrent form, as well as the ineffectiveness of first-line conservative therapy. As a rule, repeated episodes of reactive arthritis are observed in Reiter's syndrome due to the difficult treatment of chlamydial infection. A severe course is observed in cancer patients and HIV-infected people.
Among the traditional methods, the most effective in the treatment of reactive arthritis are the following:
The daily set of classes lasts 15-30 minutes and may include:
All exercises are performed at a slow pace. If any unpleasant sensations occur, you must stop training and resume it after a certain period of time in a more gentle mode.
After the acute phase of the disease subsides, it is recommended to perform therapeutic massage of the affected joints. Movements should be smooth, soft, and at the same time lead to a rush of blood and improve its outflow.
Taking vitamins and minerals, as well as following a healthy diet, speeds up a person’s recovery and increases the immune system’s own protective functions. The diet in the acute stage of the disease involves reducing the load on the gastrointestinal tract by reducing the proportion of animal fats, fried foods, as well as eliminating allergenic foods, smoked meats and spices. At the recovery stage, the main goal of nutrition is to meet the need for essential nutrients, for which you need to eat as many vegetables and fruits as possible, drink rosehip and hawthorn decoctions.
The main goal of prevention is to prevent the occurrence of an infectious disease that can cause the development of reactive arthritis:
Today we will tell the story of the wonderful Larisa, who recently became a mother! She’s smart... you’ll understand everything yourself. Great weekend to everyone ??
Good day! Julia, first I want to thank you for your work! For your responsiveness and concern! My name is Larisa, 26 years old. She got sick at the age of 9. First, the little finger on my right hand became swollen. They thought it was a bruise. Then the thumb on the same hand, and then the wrist joint. For a year they could not establish a diagnosis; they lost time. Because of this, the wrist joint was damaged. Deformation has appeared. When RA was diagnosed, he was treated with methotrexate for several years. But there was no improvement. New joints were involved. Then I noticed that intolerance to methotrexate had appeared. Very strong weakness, nausea. At the age of 14, Arava (lefolunomide) was prescribed. At that time, the elbow joint of the left hand was still affected, as well as the wrist, and a deformity appeared. My knees were very swollen. Well, in general, all the joints ached.
After Leflunomide I immediately felt better! The disease went into stable remission. While continuing to take Leflunomide, I led a normal, active lifestyle, like everyone else! Sometimes, of course, there were minor exacerbations, which were quickly suppressed by NSAIDs. At the age of 24, my husband, my rheumatologist, and I began planning a pregnancy. It is necessary to cleanse the body of Leflunomide within 1-2 years. We stopped it and I didn't take anything for a year and felt great. Then things started to get worse. Metipred 8 mg was prescribed and the condition improved. Then we began to reduce the dose until it stopped. And after 2 months I became pregnant!
At that time, my condition was as follows: a deformed wrist joint of the right hand, limited movement; deformed ulnar left arm, almost unbends to the end. Plus, over the years of illness, the cervical and lumbar regions began to hurt frequently. And at night there were stiffness in the shoulder joints. In general, I felt fine, I even did yoga. The pregnancy was going well. Sometimes she resorted to NSAIDs.
I removed all physical activity, stopped doing yoga, but in vain, as it turned out later. She gave birth at 41 weeks, a healthy, strong baby, 3620g. The first month it was still holding up. From the second, a strong aggravation began. I started taking Metypred and NSAIDs. I'm breastfeeding because... the doctors said it was possible. At the moment my baby is 2.5 months old. My condition leaves much to be desired, but I am holding on. During pregnancy, I lost almost 90% of the mobility in the wrist of my right hand (((That is, now the hand hardly moves, there is deformation and atrophy of the muscles. I really regret that I didn’t warm it up during pregnancy. I think then this would have been possible to avoid.
My summary: RA is not a death sentence. You can live fully and happily. The main thing is timely treatment and physical activity!! And definitely, I emphasize, we definitely need to engage in physical activity, acceptable sports!
One of the common diseases of the musculoskeletal system is reactive arthritis. This disease of the osteoarticular system is accompanied by a purulent-inflammatory process in the area of the knee, ankle, elbow and wrist joints. The key symptoms of this disease are formed on the basis of those pathological processes that develop in large and small joints of the human body. This pathology has been assigned an individual code according to ICD-10, which corresponds to the M-02 marking. 9 (reactive arthropathy).
Interesting fact! The above-mentioned term “arthropathy” is not an independent clinical diagnosis. This terminology implies acute or chronic joint damage that occurs against the background of a particular disease in the human body.
The main causes of reactive arthritis are, to one degree or another, associated with the entry of pathogenic microorganisms into the human body, with the subsequent development of an infectious-inflammatory reaction.
By going to a forum whose topic is reactive arthritis, you can appreciate the variety of infectious pathogens, the harmful effects of which lead people to develop this disease. Reviews from patients of various ages are confirmed by the fact that intestinal, genitourinary and nasopharyngeal groups of infectious pathogens can provoke reactive arthritis . Their activation occurs under the influence of provoking factors, one of which is a sharp decrease in a person’s immune status.
There is a separate clinical classification of this disease of the osteoarticular system. Considering the causes of pathology, the following types are distinguished:
Based on the nature of the pathological process, the following types of disease are distinguished:
Acute form of reactive arthritis, lasting less than 60 days
In order to confirm the diagnosis of reactive arthritis, a person must undergo appropriate tests and undergo certain instrumental examination procedures. Speaking about what tests to take if you suspect reactive arthritis, you need to familiarize yourself with the list of the most informative laboratory techniques. Which methods include:
As an additional method of laboratory diagnosis, puncture of the damaged joint can be used, followed by examination of the intra-articular fluid.
Instrumental diagnosis of reactive arthritis involves performing an X-ray examination of all joints that are involved in the pathological process. If X-ray images are of little information, the patient is recommended to undergo computed tomography or magnetic resonance imaging. If a patient has complaints from the cardiovascular system, he is prescribed an ultrasound examination of the heart (echocardiography), as well as an electrocardiography technique.
The clinical symptoms of this disease of the musculoskeletal system may differ slightly in adults and children. Considering the fact that reactive arthritis is a secondary lesion of the articular apparatus, a person may complain of pathological signs from other organs. Pathological changes often affect the skin, organs of vision, as well as the mucous membranes of the genitals and oral cavity. Reactive arthritis is characterized by an acute onset, accompanied by weakness and general malaise, as well as an increase in body temperature. Below we will list the main manifestations of this disease, which occur with equal frequency in both men and women of different ages.
If the infectious-inflammatory process affects the skin, a condition called keratoderma forms on its surface. The essence of the pathology is the systematic keratinization of the skin. A person with skin manifestations of reactive arthritis complains of excessive dryness, flaking and itching.
Important! Skin manifestations of reactive arthritis affect the plantar part of the foot and palm. A blistering rash (papules) forms on these areas, which often contains bloody secretions. In addition, the toes of such a patient may acquire a yellowish tint with characteristic brittle nails.
Characteristic articular manifestations of arthropathy in reactive arthritis are expressed in the following signs:
Most often, with reactive arthritis, inflammatory damage to the large joints of one of the lower extremities is observed. The process involves the ankle and knee joints, as well as the joint in the area of the big toe. The most rare site of localization of the inflammatory process is the intervertebral joints.
The spread of the inflammatory process to the mucous membrane of the genitourinary tract is accompanied by a burning sensation in the external genital area, as well as painful sensations when urinating. Some patients develop infectious and inflammatory damage to the mucous membrane of the cervix, cystitis, and inflammation of the prostate gland (prostatitis). When the mucous membrane of the oral cavity is involved, small ulcerations are formed, spreading to the area of the soft and hard palate, as well as the surface of the tongue.
People with ocular manifestations of reactive arthritis are characterized by low-symptomatic conjunctivitis, the signs of which are redness of the eyes, lacrimation, a feeling of sand in the eyes and constant dryness.
In the clinical diagnosis of reactive arthritis, the presence of three key symptoms that confirm this diagnosis is of great importance. Such symptoms include conjunctivitis, arthritis and urethritis. Reiter's triad got its name after the name of a German medical specialist who identified these symptoms as reliable signs of reactive arthritis.
Regarding the issues of diagnosing and providing assistance to people faced with a reactive form of arthritis, there are so-called national recommendations, the list of which includes the main methods for diagnosing this disease, criteria for making a diagnosis, as well as key methods of treating the pathology. These recommendations were developed in accordance with international standards for the diagnosis and treatment of pathologies of the musculoskeletal system.
World statistics on the incidence of reactive arthritis indicate that the peak activity of this disease occurs between the ages of 20 and 45 years . Males with chronic diseases of organs or systems are at greatest risk of developing pathology. Reactive arthritis caused by chlamydial urogenital infection accounts for up to 3% of all morbidity cases. Intestinal pathogens account for about 4% of all cases.
According to national recommendations, laboratory testing of the blood of patients with suspected reactive arthritis in the acute phase of the disease reveals thrombocytosis, leukocytosis, and an increase in ESR. In the chronic course of the pathology, laboratory diagnostics reveal normocytic or moderate normochromic anemia, indicating a sluggish chronic course of the inflammatory process. When analyzing intra-articular fluid, poor formation of a mucin clot, low viscosity, increased concentration of protein and complement, as well as leukocytosis with a predominance of segmented leukocytes are determined.
People faced with clinical manifestations of reactive arthritis have a question about which doctor to contact with such symptoms. A rheumatologist and therapist deals with the diagnosis and treatment of this disease. In addition, if other organs and systems are involved in the infectious-inflammatory process, a person will need an in-person consultation with such specialists as an ophthalmologist, urologist, infectious disease specialist, gynecologist, hepatologist, nephrologist and cardiologist.
The prognosis for the future in people with reactive arthritis directly depends on the degree of infectious and inflammatory damage to the body, as well as on the nature of the complications. If a patient has Reiter's triad, the likelihood of developing a chronic form of the disease is about 40-50%. Persistent disability is observed in 15-20% of people with an established diagnosis . The most unfavorable prognosis for health and life is associated with the formation of amyloid cardiopathy.
Important! The maximum severity of clinical manifestations and complications of this disease is typical for patients with reactive arthritis associated with HIV infection. This severity is due to the lack of any immune reserves to combat infectious and inflammatory damage to the body.
The main clinical symptoms and treatment of the active form of this disease directly depend on the severity of pathological changes in the human body. For any degree of severity of the characteristic signs of the disease, it is strictly not recommended to be treated by independently choosing pharmaceutical medications and their dosage. In addition, treatment with folk remedies can serve as an impetus for the deterioration of the general condition and aggravate the severity of the inflammatory process. The treatment regimen for reactive arthritis is selected only by a specialist rheumatologist on an individual basis, taking into account the characteristics of the individual patient’s body. If this diagnosis is made, treatment with antibiotics and other groups of medications is practiced. The speed of recovery and prognosis for reactive arthritis depends on many factors, including the severity of the pathology, the adequacy of the selected therapy, and the state of the person’s immunity.
The question of how to cure this disease without the risk of complications is relevant for both patients and medical specialists. Key methods of non-drug and drug therapy for reactive arthritis are presented in the form of a table.
Drug therapy - groups of drugs
Important! Those people who are interested in the question of how to treat reactive arthritis with folk remedies need to understand that this disease poses a great danger to the human body. That is why treatment with unconventional methods provokes an unjustified risk, which can lead to a deterioration in the general condition.
Many parents have doubts about the possibility of doing tuberculin tests for their child, since there is information that this procedure can provoke the occurrence of reactive arthritis in the baby. Tuberculin itself is a safe biological compound, so the question of whether to give manta to a child has no special right to life.
Considering the fact that this disease is infectious in nature, broad-spectrum antibacterial drugs are used to combat its pathogens. The drugs used usually have a detrimental effect on microorganisms that parasitize inside the cell. Tetracyclines, macrolides and fluoroquinolones have the maximum effect. The drugs of choice for the treatment of reactive arthritis are Spiramycin, Doxycycline, Clarithromycin and Azithromycin. If for some reason the patient has an individual intolerance to the drugs mentioned, then antibacterial therapy is formed from 2nd line drugs. These medications include Lomefloxacin, Ofloxacin and Ciprofloxacin.
Along with antibiotics, drug therapy for reactive arthritis includes the use of immunosuppressive medications, which are especially effective in prolonged and severe cases of the disease. Effective representatives of this group of drugs are Sulfasalazine and Methotrexate. Previously, medical professionals widely used Azathioprine.
Of great importance in the fight against the clinical manifestations of reactive arthritis is a therapeutic diet, which is aimed at improving metabolism, as well as maintaining normal body weight. Nutritionists identify the following criteria for rational nutrition for diagnosed reactive arthritis:
As mentioned earlier, even children are not immune from the incidence of this pathology of the musculoskeletal system. The main causes of reactive arthritis in children are also directly related to the presence of an infectious inflammatory focus in the child’s body. This disease in childhood is supported by symptoms such as increased body temperature, swelling of the soft tissues around a particular joint, general malaise and signs of general intoxication of the body.
Diagnosis and treatment of this pathology in children is not much different from similar measures in adult patients. Children are prescribed antibacterial medications, non-steroidal anti-inflammatory drugs for external and internal use.
There are federal clinical guidelines that describe in detail the specifics of reactive arthritis in children of different ages, stages and diagnostic criteria, as well as key methods of treating this disease. At the beginning of the development of the inflammatory process, laboratory diagnostic results may indicate a slight decrease in hemoglobin and hematocrit, moderate neutrophilia and leukocytosis, increased ESR and thrombocytosis. The occurrence of reactive arthritis in childhood entails severe consequences that can affect any organ or system in the body.
If the tests show increased asat in a child with reactive arthritis, then this indicator may indicate that the heart is involved in the infectious-inflammatory process.
There are a lot of resources on the Internet dedicated to the problem of reactive arthritis in children of different ages. The forum will not help cure this disease in a child, but it can unite parents who are faced with this problem. Using these virtual resources, you can evaluate the success of treatment for this disease in newborns, as well as in children 3 years of age and older. Reactive arthritis in adolescents deserves special attention, and is also actively discussed in forums devoted to issues of pediatric rheumatology and pediatrics.
Not only acute reactive arthritis, but also its chronic form deserves increased attention. In medical practice, enterogenous and urogenic types of diseases are distinguished, which are classified depending on the types of infectious pathogens. The transition from acute to chronic form is observed in 40% of patients with an established diagnosis. In the medical practice of rheumatologist specialists, there is such a thing as post-streptococcal reactive arthritis, which occurs against the background of previous infectious diseases provoked by streptococcal microflora.
Chlamydial arthritis is often encountered, treatment of which involves the use of 2-3 generation fluoroquinolones, macrolides and tetracyclines. Penicillin antibiotics and cephalosporins are not recommended for the treatment of this form of the disease, as they cause chlamydia resistance to antibacterial therapy.
The prospects for treating the chronic form of this disease remain questionable, since the main links of therapy are aimed at reducing the intensity of the clinical manifestations of this pathology, and not at eliminating the root cause.
Like any other infectious disease, an acute respiratory viral infection can affect the development of reactive arthritis. This is especially true for children of preschool and school age, as well as adolescents. In the mechanism of arthritis formation during ARVI, a decisive role is played by the entry of pathogenic microorganisms into the internal environment, as well as a decrease in the body’s defenses. Pregnancy is not an obstacle to the development of this disease. In addition, women who are carrying a child experience serious immunodeficiency, which is fertile ground for the development of an infectious and inflammatory process.
Along with the above symptoms of reactive arthritis, it is necessary to pay attention to how long a person’s low-grade fever lasts. If this indicator remains unchanged for 1-1.5 weeks, and pain and discomfort are observed in the joint area, then each person is advised to immediately seek advice from a medical specialist, a rheumatologist. It is low-grade fever that indicates a sluggish and hidden infectious-inflammatory focus. Laboratory diagnostics and visual examination of the joints can confirm this fact.
Despite the fact that reactive arthritis poses a threat to a person’s health and ability to work, its presence is not a death sentence. Timely, high-quality diagnosis and selected treatment guarantee relief of acute manifestations of the disease and a return to normal living conditions.
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17 Nov 2013 21:09
20 Nov 2013 22:25
I'll tell you my story. Maybe it will be useful to someone, and someone can give advice or just support with a kind word
I am 39 years old. I have been sick since 2008. It all started with swelling of the knees, and then a little later on the finger on the hand. While it was tolerable as always, I had no time or desire to run to the doctor. Then it suddenly became very swollen and I decided to go to the doctor. There was no rheumatoid factor in the tests, but ESR and reactive protein were off the charts. The doctor prescribed delagil for a long time and NSAIDs, either movalis or injections, and I don’t remember which ones. I drank for a year and only after a year did my knees and fingers stop hurting so much. BEFORE this, I actually hit my leg a year ago and never went to the doctor, it didn’t seem to hurt, but my toes remained on my leg in a bent state - my husband still thinks that’s why it all started. So, after drinking Delagil (I also drank Zinaxin on my own) and feeling relief and the onset of remission, we decided that we needed a baby. The doctor said that we needed to stop drinking everything. I stopped taking the basic medication, but took Zinaxin. A lot of time was still spent on examinations in the field of reproduction. Then, giving up on everything, she scored and became pregnant. I want to say that my doctor did not dissuade me from the idea of having children. During pregnancy there were slight pains until the 20th week, then I felt like a very healthy person. Experiencing pain every day and forgetting how wonderful it is to live without it. I led an active lifestyle and did everything that I couldn’t afford for a long time, in general I felt great. During the consultation, the devil pulled me to say that I have rheumatoid arthritis, so the therapist, out of fear, sent me to the regional hospital for a consultation. After spending time there in a half-starved state, they told me it was like giving birth, like I asked them. I gave birth perfectly, well, I really wanted to breastfeed the baby and I fed the baby until 8 months, until the pain intensified so much that I couldn’t bear it, especially since I have to constantly carry the baby and the load is enormous. And since the child was 8 months old, I have not lived a day without pain (the child is already 2 years old). Having found strength and some time and patience, I went to the hospital in the summer on IVs to the doctor who was recommended. They injected me with rheosorbilact and something else. It was easier for exactly 5 days and that’s it. The pictures showed that there is arthrosis in the knees and there are osteophytes, which is why there is pain. Two hands already hurt - fingers, wrists, elbow. When I stopped breastfeeding I started drinking lefno. I took it for 8 months, but there was no improvement. I said this at the hospital, they prescribed me methotrexate 10 mg, or they said the money would be given if I had Methodject. Take NSAIDs as needed. But how can you not drink every day, if you have to walk with the little one, sometimes you get up at night, but I just can’t, I drink airtal every day. So I took the first injection of the method, one finger seems to have shrunk a little - I just noticed it the most. In total, I have been taking methotrexate for the 5th month now. I know many members of the forum say you need to drink it for half a year to understand whether it’s suitable or not. So I decided to pierce Methodject for a couple of months, if it doesn’t work out better I’ll give up again.
Lately I have been either overcome by depression or trying to calm myself down, because I have to hold on, a child needs a cheerful mother, not one who is depressed all the time. Although it is very difficult when your whole body hurts and causes you suffering.
I really hope for improvements on the methodject. Just praying for remission. But sometimes you give up and don’t want to live. I think they will only understand me here, because if you don’t feel what it is, you don’t understand how it is.
Good luck and health to everyone, it is very valuable to us.
Chlamydial arthritis is an autoimmune joint disorder resulting from infection with chlamydia (Clamidia trachomatis). The disease is transmitted through sexual contact from a sick person or carrier. The pathology is included in the Reiter's triad along with urethritis and conjunctivitis, and is the most common cause of reactive arthritis. The disease occurs in people of sexually active age, which usually occurs between 20-45 years. Men more often develop a clear clinical picture, and women in most cases are asymptomatic carriers of the pathogen.
Chlamydial arthritis refers to the so-called “sterile” joint damage. The inflammatory process involves the joint capsule, synovial membrane, cartilage and adjacent areas of bone, periarticular soft tissue (ligaments, tendons, muscles). However, the pathogen does not penetrate the joint cavity, but causes autoimmune damage to the anatomical structures of the joint.
Chlamydia is a gram-negative bacterium that parasitizes inside cells and has receptors on its surface similar to connective tissue. In some cases, after infection with chlamydia, the immune system fails. It begins to produce antibodies not only to pathogens, but also to the tissue cells of its own joints. This process is called an autoimmune reaction and is accompanied by the formation of circulating antigen-antibody immune complexes that attack and destroy the connective tissue of the musculoskeletal system.
Infectious arthritis develops 30-45 days after infection with chlamydia. First of all, chlamydia urethritis occurs, which appears 1-3 weeks after intimate relations with a sick sexual partner. More pronounced clinical signs are observed in male patients; in women, the disease in most cases occurs latently.
Chlamydia infection is a common cause of reactive arthritis
Symptoms of damage to the urogenital tract include:
The inflammatory reaction of the urogenital tract is soon accompanied by eye damage. The pathology occurs with varying degrees of severity and is manifested by conjunctivitis, blepharitis, iridocyclitis, and uveitis.
Symptoms of eye damage include:
Eye damage due to chlamydial arthritis
The last stage in the development of the disease is damage to the joints. The characteristic localization of the pathological process is the knee, ankle joints, and small joints of the foot. As the disease progresses, it can affect the hands, spine in the area of the sacroiliac joints, shoulder and temporomandibular joints.
Symptoms of damage to the musculoskeletal system:
The inflammatory process usually involves one (monoarthritis) or two joints (oligoarthritis). Damage to three or more joints (polyarthritis) is observed much less frequently.
Damage to the joints of the toes - swelling and redness of the skin
The occurrence of a triad of symptoms in the clinical picture is usually called Reiter's disease:
The symptom complex is considered a classic variant of the course of reactive arthritis, which includes autoimmune damage to the joints of a chlamydial nature. Sometimes the clinical picture occurs without damage to the eyes or urinary system, or the manifestations of the pathology have a hidden course and are not diagnosed.
Thus, infectious arthritis has several stages:
Damage to the musculoskeletal system can involve the skin (keratoderma), nails (separation, fragility of nail plates), oral mucosa (ulcerative stomatitis), nervous system (polyneuropathy, encephalitis), internal organs (heart, kidneys) in the pathological process.
To identify chlamydial arthritis, an anamnesis (history) of the disease is collected, the patient’s complaints and objective examination data are assessed, laboratory and instrumental research methods are prescribed.
Narrowing of the joint space due to arthritis on x-ray
In the last decade, a connection has been proven between the incidence of reactive arthritis and carriage of the HLA-B27 gene, which occurs in 80% of patients with this pathology.
Treatment of the disease must begin at an early stage of the pathological process. Timely consultation with a doctor reduces the likelihood of the disease progressing and turning into a chronic relapsing form.
Arthritis therapy is aimed at eliminating the infectious process and the body's autoimmune reaction
To treat reactive arthritis of chlamydial nature, conservative methods are used, which include:
Treatment is carried out in inpatient and outpatient settings under the supervision of specialists - gynecologist, urologist, ophthalmologist, rheumatologist. Infection with chlamydia requires treatment of the infection for the sexual partner.
Chlamydial arthritis refers to damage to the musculoskeletal system of an autoimmune nature. With timely diagnosis and treatment, the disease has a favorable outcome. In case of late consultation with a doctor and inadequate therapy, the pathology becomes chronic with periods of exacerbation. This can cause anatomical and functional changes in the affected joints and lead to limitation of motor activity.
Ministry of Education and Science of the Russian Federation
Ministry of Health and Social Development of the Russian Federation
State educational institution
higher professional education
Samara State Medical University
Department of Faculty Pediatrics and Propaedeutics of Childhood Diseases
Head Department: Doctor of Medical Sciences ,
Professor Keltsev V. A
Ass. Zimnukhova S. I.
Diagnosis: “Juvenile idiopathic arthritis, polyarthritis, RF negative, degree of activity 1, radiological stage II, functional insufficiency of the musculoskeletal system 1”
Diagnosis: “Artritis juvenilis idiopatica, polyarthritis, RF-negativis, gradus actionis 1, stadium roentgenologicum II, typus functionalis aegroti 1.”
General information about the child
Date of birth, age
Mother's place of work
Father's place of work
Diagnosis in the referral document
25. 05. 2009 11: 25
Juvenile idiopathic arthritis,
Juvenile idiopathic arthritis, polyarthritis, activity level 1.
Artritis juvenilis idiopatica, polyarthritis, degree actionis 1
Juvenile idiopathic arthritis, polyarthritis, RF-negative, activity degree 1, radiological stage 2, functional insufficiency of the musculoskeletal system 1
Artritis juvenilis idiopatica, polyarthritis, RF-negativis, gradus actionis 1, stadium roentgenologicum 2, typus functionalis aegroti 1
At the time of supervision, no complaints
I fell ill in the summer of 2007, when pain first appeared in my right ankle joint. In the fall of 2007, he was hospitalized in the Regional Children's Hospital with complaints of pain in the lower back, knee, and ankle joints when moving, morning stiffness, short-term (disappears 30 minutes after getting out of bed), restless sleep, soreness of the calf muscles, lameness, where the diagnosis was made "Juvenile idiopathic arthritis." He was treated with sulfasalazine. In February 2008, he was treated at the Moscow Institute of Rheumatology, where, for health reasons, he began receiving the drug Remicade. Currently he is in the Regional Children's Hospital for planned treatment to receive Remicade.
Mother, 38 years old, healthy. The child’s mother visits medical institutions only when necessary. Denies tuberculosis, HIV infection, sexually transmitted diseases, and the presence of bad habits.
Father. 41 years old, healthy, visits medical institutions only when necessary. Denies tuberculosis, HIV infection, sexually transmitted diseases, and the presence of bad habits.
Heredity is not burdened.
The family is complete. Child from the first pregnancy. The course of pregnancy is toxicosis of the first half. The pregnant woman followed a daily routine, the food was nutritious and complied with the recommendations of the doctor monitoring the pregnancy. First birth, urgent, spontaneous, early rupture of amniotic fluid. Date of birth: March 14, 1993. BCG was done in the maternity hospital. The neonatal period was uneventful. The child did not lag behind in physical and mental development. Preventive vaccinations were given according to the calendar; there were no medical outlets. Social and living conditions of the child: the boy lives with his father and mother in a 3-room apartment. The apartment is dry, bright, comfortable. The child has a separate room.
According to the boy, his relationships with his peers are good and he has many friends. Denies the presence of bad habits. Mother and grandfather participate in raising the child.
The child’s daily routine: full sleep, spending an average of 4-6 hours in the fresh air every day, does not attend additional clubs or sections.
Epidemiological history: I have not been in contact with infectious patients in the last 7-10 days.
Allergic history - intolerance to sulfasalazine is noted.
Status praesens communis
The general condition of the patient is satisfactory. Position active. Consciousness is clear. The facial expression is calm, the behavior is normal, the emotional status is appropriate for the age. The physique is correct, development is proportional.
Body temperature 36.8 0 C.
Body weight 64 kg, height 186 cm. BMI = 18.96. Mesasomatic type of development. Development is harmonious. Normostenic.
The skin is pale, normal turgor, elastic, clean. Hair and nails are smooth and shiny. Nail color is pink.
The mucous membranes are pale pink, clean, no rash. The tonsils protrude beyond the palatine arches, there are no plaques.
The subcutaneous tissue is of normal development, the thickness of the fat fold at the navel level is 1 cm, above the shoulder blades is 1.5 cm, there is no edema, tissue turgor is good.
The degree of muscle development is normal, the tone is normal, there is no contra-crown.
Posture is correct, development is proportional. The head is of correct shape, size corresponds to age, there are no deformations or softening of the bones. No rachitic changes were found. The shape of the chest is correct. Limbs of proportional length, smooth.
Cervical, axillary, inguinal, submandibular, occipital, subclavian lymph nodes cannot be palpated.
The joints are of normal configuration, painless, full range of motion, free, without pathological abnormalities.
Nervous system research
Sensitivity is not impaired, reflexes (abdominal and tendon) are positive, not changed, no pathological reflexion has been identified. Coordination of movement is not impaired. The gait is normal, the Romberg position is stable. No meningeal symptoms were detected.
Examination of the autonomic nervous system: pharyngeal reflexes without features, corneal reactions of the pupils to light are positive on both sides, dermographism is within normal limits.
Locomotor function is without impairment, behavior is normal, emotions are restrained.
There is no cyanosis, no shortness of breath. The respiratory rate is 17 d/min, the rhythm is correct. The voice is normal, not hoarse. Nasal breathing is free.
The shape of the chest is normosthenic, there is no asymmetry. Retraction of the supraclavicular and subclavian spaces was not detected. The width of the intercostal spaces is 1 cm. The shoulder blades are adjacent to the chest. Movements of the chest are uniform and symmetrical. No pain was detected on palpation of the chest. Resistance is not increased, vocal tremors are uniform.
During comparative percussion, a pulmonary percussion sound is noted in all sections.
With topographic percussion: the height of the apexes of the lungs in front is 3 cm, in the back - at the level of the spinous processes of the VII cervical vertebra, the width of the Krenig fields is 4.5 cm on both sides.
Lower borders of the lungs:
Spinous process of the XI thoracic vertebra
Mobility of the pulmonary edges:
Auscultation: vesicular breathing. There is no pleural friction noise.
Examination revealed no cyanosis, no deformations of the chest in the area of the heart and no visible pulsation of blood vessels.
On palpation: apex impulse in the 5th intercostal space along the midclavicular line of moderate strength, not diffuse, no tremors. Pulse 78 beats/min, regular, rhythmic, soft, sufficient filling.
The femoral artery pulse was preserved.
Limits of relative dullness of the heart
Along the right edge of the sternum
1 cm medially from the border of relative dullness of the heart
In the third intercostal space
The heart configuration is normal. The vascular bundle does not extend beyond the edges of the sternum.
Auscultation: the rhythm is correct, heart sounds are clear, clear, ringing. No noise was detected.
There is no bad breath. When examining the oral cavity: the tongue is moist, pink, there is no plaque, the tonsils extend beyond the boundaries of the arches, the palatine arches are unchanged. The oral mucosa is moist, pink, and clean. The gums are free of inflammation and do not bleed. The act of swallowing is not impaired.
The abdomen is not enlarged in size, is symmetrical, and participates in the act of breathing. Visible peristalsis of the intestines and stomach is not observed. No free fluid was detected in the abdominal cavity. Deep sliding palpation of internal organs according to Obraztsov-Strazhesko: the curvature of the stomach is located on both sides of the midline of the body, 3 cm above the navel, in the form of a roller lying on the spine and on the sides of it. The pylorus is defined in a triangle formed by the lower edge of the liver to the right of the midline, the midline of the body and a transverse line drawn 3 cm above the navel, in the area of the right rectus abdominis muscle. The abdomen is soft, painless, the sigmoid colon in the left iliac region is painless. The colon is painless. The pancreas is not palpable. There is no discrepancy of the rectus abdominis muscles or hernial orifices. Superficial palpation revealed no areas of pain. Shchetkin-Blumberg's symptom is negative. A portal blood flow disorder in the form of a “jellyfish head” was not detected. Auscultation: sound of intestinal peristalsis. The stool is formed, regular, once a day.
Hepatolienal system . There is no peripheral edema. With deep palpation of the liver, the lower edge of the liver does not protrude from under the edge of the costal arch, has a dense elastic consistency, and is painless. Percussion size of the liver according to Kurlov: 9×8×7. The spleen is not palpable. The gallbladder point is painless. Ortner's, Courvoisier's, Kera's, and Frenicus symptoms are negative.
Urinary system . There is no swelling. No swelling was detected in the renal area. With deep palpation, the kidneys are not palpable. The symptom of effleurage is negative. The bladder is painless on palpation. Urination is painless, regular, 3-5 times a day.
Endocrine system . The thyroid gland is not palpable.
The genitals are formed correctly, according to age.
Juvenile idiopathic arthritis, polyarthritis, degree of activity
Arthritis juvenilis idiopatica, polyarthritis, gradus actionis 1.
05/25/2009 Curator E. N. Burakova
1. General blood test - carried out to identify the presence of infectious and allergic processes in the body.
2. General urine analysis - determine the physical properties, chemical composition, microscopy of sediment.
3. Feces for worm eggs
4. Biochemical blood test - quantitative analysis of biochemical blood parameters.
5. Immunological blood test
6. Blood test for rheumatoid factor
7. “Ro” of the knee and ankle joints - detect changes in the joints.
8. ECG - diagnosis of pathological conditions of the myocardium, its electrophysiological properties
9. EchoCG - assess the functional state of the heart, assess hemodynamics.
10. Examination by specialized specialists: ophthalmologist.
Results of additional research methods.
Red blood cells 5.3•10 12 N 4−5•10 12 /l
Leukocytes 13•10 9 N 4−9•10 9 /l
Hemoglobin 149 g/l N 130−160 g/l
Color index 0.9 N 0. 85−1
ESR 3 mm/h N 2−15 mm/h
Eosinophils 4 N 2−5%
Segmented 48 N 45−70%
Lymphocytes 44 ^ 18−38%
Monocytes 4 N 2−8%
Specific gravity - m/m
Transparency neg N
Reaction is acidic N
Leukocytes 2−4 in field N
Flat 4−6 in field N
Bilirubin 6 µm/l N 3.4−13.6
Seromucoid 10 units N 0−20.0
Fibrinogen 4 g/l N 2−4
Prothrombin according to Quincke 85 N 70.0−120.0
The x-ray shows signs of osteoporosis of the hip joints, narrowing of the gaps, and blurred edges of the left sacroiliac joint.
Ophthalmologist's report: 02/21/09
Fundus: pale pink, ratio and caliber are normal.
In this case, the leading syndrome is articular, which occurs in the following conditions: acute rheumatic fever, psoriatic arthritis, reactive arthritis.
Psoriatic arthritis manifests itself, in the vast majority of patients, against the background of existing cutaneous psoriasis. Any joints can be involved in the process; the disease begins with asymmetric monoarthritis or oligoarthritis, which is prone to recurrence. The skin over the joints has a characteristic bluish-purple color. Periarticular tissues are involved in the process. With a malignant course, exhaustion increases, myotrophy, myalgia, myositis, lymphadenopathy, hepatosplenomegaly, glomerulonephritis and amyloidosis are expressed.
If there are elements of psoriasis on the skin, there is no need for a differential diagnosis.
Acute rheumatic fever is characterized by damage mainly to large joints of the extremities (knees, ankles, elbows), usually symmetrical. The lesion is flying, migrating - various joints are covered in 1-7 days, which is not typical for JIA. The joints are swollen, their contours are smoothed, passive and active movements are sharply limited, which is also observed in JIA, but in this case the skin over the joints is hyperemic and hot to the touch.
Also, unlike JIA, acute rheumatic fever is characterized by a sudden increase in temperature (38−39? C), symptoms of intoxication. Simultaneously with the damage to the joints, signs of rheumatic carditis are identified and become leading (severe general condition, pallor of the skin, shortness of breath, pain in the heart, palpitations, tachycardia, dullness of tones, systolic murmur at the apex, enlargement of the borders of the heart). There is also a characteristic connection with streptococcal infection.
Reactive arthritis occurs in two forms: postenterocolitic and urogenital.
Postenterocolitic reactive arthritis develops against the background of intestinal infections, usually after 1-3 weeks. The onset is acute, localized in the joints of the lower extremities, but the joints of the upper extremities can also be affected. Erythema nodosum, tendovaginitis, bursitis, and conjunctivitis often develop.
Urogenital reactive arthritis (Reith's disease) is characterized by a triad of symptoms: urethritis, conjunctivitis and arthritis. The disease begins with damage to the urethra and eyes, and subsequently changes in the joints develop.
Patients complain of pain when urinating, the appearance of mucous discharge from the urethra, especially in the morning. Eye damage is bilateral and manifests itself in the form of catarrhal conjunctivitis lasting from several days to 1.5-2 weeks. In childhood, uveitis, episcleritis, and keratitis are less common.
Joint damage is often asymmetrical, like oligoarthritis, affecting the joints of the legs with gradual involvement of the joints of the upper extremities and the process spreading from bottom to top - the “staircase symptom”.
Articular syndrome is characterized by persistent arthralgia, exudative phenomena against the background of a resolved general condition. Muscle atrophy develops in the early stages. Arthritis of the small joints of the feet is accompanied by “sausage-shaped” swelling of all fingers and a blue-purple coloration of the skin. Some patients show signs of damage to the spine, mainly the thoracic and lumbar regions, as well as the sacroiliac joint.
Quite often, Reith's disease is accompanied by damage to the skin and mucous membranes in the form of pustular, urticarial, blistering rashes and psoriasis-like elements. They can be localized on any area of the skin, and can be either focal or widespread. Keratoderma of the feet and erosive balanoposthitis are more common. Quite often, the skin and mucous elements become lakolized around the head of the penis.
In the chronic course of the disease and in its later phases, damage to the heart, kidneys, and aorta is detected.
Having carried out a differential diagnosis, the presence of acute rheumatic fever, psoriatic arthritis and reactive arthritis can be excluded in this patient.
Clinical diagnosis and its rationale
Juvenile idiopathic arthritis, polyarthritis, seronegative, degree of activity 1, radiological stage 2, functional insufficiency of the musculoskeletal system 1.
Arthritis juvenilis idiopatica, polyarthritis, seronegativis, gradus actionis 1, stadium roentgenologicum 2, typus functionalis aegroti 1.
The diagnosis of juvenile idiopathic arthritis is made based on the following data:
- age of onset of disease up to 16 years;
— duration of the disease over 2 years;
— the duration of joint changes is more than 6 weeks.
Polyarthritis is characterized by more than 5 joints during the first 6 months of the disease, as was the case in our patient.
Activity level 1 is assigned based on the following data: in the UAC dated May 26, 09, ESR is 3 mm/h.
X-ray stage II is determined based on the conclusion of the radiologist: the X-ray shows signs of osteoporosis + narrowing of the joint space.
Functional insufficiency of OPDA - 1 is diagnosed on the basis that the functional ability of the joints is preserved.
The cause of JIA has not yet been established. Among the possible factors underlying the pathological process are discussed:
— infectious nature of the disease;
— disruption of immune mechanisms with subsequent development of autoimmune reactions;
The pathogenesis of JIA is based on profound disturbances in the immune response with an imbalance in the quantitative composition of immunocompetent cells, with a violation of their functional activity and cellular cooperation.
The essence of the pathological process in JIA is systemic autoimmune inflammation, which affects the synovium of the joint with maximum intensity. It is assumed that in the early stages of JIA, joint damage is not associated with a specific immune response to an “arthritogenic” antigen, but with a “nonspecific” inflammatory reaction induced by various stimuli, which in turn (in genetically predisposed individuals) leads to a pathological reaction of synovial cells. Subsequently, as a result of the “recruitment” of immune cells (T- and B-lymphocytes, dendritic cells) in the joint cavity, the formation of an “ectopic” lymphoid organ occurs, the cells of which begin to synthesize autoantibodies to the components of the synovial membrane. Autoantibodies (rheumatoid factors, antibodies to fillagrin, glucose-6-phosphate dehydrogenase, etc.) and immune complexes, activating the complement system, further enhance the inflammatory response, causing progressive damage to joint tissues. At the same time, the activation and aggressive proliferation of synovial cells, as well as articular macrophages, is modulated by various colony-stimulating factors (CSF-GM, CSF-G), cytokines, products of arachidonic acid metabolism and other mediator substances, which are also produced by bone marrow cells of the myeloid lineage.
As a result of immune disorders, B lymphocytes produce aggregated IgG, which has the ability to enter into an immune reaction of the antigonene antibody type. Perceiving the altered IgG as a foreign antigen, the plasma cells of the synovial membrane produce rheumotoid factor (RF) antibodies - the IgG and IgM classes.
When rheumatoid factors and immunoglobulins interact, immune complexes are formed, which cause activation of the blood coagulation system, induce the production of cytokines (interleukins, tumor necrosis factor) and activate complement components, which have the ability to cause chemotaxis and cell damage. This leads to the development of an immune-inflammatory process in the tissues of the joints and internal organs.
Thus, the basis of the pathogenesis of JIA is immune-inflammatory reactions. This is evidenced by a number of signs: the identification in patients of various autoantibodies, rheumatoid factors, circulating and fixed in tissue immune complexes, lymphocytes sensitized to connective tissue components, polyclonal activation of B-lymphocytes, impaired production of cytokines, adhesion molecules, etc.
2. Diet - table No. 10. Purpose of prescription: sharp limitation of table salt and enrichment of the diet with potassium. Protein content is within the lower limit of the physiological norm, moderate restriction of fat and carbohydrates. Food is prepared without salt; salt-free bread is specially baked. The introduction of free fluid is limited. Culinary processing: pureed and cooked boiled or steamed.
a) basic therapy:
1. Rp.: Methotrexati 0.005
Methotrexate is a cytotoxic drug, an antagonist of folic acid, its action leads to disruption of DNA synthesis in the S-phase of the cell cycle. Reduces the production of anti-inflammatory cytokines. Monitoring the level of hemoglobin, leukocytes, platelets, bilirubin and transaminases is necessary.
MDS Administer intravenously 5 ml per hour. Every 30 minutes add 5 ml/hour. Maximum 25−30 ml per hour.
Remicade suppresses the pathological effects of TNF-b, neutralizing both transmembrane TNF-b and soluble TNF-b in solution. Causes lysis of TNF-producing cells by complement fixation or antibody-dependent cytotoxicity.
b) other types of drug therapy:
It is a source of calcium for proper mineralization of bones and teeth.
Body temperature 36.8 0 C. Respiratory rate 17 beats per minute. Heart rate 68 beats per minute.
At the time of supervision, the patient has no complaints, joint pain does not bother him, and his range of motion is full. At the time of supervision, the child’s general condition is satisfactory, consciousness is clear, position is active, facial expression is calm. On objective examination: the mucous membranes of the oral cavity, tongue, and gums are pink. Normal humidity. The tongue is moist and clean. The pharynx and tonsils are without plaque or rash. Percussion: pulmonary sound in the lungs. Auscultation reveals vesicular breathing in the lungs, no wheezing. When auscultating the heart, it is noted: heart sounds are sonorous, rhythmic, no murmurs are heard. The abdomen is soft, the liver is not enlarged. Stool and urine output are normal.
The child's condition is satisfactory. There are no complaints, no pain in the joints, the range of motion is full. Temperature 36.4? C. Breathing is vesicular, hemodynamics are stable (respiratory rate 27 beats per minute, heart rate 78 beats per minute). The mucous membranes of the oral cavity, tongue, and gums are pink. Normal humidity. The tongue is moist and clean. The pharynx and tonsils are without plaque or rash. The abdomen is soft and painless. The liver is not enlarged. Stool and urine output are normal.
The condition is satisfactory, no complaints. Temperature 36.7? C. Breathing is vesicular, hemodynamics are stable (respiratory rate 25 beats per minute, heart rate 77 beats per minute). The skin and mucous membranes are without any features. The abdomen is soft and painless. The liver is not enlarged. Stool and urine output are normal.
___________ is currently in the department of cardiac surgery and cardiorheumatology of the SRCCD. She was admitted with complaints of pain in the lower back, knee, ankle joints when moving, morning stiffness, short-term (disappears 30 minutes after getting out of bed), restless sleep, soreness of the calf muscles, lameness. An objective examination at the time of supervision revealed no visible changes in the knee and ankle joints.
During the hospital stay the following studies were carried out:
— OAM — no pathology detected;
— ECG pathology was not detected;
- X-ray - signs of osteoporosis of the hip joints, narrowing of the joint space and blurred edges of the sacroiliac joint.
- Consultation with an ophthalmologist - no pathology was detected.
Based on complaints, history of the present disease, data from laboratory and instrumental research methods, a diagnosis of “Juvenile idiopathic arthritis, spreading oligoarthritis, activity degree 1, radiological stage 2, functional class of the patient 1” was made.
During his hospital stay, the child received the following treatment:
S. Dissolve the contents of the bottle in 5 ml of water for injection. Administer intramuscularly once a week.
2. Rp.: Sol. Natrii chloridi 0.9% – 250 ml
S. 1 tablet 2 times a day
During the stay in the hospital, positive dynamics are noted. Currently, the child’s condition is satisfactory, there are no complaints, there is no pain in the joints, and the range of motion in the joints is full.
At the end of the course of treatment, the child will be discharged under the supervision of a local pediatrician and a regional cardiologist, with the following list of recommendations:
1) observation by a pediatrician and cardiologist - monthly;
2) UAC - once every 3 months;
3) biochemical blood test - once every 3 months;
4) analysis of immunological indicators (CD3, CD4, CD8, CD16, CD95, CD4/CD8, IgA, IgM, IgG, CRP, RF, complement) - once every 6 months;
5) ECG - once every 3 months;
6) radiography of the affected joints once every 6 months;
7) FGDS - once every 6 months;
8) consultation with an ophthalmologist - once every 3 months;
9) examination using a slit lamp - once every 3 months;
10) hospitalization in the Regional Clinical Clinical Hospital for a full examination and correction of therapy - once every 4 months;
11) Continue the started treatment. Methotrexate 7.5 mg 2 times a day for 2 days, then a break of 5 days. Calcenov tablets, 1 tablet 2 times a day.
12) Treatment with Remicade should be repeated in a hospital setting every 4 months.
May 28, 2009 Curator E. N. Burakova
1. Keltsev V. A. Juvenile idiopathic arthritis. - Samara, 2005.
2. Keltsev V. A. Rheumatoid arthritis in children. - Samara, 1991.
3. Keltsev V. A. Selected lectures on pediatric cardiology. - Samara, 2001.
4. Shchukin Yu. V., Bekisheva E. V. Greco-Latin terminology of internal diseases. — Samara 2006.