Rheumatoid arthritis is a common rheumatic autoimmune disease of the joints and internal organs. This pathology has a steadily progressive course and can lead to disability.
The stages of rheumatoid arthritis are determined by rheumatologists based on clinical and radiological signs. Determining the stage of the disease is extremely important, since in each specific case the approach to treating patients is different.
First of all, you should understand the features of a disease such as rheumatoid arthritis. The incidence of this pathology in Russia is growing every year, while the causes of the process have not yet been identified.
The body's own immune cells are involved in the development of arthritis. They attack the synovium of the joints, causing chronic inflammation. This process sooner or later leads to the formation of deformities in the joint.
The main clinical signs of arthritis are:
The listed signs can only suggest the presence of the disease. To make a specific diagnosis, radiography is required.
X-ray examination allows not only to make this diagnosis, but also to determine the stages of rheumatoid arthritis. There are a number of criteria that the doctor determines on the image to make a correct diagnosis.
Radiological signs of rheumatoid arthritis follow a certain sequential path. It is a change in the X-ray picture that allows a reliable diagnosis.
The following radiological stages of rheumatoid arthritis are distinguished:
When diagnosing arthritis, other parameters are also taken into account, including numerous laboratory tests. However, it is the x-ray that shows how far the pathological process has gone.
It is extremely difficult to detect rheumatoid arthritis in the first stage of the disease. The disease has a minimal number of clinical manifestations, and changes on the radiograph are nonspecific.
The initial signs of the disease may be aching pain in the joints after exercise. Gradually, the arthritis intensifies, and some tissue swelling and morning pain may appear. Stiffness in the joints in the first stage is usually absent. Sometimes stiffness does not bother patients for long.
Such signs can be mistaken for osteoarthritis or damage to periarticular tissues.
If a person takes an x-ray, the only manifestation revealed in the image is periarticular osteoporosis. This phenomenon indicates a decrease in bone density in the joint area. In the picture, the bone becomes less bright than in a healthy joint.
Periarticular osteoporosis is an extremely nonspecific X-ray sign; it can also be present in other diseases - any inflammatory process in the joint, calcium and vitamin D deficiency, and so on.
X-ray signs do not allow us to definitively diagnose arthritis at the first stage. However, if the doctor suspects this disease, he may prescribe specific treatment.
The principle of complex treatment is widely used in the treatment of orthopedic diseases, and such pathology as rheumatoid arthritis is no exception; the stages of this disease determine the tactics of therapy. It is for this purpose that doctors differentiate the symptoms of the disease into several degrees.
At the first stage of the disease, treatment of rheumatoid arthritis has a number of the following features:
At the first stage, regular visits to the doctor and control X-ray examinations are very important. This is the only way to make a final clinical diagnosis in time or to refute the presence of a rheumatoid process.
Making a diagnosis for stage 2 disease is much easier. Stage 2 of the disease is characterized by a more vivid clinical picture and the appearance of specific radiological symptoms.
Patients begin to experience fairly intense pain in the joints; they often require the use of non-steroidal anti-inflammatory drugs. Stage 2 of the disease is manifested by prolonged morning stiffness in the joints.
Deformations in the joints are not determined, but a change in the shape of the joints is possible due to quite severe synovitis - swelling of the articular cavity.
At stage 2, radiological signs become specific:
Such symptoms make it possible to make a fairly reliable diagnosis and begin specific treatment.
Therapy for stage 2 of the disease is seriously different from the first, since the diagnosis becomes obvious. The doctor tries to prevent the progression of the disease, avoid recurring exacerbations, and reduce the intensity of symptoms.
Basic principles of treatment for this type of pathology:
At the second stage, you can achieve a very good effect from the treatment. Many patients live for a long time with minimal symptoms on basic therapy.
Arthritis of the 3rd degree is already a much less favorable situation for starting treatment. Many patients do not seek medical help for a long time and come to the doctor when the symptoms of the disease are already advanced.
Stage 3 of the disease is associated with a fairly typical clinical picture described above. In small affected joints, quite pronounced deformations occur due to the formation of subluxation. Large joints become limited in movement and become very painful.
Extra-articular symptoms may appear - rheumatoid nodules in the subcutaneous tissue, inflammation of blood vessels (vasculitis) on the nail plate, terminal phalanges of the fingers, neuropathy, pleurisy and pericarditis, inflammatory eye diseases.
On an x-ray, the doctor detects the following changes:
Treatment should begin immediately after the detection of these signs. If the patient previously received basic therapy, it needs to be corrected.
In order to prevent the transition of the rheumatoid process to stage 4, the treatment of the disease should be very carefully selected. Contact the most qualified specialist in this field - a rheumatologist.
In treatment, the doctor will adhere to the following principles:
After achieving remission, regular monitoring of the condition and supervision of a rheumatologist is required. Trips to the sanatorium at least once a year are highly recommended.
The most severe, irreversible stage of joint damage is grade 4. It is with this form of the disease that complications are most often observed, as well as extra-articular manifestations of the process.
Clinical signs of stage 4 are:
These signs are most often observed 10–20 years after the onset of the disease, however, the period of development of complications is influenced by the patient’s adherence to treatment and concomitant pathology.
On an x-ray, the doctor determines the same signs as in the third stage. The only difference is the appearance of ankylosis - irreversible adhesions between the articular surfaces. Due to the growth of osteophytes and chronic inflammation, the gap between the bones decreases and disappears completely.
Treating the fourth stage of the disease is extremely difficult. The doctor’s tactics will depend on how many joints are affected by the disease.
The principles of therapy are as follows:
From the above we can conclude that each subsequent stage of the disease seriously affects the possibilities of treatment and the state of human health. It is necessary to seek help in time to prevent severe manifestations of the process.
Symptoms of arthrosis, as well as treatment methods for this disease, vary significantly at different stages. If stage 1 is often asymptomatic, then at stage 3 the clinical manifestations are noticeable even to a non-specialist. If at an early stage they resort to various therapeutic methods, then at a later stage only surgery can usually help. Therefore, the diagnosis is always made indicating the degree of arthrosis. There are different classifications of osteoarthritis, including different approaches to determining its degree, and different names of stages. In most classifications there are 3 stages of arthrosis, in some sources – 4.
The development of osteoarthritis begins with degenerative-dystrophic processes in articular cartilage. The functions of the intercellular substance - the matrix - are disrupted; it cannot bind and retain fluid, its excess is absorbed by collagen fibers. As a result, they begin to disintegrate. The cartilage tissue softens, exfoliates, cracks form in it, and decay products settle on the surface, making it rough. The cartilage dries out and loses its elasticity, and cannot fully absorb the load that occurs when the bones move in the joint. At the same time, regeneration processes are activated, but instead of functional cartilage tissue, granulation tissue grows, and this happens mainly at the edges. Over time, this tissue is transformed into bone, and small points are formed at the edges of the bone areas - initial osteophytes.
This stage of arthrosis is characterized by mild and short-term manifestations:
When bone tissue is involved in the process, the initial stage of arthrosis gives way to the next, and the clinical manifestations become more pronounced. At stage 2 of arthrosis, cracks in the cartilage reach the subchondral parts of the bones, pieces break off from the cartilage, it becomes even thinner, and the articular areas of the bones are exposed in places. The bone tissue reacts to the increased load, the articular areas lose their relief, while their area increases due to the ossification of the growths of granulation tissue. Osteophytes become rougher and larger. The bone tissue begins to thicken (osteosclerosis develops).
In places, cavities and cysts may form in the bone tissue, but this is an optional sign of osteoarthritis. This process is more typical for coxarthrosis and arthrosis of the interphalangeal joints. In the first case, the cysts are localized mainly in the central part of the subchondral region, in the second - along the edges.
The duration of pain increases, its intensity increases, mechanical pain during movement is joined by vascular and inflammatory pain, which usually occurs at rest. The range of motion is reduced and it takes longer to overcome stiffness. The movements are accompanied by crunching, crackling, and clicking sounds. Joints quite often crunch when moving, but arthritic crunching is rougher. Typically, at this stage of osteoarthritis, inflammation of the synovial membrane (synovitis) develops. Its symptoms are not as striking as with arthritis, but they leave their mark on the clinical picture. The joint swells due to the accumulation of inflammatory effusion in the cavity, soft tissues swell, but this process is not always accompanied by an increase in temperature.
The inflammatory process leads to fibrosis of the synovial membrane (replacement of functional connective tissue), its blood supply deteriorates, as a result, the articular cartilage receives less nutrients and is destroyed even more actively. Chipped, dead pieces of cartilage and accumulations of calcium salts can enter the joint space, causing joint jamming and acute pain. Due to increasing stiffness and pain in the joint, significantly less movement is performed. Due to inactivity, muscle tissue begins to atrophy, and ligaments shorten and become hard and rigid.
At stage 3 of deforming arthrosis, the cartilage is almost completely destroyed, osteosclerosis and osteophytosis, degeneration of the synovial membrane, and muscle wasting progress. The shape of the articular ends of the bones changes, and the growths are visible through the skin and soft tissues. They irritate and injure muscles. The joint areas close, but do not fuse, ankylosis (the formation of adhesions between the bones, leading to immobilization of the joint) is not the last degree of arthrosis, but a separate pathology. At a late stage, osteoarthritis manifests itself with the following symptoms:
The stages of arthrosis are determined based on a combination of clinical and radiological signs. There are several classifications of degrees of arthrosis according to radiological criteria. In our country, during medical and social examination, they resort to the 3-stage clinical and radiological classification of arthrosis according to Kosinskaya.
The Kellgren-Lawrence classification of arthrosis, based solely on radiological criteria, is also widespread. In addition to 4 stages of the disease, a zero stage is distinguished; stages 2–4 in this classification, according to radiological signs, correspond to stages 1–3 according to Kosinskaya. The severity of radiological changes at each stage is assessed as follows:
The severity of clinical manifestations does not always correspond to the radiological stage. A more severe course is typical for arthrosis, complicated by reactive synovitis, developing against the background of cardiovascular diseases or menopausal changes. Taking this into account, Pavlenko, Latyshev and other employees of the Yaroslavl Medical Institute developed a classification within which 3 degrees of osteoarthritis are distinguished:
Prearthrosis is diagnosed in patients at risk. Risk factors include heavy physical work and professional sports associated with excessive stress on the joints, genetic predisposition, and obesity. If at this stage the provoking factors are eliminated and a course of preventive measures is carried out, the development of arthrosis itself can be prevented.
The concepts of the degree of arthrosis and the degree of functional insufficiency of the joint (FJ), violation of static-dynamic function (SDF) should not be confused. These concepts are used when conducting a medical and social examination. There are 4 degrees of violation of the SDF; when determining them, the following are taken into account:
A more pronounced degree of functional impairment corresponds to a later stage of arthrosis, but the functions of the joint are impaired not only with this disease, but also with arthritis due to injuries. The 4th degree of FNS no longer corresponds to arthrosis, but to ankylosis in a functionally disadvantageous position.
The fact that grade 1 arthrosis occurs without pronounced symptoms, and radiological signs at an early stage are questionable, makes diagnosing the disease difficult. Therefore, treatment of osteoarthritis usually begins at stage 2 or even 3, when its effectiveness is significantly reduced. Patients with stage 3 arthrosis often face disability; in severe cases, with simultaneous damage to several joints, the group is assigned already at stage 2. To prevent such an outcome of the disease and avoid surgery, it is recommended to regularly examine patients at risk and, if the initial stage of arthrosis is suspected, to carry out treatment aimed at preventing complications.
Rheumatoid arthritis is one of the most severe joint diseases, during which a huge number of complications are observed.
This disease affects people of different age groups, however, rheumatoid arthritis most often occurs in people over 35 years of age. This disease occurs five times more often in women than in men. According to statistics, 1-3% of the world's population suffers from this type of arthritis.
The symptoms of rheumatoid arthritis are difficult to confuse with other joint diseases. Many cases are characterized by inflammation and swelling of the metacarpophalangeal joints on the index and middle fingers in the initial stage.
Along with the above symptoms, inflammation and swelling of the wrist joints is observed. A fairly characteristic phenomenon is the symmetry in inflammation of the joints during rheumatoid arthritis.
With articular lesions of the right hand, in almost all cases, damage to the same joints on the left is noted. Rheumatoid arthritis differs from rheumatism in the persistence, swelling and pain in the joints for several years.
Reduction of joint pain occurs closer to night or in the morning. Before noon, the pain is characterized by its intensity. Many patients compare the intensity of pain in rheumatoid arthritis with pain in the teeth.
In the afternoon the level of pain decreases, and in the evening they are not noticeable at all. In addition, the initial stage of rheumatoid arthritis is characterized by a decrease in pain after warm-up or activity. Along with the appearance of pain in the joints of the upper extremities during illness, in almost every case there is damage to the small joints of the feet.
There is inflammation in the joints that are located at the bases of the fingers. The inflammatory process in the joints of the legs occurs with the same complete symmetry as in the arms.
Inflammation of larger joints, for example, shoulders, knees and elbows, usually occurs after a certain period of time (from a week to a month). However, there are other types of disease characterized by inflammation of the joints of the knees and shoulders or the heel tendons.
Small joints have a delayed effect on the onset of the inflammatory process, and pain in them appears a little later. This form of arthritis affects people whose age exceeds 65-70 years.
Constant pain in rheumatoid arthritis alternates with the so-called “morning stiffness” symptom. Most patients describe this phenomenon as a feeling when the whole body and joints are numb.
If rheumatoid arthritis is relatively mild, then such stiffness goes away 2-3 hours after the patient gets out of bed. If we talk about the severe course of the disease, then this feeling may disappear only after lunch and even later.
At this stage, many patients discover the formation of rheumatoid nodules under the skin. They are distinguished by their high density, the size of a pea and their location slightly below the elbow bend.
In some cases, such nodules appear in places such as feet, hands, etc. Quite often they appear in small numbers (2-3), but sometimes there are quite a lot of them. As a rule, rheumatoid nodules are not very large in size (3-4 cm in diameter), but sometimes they are large.
The above symptoms are accompanied by a feeling of weakness, a moderate increase in body temperature, chills, as well as deterioration of appetite and sleep. There have been cases where the patient suddenly lost weight, sometimes significantly.
Along with the development of rheumatoid arthritis, persistent deformation of the fingers and hands appears. The development of “ulnar deviation” on the hands is very often noted. This phenomenon is characterized by fixation of the hands and fingers in incorrect positions and outward deviation.
There is a sharp decrease in mobility in the wrist joints, as well as difficulty in flexing and extending the arms. Due to a disruption in the rhythm of blood supply, the skin on the hands appears pale and acquires properties such as dryness, thinness, etc. As the disease progresses, the above phenomena intensify.
Another significant symptom of the disease is the gradual involvement of other joints in the pathological process. Inflammation of the knees, elbows, shoulder joints and ankles is often noted. As for the joints of the shoulders and elbows, their inflammatory process is quite mild, but is also the reason for its difficult mobility.
If rheumatoid arthritis occurs in the knee joints, then the symptoms are of little comfort. In this case, there is an accumulation of a large amount of pathological fluid in the articular cavity, which causes stretching of the joint capsule. This symptom is called “Baker's cyst”.
The most severe cases are characterized by rupture of the cyst due to excess fluid, which leads to swelling of the lower leg, resulting in severe pain in the legs. After the activity of the inflammatory process is suppressed, the increased production of this fluid stops and the rupture gradually heals.
According to the classification, rheumatoid arthritis belongs to the group of autoimmune pathologies with a chronic course, which develops when a person’s immune status is weakened. The exact reasons why this pathology develops have not been identified to this day.
Predisposing factors include genetic predisposition, previous infectious processes (measles, mumps, hepatitis B), the effect of toxic substances on the human body, menopause and other autoimmune pathologies.
With the active progression of RA, symmetrical damage to the joints of the legs and arms (elbows, shoulders, hips, knees, hands and feet) develops. Small joint structures located on the upper extremities are usually affected first. First, the synovial membrane is involved in the inflammatory process, then this process affects the cartilage tissue, and as a result, the formation of erosions and irreversible deformation of the joints.
Arthritis can affect more than just joint elements. There are examples when it involves other organs and systems in the process. And the following changes begin to develop in the body: atrophy of the skeletal muscles, enlarged lymph nodes, the liver does not fully perform its functions, the gastrointestinal tract, lung tissue and heart muscle are affected, and possible damage to the skin.
With the help of X-ray examination, it is possible to determine the level of joint damage and deformation of bone structures, and of course cartilage and soft periarticular tissues. When determining the stage of RA, special attention is paid to the most affected joint, and the number of erosions formed in the bone tissue is calculated.
These manifestations make it possible to determine the stage of rheumatoid arthritis for a particular patient individually, since for each victim the degree of joint destruction and the number of erosions formed may be different.
It is very important to determine the presence of pathological formations such as erosions and cyst-like clearings during an x-ray. Unfortunately, they are almost impossible to notice using X-rays, since they are small in size and the equipment has poor clarity.
To establish the correct diagnosis in the initial stages, magnetic resonance or computed tomography is additionally used to study in detail the degenerative processes in the joints.
Based on X-ray images, four stages of rheumatoid arthritis can be distinguished.
The first stage or initial. At the initial level, the joints of the hands and metatarsophalangeal joints undergo degenerative changes.
In the photo you can see thickening and compaction of the periarticular soft tissues, bone damage. Namely, their thinning and the presence of small cyst-like clearings in them.
You can very clearly see periarticular osteoporosis, which is characterized by degenerative modifications in bone tissue. Bone structures become looser, their porosity increases, which leads to their fragility.
An experienced specialist may notice a narrowing of the joint space in the image, which is a characteristic sign of disease progression.
This stage is characterized by morning stiffness of the joints, which goes away on its own within 1 hour after waking up. The affected area is slightly swollen, and during minor physical activity or heavy lifting the patient experiences unpleasant but tolerable pain.
These are the main external indicators of the development of pathology, and if they occur, you should consult a rheumatologist.
Primary manifestations of rheumatoid arthritis can develop at any age. They can be either in a small patient or in a fairly adult person. And the disease can progress in different ways: rapid development may occur immediately after the initial signs, or there may be a lull for several years.
During the active progression of the second stage of rheumatoid arthritis, numerous cysts form in the bone structures, periarticular osteoporosis gains momentum and the lumen of the joint space narrows in one or several joints at once - these are characteristic signs of stage 2A. Stage 2A lasts until bone erosions begin to form.
Erosive formations can be divided into three groups:
Formations are the primary diagnostic feature of the formation of rheumatoid arthritis. As soon as the formation of erosive structures is visible on the X-ray image, we can begin to describe the next stage - 2B, which continues until four erosions are formed.
At this stage, mobility may be lost for 2-3 hours a day, this is due to the destruction of cartilage tissue. During physical activity, the patient's pain increases.
After five erosive formations have formed, we can move on to discussing the third stage of RA. Atrophic changes in the muscle tissue surrounding the joint develop.
Compression of joint spaces, multiple formed cysts and progressive periarticular osteoporosis are accompanied by dislocations with deformation of the hands.
These deformations have different names. The most common hand modifications include “walrus fins,” “swan necks,” and “button loops.”
Using an x-ray, you can see the formation of calcifications near the affected area. In their structure, calcifications resemble rheumatoid nodules, which grow in diameter up to 2 - 3 cm.
Due to the oversaturation of the body with calcium salts, calcifications begin to form. In their structure, rheumatoid nodules are quite dense, have a round shape, and are painless during palpation.
Calcifications are very clearly visible on x-ray images.
Pain and limited movement limit a person to such an extent that he cannot perform the simplest daily activities. And physical exercise or training becomes impossible and is excluded from the patient’s daily routine.
At this stage, periarticular osteoporosis begins to progress rapidly.
Various cyst-like clearings, dislocations and subluxations of joints, as well as deformed bone tissue are accompanied by ankylosis of the joints and subchondral osteosclerosis.
An x-ray can reveal a bone formation under the cartilage - this is subchondral osteosclerosis. This pathology is formed when the joint space is severely narrowed. Due to progressive deformation of the cartilage or its complete absence, a process of friction occurs between the exposed bones of the joints.
Ankylosis is the complete immobilization of a joint due to irreversible deformation processes that occurred as a result of the progression of rheumatoid arthritis. At this stage, the patient develops almost complete immobilization and severe, incessant pain.
Unfortunately, there is no complete cure for rheumatoid arthritis. Therapeutic measures consist of reducing pain and the severity of the inflammatory process, as well as reducing the processes of deformation and destruction of joints.
Along with drug treatment, it is worth following a strict diet, namely a vegetarian diet. Physical therapy also plays an important role, thanks to which you can at least maintain some mobility in the joints and prevent the development of muscle atrophy.
At the first stage of rheumatoid arthritis, therapeutic massage and physiotherapeutic procedures will also be effective, but when the fourth stage of arthritis has formed, only surgical intervention is indicated.
With long-term use of drugs to relieve rheumatoid arthritis, the patient shortens his life by seven years due to their toxic effects on organs and systems.
For preventive purposes, it is worth avoiding hypothermia of the body, preventing severe emotional stress and promptly treating infectious processes in the body.
Gout is a chronic progressive disease caused by a disorder of purine metabolism, characterized by an increased (normal for adult women - 150-350 µmol/l; for adult men - 210-420 µmol/l) level of uric acid in the blood (hyperuricemia), with subsequent deposition of urates in articular and/or periarticular tissues. Detection of hyperuricemia is not sufficient to establish a diagnosis, since only 10% of individuals who suffer from this disease have gout. Almost 95% of people diagnosed with gout are men between 40 and 50 years of age, although the disease is noted to be “getting younger.”
The rest are menopausal women. Gout has increasingly become accompanied by individual diseases such as obesity, hypertriglyceridemia (increased levels of neutral fats in the blood) and insulin resistance (impaired amount of insulin in the blood). We can conclude that gout is not a cause, but a consequence of metabolic disorders in the body. There are two types of gout: primary and secondary. Primary gout is a hereditary disease (11-42% of cases), which is associated primarily with a predisposition to hyperuricemia, which is transmitted in an autosomal dominant manner.
The cause of primary gout is the impaired activity of enzymes that are involved in the formation of uric acid from purine bases or in the mechanisms of urate excretion by the kidneys. And the causes of secondary gout are renal failure, blood diseases accompanied by increased catabolism (processes aimed at destroying substances in the body), and the use of a number of medications (diuretics, salicylates, etc.).
The main function of the kidneys is filtration and absorption, which are aimed at removing harmful and dangerous substances from the body, in particular waste products. The reserves of uric acid in the body are 900-1600 mg, and about 60% of this amount is replaced daily by new formation due to the breakdown of nucleotides and erythroblasts and the synthesis of nitrogen-containing compounds.
With prolonged hyperuricemia (with increased formation of uric acid in the body), adaptive reactions develop to reduce the level of uric acid in the blood. This occurs due to an increase in kidney activity and the deposition of urates in the soft tissues of cartilage. The clinical symptom of gout is associated precisely with the deposition of uric acid crystals in soft tissues. Although the mechanism of urate deposition is not fully understood, there are two main factors:
It has been proven that complete dissolution of uric acid salts occurs at pH = 12.0-13.0 (strongly alkaline solution), which in reality exists inside the human body. Hypothermia of peripheral joints (ankles, phalanges of fingers) promotes accelerated crystallization of urates and the formation of microtophi. With a high concentration of microcrystals in tissues (joint cartilage, bone epiphyses, etc.), the formation of micro- and macrotophi begins. Sizes range from millet grain to chicken egg. The accumulation of urates leads to cartilage destruction. Next, uric acid salts begin to be deposited in the subchondral bone (the foundation for cartilage, providing its trophism) with its destruction (radiological name - a puncture symptom).
Uric acid also accumulates in the kidneys (gouty kidney or gouty nephropathy). All patients with gout have affected kidneys, so renal failure is considered not as a complication, but as one of the visceral (internal) manifestations of the disease. Gouty kidney (nephropathy) may manifest itself in the form of urolithiasis, interstitial nephritis, glomerulonephritis or arteriolonephrosclerosis.
In total, there are 4 different clinical stages:
There are three stages in the development of gout. The premorbid period is characterized by the asymptomatic formation of increased amounts of uric acid in the body and/or the passage of urate stones with or without attacks of colic. This period can be quite long. The onset of attacks of the first gouty crisis indicates that the disease has begun to actively develop.
During the intermittent period, acute attacks of gouty arthritis alternate with asymptomatic intervals between them. Long-term hyperuricemia and exposure to provoking factors (drinking alcohol, prolonged fasting, eating foods rich in purines, trauma, taking medications, etc.) lead to nocturnal acute attacks of gouty arthritis in 50-60% of cases. The onset of the attack is a sharp pain in the first metatarsophalangeal joint of the leg (big toe). The affected area quickly swells, the skin becomes hot from a sudden rush of blood, the swelling tightens the skin, which affects pain receptors. Shiny, tense, red skin soon becomes bluish-purple, which is accompanied by peeling, fever, and leukocytosis. There is a dysfunction of the joint, the attack is accompanied by fever. Other spherical joints, foot joints, and, somewhat less frequently, ankle and knee joints are also affected.
Less commonly affected are the elbow, wrist and hand joints; extremely rare - shoulder, sternoclavicular, hip, temporomandibular, sacroiliac and spinal joints. Acute gouty bursitis (inflammation of the mucous bursae, mainly of the joints) is known; the prepatellar (located under the skin in front of the kneecap) or ulnar bursa is usually affected. Under the influence of synovitis (inflammation of the synovial membranes of the joint), the joints become deformed, the skin at the site of inflammation becomes tense, shiny, stretched, and when pressed, the dimple disappears. The boundaries of hyperemia (poor circulation) are unclear, bordered by a narrow strip of pale skin. This picture is observed from 1-2 to 7 days, then local inflammatory processes decrease, but the pain can sometimes continue at night. Gouty arthritis begins to subside within a few days with proper treatment. First, the redness of the skin disappears, its temperature normalizes, and later the pain and swelling of the tissues disappear. The skin wrinkles, there is abundant pityriasis-like peeling and local itching. Sometimes gout-specific tophi appear. The early stages of intermittent gout are characterized by rare recurrences of attacks (1-2 times a year). But the longer the disease progresses, the more often the symptoms of gouty arthritis return, becoming longer lasting and less acute.
Each time, the intervals between attacks of the disease shorten and cease to be asymptomatic, and blood tests can reveal an increased content of uric acid. This is an indicator that the disease is becoming chronic. Chronic gout is described by the occurrence of tophi and/or chronic gouty polyarthritis. The disease develops 5-10 years after the first attack and is characterized by chronic inflammation of the joints and periarticular (periarticular) tissues, the appearance of tophi (subcutaneous deposits of uric acid crystals), as well as combined damage to the joints (polyarthritis), soft tissues and internal organs (usually the kidneys) .
The location of tophi is different: it can be the ears, the area of the elbow joints, hands, feet, Achilles tendons. The presence of tophi indicates a progressive inability of the body to remove uric acid salts at a rate equal to the rate of their formation.
When gouty arthritis develops for quite some time, the formation of tophi occurs everywhere: in cartilage, in internal organs and bone tissue. Subcutaneous or intradermal formations consisting of monocrystals of sodium urate in the area of the fingers and toes, knee joints, elbows and ears are a sign that gouty arthritis has entered the chronic stage. Sometimes ulcers can be noted on the surface of the tophi, from which spontaneous discharge of a white pasty mass is possible. The formation of tophi in the bone space is called a puncture or break symptom, which can be diagnosed using x-rays.
Nephrolithiasis (kidney stone disease) in gout occurs due to the deposition of urate in the kidneys, forming stones. The more actively hyperuricemia progresses and the rate of crystal deposition increases, the greater the likelihood that tophi formations will appear in the early stages of the disease. This is often observed against the background of chronic renal failure in elderly women taking diuretics; in some forms of juvenile gout, myeloproliferative diseases (associated with disruption of brain stem cells) and post-transplant (cyclosporine) gout. Typically, the presence of tophi of any localization is combined with chronic gouty arthritis, in which there is no asymptomatic period, and is accompanied by polyarthritis (multiple joint damage).
Gout is a disease that is difficult to diagnose in the early stages, since most of the time it is asymptomatic, and during periods of acute attacks its course resembles reactive arthritis. Therefore, an important part of the diagnosis of gout is an analysis of the level of uric acid in the blood, in daily urine and the clearance (speed of purification) of uric acid.
During an attack, laboratory acute-phase reactions are detected; a urine test may show slight proteinuria, leukocyturia, and microhematuria. Deterioration in the concentrating ability of the kidneys according to the Zimnitsky test indicates the presence of asymptomatic interstitial nephritis (inflammation of the kidneys) with the gradual development of nephrosclerosis (overgrowth of connective tissue in the kidneys). In the synovial fluid there is a decrease in viscosity, high cytosis, and the needle-like structure of sodium urate crystals is visible under the microscope. Morphological examination of the subcutaneous tophi reveals, against the background of dystrophic (degrading) and necrotic changes in tissue, a whitish mass of sodium urate crystals, around which a zone of inflammatory reaction is visible. The mild course of the disease is characterized by rare (1-2 times a year) attacks of gouty arthritis, which occur in no more than 2 joints. There are no signs of articular destruction on radiographs; isolated tophi are observed.
Moderate gout is characterized by more frequent (3-5 times a year) exacerbation of the disease, which progresses in 2-4 joints at once, moderate skin and joint destruction, multiple tophi are observed and kidney stone disease is diagnosed. In severe cases of the disease, attacks are observed with a frequency of more than 5 times a year, multiple joint lesions, pronounced osteoarticular destruction, multiple large tophi, severe nephropathy (kidney destruction).
In the early stages of gouty arthritis, X-ray examination of the affected joints is not very informative. The radiological phenomenon typical of late gout is quite well known - the “punch” symptom. This is a defect in the bone on which the joint rests, can be 5 mm in diameter or more, located in the middle part of the base of the diaphysis (the middle part of the long tubular bones) or in the head of the phalanx, most often the first metatarsophalangeal joint. But as information accumulated, it became clear that a situation is more often observed when radiographic changes are not detected in patients with gouty arthritis.
It is necessary to note a number of points that make the radiological symptoms of the punch significant. The pathomorphological (i.e., internal structure different from the norm) substrate of this X-ray phenomenon is intraosseous tophi, which is similar to a cystic (having a separate wall and cavity) formation, due to the fact that uric acid salt crystals do not retain X-rays. The identified “puncher” determines the stage of the disease as chronic tophi. It is worth noting that identification of tophi of any location is a direct indication for starting anti-gout therapy. In general, the “puncture” symptom in patients with primary gout is a late sign and is associated with a long course of the disease and chronic arthritis.
On the other hand, an early radiological sign of gout is a reversible diffuse thickening of soft tissues during an acute attack due to the fact that during inflammatory processes there is a rush of blood and deposition of solid crystalline forms in areas of edema. In this case, local thinning of the bone substance (transient arthritis) can be detected, and as the disease progresses, destructive processes in this area can also occur. X-ray manifestations: initially, erosion can form along the edges of the bone in the form of a shell or shell with overhanging bone edges, with clearly defined contours, which is very typical for gouty arthritis, in contrast to rheumatoid arthritis, tuberculosis, sarcoidosis, syphilis, leprosy. Erosion processes can be detected both in the joint itself and outside it.
With intra-articular localization of tophi, destructive processes begin from the edges and, as they develop, move towards the center. Extra-articular erosions are usually localized in the cortical layer of the metamyphyses (from the medulla of the edges of the long tubular bone) and the diaphysis of the bones. Most often, this erosion is associated with close adjacent soft tissue tophi and is defined as round or oval marginal bone defects with pronounced sclerotic changes at the base of the erosion. Without treatment, such “holes” increase in size, covering deeper layers of bone tissue. X-ray images resemble “rat bites.” Asymmetrical erosions with destruction of cartilage are typical; bone ankylosis (fusion of articular surfaces) is rarely formed. If calcium is present in the tophi structures, then X-ray positive inclusions can be detected, which sometimes stimulate chondromas (a tumor consisting of cartilage tissue). The joint space width of the affected joints usually remains normal until the late stages of gouty arthritis. These changes can mimic osteoarthritis (joint degradation), but in some cases both conditions occur.
With timely recognition and treatment of gout, unpleasant consequences or development into a chronic form of the disease can be avoided. Unfavorable factors that influence the degree of development of the disease: age under 30 years, persistent hyperuricemia exceeding 0.6 mmol/l (10 mg%), persistent hyperuricosuria exceeding 1100 mg/day, the presence of urolithiasis in combination with a urinary tract infection; progressive nephropathy, especially in combination with diabetes mellitus and arterial hypertension. Life expectancy is determined by the development of renal and cardiovascular pathologies. In conclusion, it is worth noting that gout is a difficult to diagnose systemic disease, the symptoms of which are varied and often overlap with various other diseases.
Only in 10% of cases can a doctor immediately diagnose gout, since its early form is sluggish, almost asymptomatic. That is why it is important to monitor diseases that have obvious external manifestations (pain or deformation of any part of the body), and the condition of the blood. Blood is an indicator of a person's condition. A timely diagnosis of gout will allow you to choose the most effective treatment method. And if the final diagnosis was made only at a late stage, then, in order to be able to move normally (gout affects the joints, deforming them), only surgical intervention and a long rehabilitation period will help, without a guarantee that the disease will not return again. Be healthy!