The classification of the RA has changed several times and the last of them was adopted at the congress of rheumatologists in 1978 is also not without flaws (see table. 5).
Additionally, with this classification, we present a table with a characteristic of clinical and laboratory signs of RA activity.
The functional ability of the patient is established after
the following criteria: I degree – a slight limitation of the function of the joints while maintaining
professional performance; Grade II – lost professional ability; Grade III – loss of ability to self-service. We give approximate formulations of the diagnosis in accordance
with modern classification of RA: 1. Rheumatoid monoarthritis of the right knee joint,
positive, with a slowly progressive course of stage II activity, stage II, functional insufficiency (FN) stage I.
Rheumatoid polyarthritis is seronegative with a slow progression, II degree of activity, III stage, rheumatoid carditis, ventricular premature beats, FN of II degree.
We give a brief description of the main variants of the disease on the basis of our own observations. By clinical and radiological signs, we divided all patients with RA into three groups.
The first group included patients who differed in the relatively favorable course of arthritis without a tendency to joint deformations, without contractures and ankylosis with the complete absence of radiological signs of destructive changes in the joints.
The course of the disease was characterized, as a rule, by the alternation of individual exudative outbreaks with pronounced
remissions The nature of the pathological process in such cases could
to comply with the exudative variant of stage I disease according to the modern classification of RA. C-reactive protein (Crb) in patients of this group was determined in 70%, and rheumatoid factor in 33.3% of cases.
The second group included patients with joint deformity, development of contractures and the appearance of destructive-proliferative changes in the joints, which are determined radiographically (respectively, stage II-III according to classification). At the same time, the remissions were short and often not at all expressed.
Characteristic was the steady progression of the disease, often with damage to the internal organs (kidney, liver, lymph and hematopoietic apparatus). In such cases, the nature of the pathological process corresponded to the exudative-proliferative variant of RA. At the same time, Srb was determined in 95%, and rheumatoid factor – in 92% of cases.
Finally, the third group consisted of the most severe patients with pronounced contractures and ankylosis with complete loss of joint function (FN of the III degree).
Patients were completely bedridden in the morning with the ability to self-care. The course of the disease in them was characterized by a steady progression of the pathological process.
The indicated clinical variant of the disease was pathologically characterized by severe fibro-sclerotic changes in the joints and corresponded to stage III – IV according to x-ray signs. Srb and rheumatoid factor in these patients were determined in 100% of cases.
In all groups, female patients over 40 years of age prevailed, with the onset of the disease over 30 years of age.
RA, which occurs only with articular syndrome, is considered the most common and typical form of the disease. Along with this, an atypical variant of the disease with a more “benign” course is found, occurring in 14% of cases. P r and benign course is usually affected 1-2 joints (mono – or oligosustavnaya form). RA, occurring with visceral lesions, occurs in 12–13% of cases and is the most severe form of the disease. In this case, feverish variant of RA is highlighted , the most unfavorable. Previously, this option was called septic. It is observed usually at a young age differs rapidly progressive course. The onset of the disease is acute with severe pain in the joints (sometimes not corresponding to moderately pronounced local changes). In the future, contractures and ankylosis develop rapidly in the joints and the internal organs remain unchanged, but myocarditis with heart failure, amyloidosis of the kidneys with azotemia, etc. are observed.
Fever can be hectic with daily fluctuations of up to 3-4 °, with chills, sweats, etc.
We observed a similar variant of RA with severe heart damage, with cardialgia and rhythm disturbance in the form of a full a-blockade. The observation was of a 69-year-old patient and it was clinically difficult to differentiate rheumatoid carditis from myocardial infarction. The section contained extensive necrotizing myocarditis. The vasculitis with fibrinoid necrosis of the vascular wall was determined histologically (micrograph, Fig. 12). On the electrocardiogram of this patient, an atrioventricular block of the first degree was initially recorded, and in the terminal period of the disease, it passed into a full block.
The severity of the lesion in visceral RA forms is determined by the severity and generalization of vasculitis.
A special variant of RA is Felty’s syndrome. This is a variant of RA, accompanied by splenomegaly and leukopenia (as well as anemia and thrombocytopenia).
Felty’s syndrome is described in 1924. This variant of RA is characterized by many systemic manifestations: subcutaneous roar with motile nodules, episcleritis, chronic ulcers of the glands, and peripheral neuropipathy (neuritis).
Felty’s syndrome is characterized by a high incidence of bacterial infection with fever, apparently as a result of existing leukoneutropenia.
Finally, RA can occur in combination with diffuse diseases of the connective tissue (collagenoses) and develop against the background of already existing osteoarthritis.