1. Characteristics and differentiation of pain syndrome
Pain is the most frequent complaint, arising from inflammation in the joint itself or periarticular tissues. It is important to analyze its circadian rhythm and relation to physical activity.
- Osteoarthritis: the pain has a "mechanical" character. It intensifies with physical activity and reaches a maximum by the end of the day.
- Gout: the attack starts extremely acutely, often peaking in the early morning. Patients describe the pain as excruciating.
It is also necessary to clarify radiation, triggering factors, and the impact on quality of life. In mild cases, activity is preserved, whereas with severe pain, the patient takes high doses of analgesics. Joint deformations and the formation of ankylosis lead to disability. In addition, hand diseases often cause severe anxiety due to the risk of losing one's profession (especially for musicians or operators).
2. Morning stiffness and periarticular pathologies
Physical changes and subjective sensations help narrow down the diagnostic search.
- Morning stiffness: this is a sensation of stiffness and "viscosity" of movements after night sleep. If the stiffness lasts at least 1 hour, it is a classical diagnostic criterion for rheumatoid arthritis.
- Periarticular lesions: joint swelling does not always indicate true arthritis. The problem may lie in the surrounding soft tissues (bursitis, tenosynovitis). Inflammation in the areas of tendon attachment (entheses) is typical for tendinitis and periarthritis. Such pain is often projected onto the joint and is aggravated by palpation.
3. Systemic manifestations and Raynaud's phenomenon
Rheumatic diseases affect the entire body. During the interview, one should look for signs of general toxic syndrome: fever, weight loss, weakness, and sweating.
- Visceral lesions: chest pain during breathing may indicate polyserositis (pleurisy or pericarditis), characteristic of systemic lupus erythematosus (SLE).
- Muscle pathology: progressive myalgia or severe weakness (up to the inability to perform simple movements) indicates inflammatory myopathies (polymyositis, dermatomyositis).
- Ophthalmological manifestations: uveitis, scleritis, and conjunctivitis reflect immunological activity and require fundus examination.
Special attention is paid to Raynaud's phenomenon—paroxysmal arterial spasm in response to cold exposure. Causes vary from rheumatic diseases (systemic sclerosis, SLE) and vibration disease to the intake of oral contraceptives and antiphospholipid syndrome.
4. Identification of triggers and pharmacological history
Linking the onset of joint syndrome to prior events helps determine the etiology:
- Infections: prior intestinal or urogenital diseases provoke reactive arthritis.
- Trauma: damage to a large joint can trigger rheumatoid arthritis, while microtraumatization leads to osteoarthritis.
- Diet: alcohol and excess meat consumption are classic triggers of gout.
- Heredity: is of particular importance in Bekhterev's disease and gout.
A huge role is played by the drug history. Patients take painkillers daily for years (e.g., metamizole sodium). Their cumulative dose can reach kilograms. This creates a fatal risk of developing analgesic nephropathy culminating in chronic renal failure (CRF) requiring hemodialysis. Also, long-term glucocorticoid intake threatens the development of secondary osteoporosis.
Briefly: answers to topical questions
Which groups of infections most frequently provoke the development of reactive arthritis?
The development of reactive arthritis is associated with preceding urogenital or intestinal infections. Chlamydial reactive arthritis is described separately. Etiotropic treatment depends on the triggering pathogen: for chlamydial arthritis, macrolides are the first-line drugs; for arthritis associated with intestinal infection, the spectrum of drugs changes, and aminoglycosides are considered among the treatment options in severe forms.
What specific complications are caused by long-term, multi-year glucocorticoid intake?
Long-term, multi-year intake of glucocorticoids leads to the development of secondary osteoporosis and a wide range of systemic side effects. The frequency and severity of complications depend on the dose and duration of use.
- Endocrine disorders — steroid-induced diabetes mellitus, adrenal suppression, Cushing's syndrome.
- Musculoskeletal system damage — osteoporosis, steroid myopathy, loss of muscle mass.
- Digestive system damage — steroid-induced gastric and duodenal ulcer, gastrointestinal bleeding, erosive esophagitis.
- Skin changes — striae, petechiae, acne (acne), delayed wound healing.
- Mineralocorticoid effects — fluid and sodium retention, hypernatremia, hypokalemic syndrome.
What clinical symptoms manifest in inflammatory myopathies (polymyositis and dermatomyositis)?
Inflammatory myopathies, including polymyositis and dermatomyositis, manifest with muscular symptoms: severe muscle weakness up to the inability to perform simple movements, myalgia progressing with movement, and predominant involvement of the proximal limb muscle groups. In dermatomyositis, the skin is affected in addition to muscles; skin manifestations include bright facial erythema combined with periorbital edema, the "spectacle" sign.
The triad of Raynaud's phenomenon changes finger color according to the white-blue-red flag principle: Paleness (ischemia) → Blueness (cyanosis) → Redness (reactive hyperemia).
Class and exam questions
What is the main difference between pain in osteoarthritis and rheumatoid arthritis?
In osteoarthritis, pain is mechanical in nature and worsens by the end of the day after exertion. In rheumatoid arthritis, the pain pattern is inflammatory and accompanied by prolonged morning stiffness.
Why is an ophthalmologist consultation necessary in rheumatic diseases?
Eye involvement (uveitis, scleritis, iridocyclitis) is a marker of high systemic immunological activity of the process and requires ophthalmoscopy.
What does uncontrolled analgesic intake for joint pain lead to?
Long-term use of large doses of painkillers can cause analgesic nephropathy. In severe cases, this leads to end-stage CRF and the need for hemodialysis.
What else to study on this topic
- Criteria for diagnosing rheumatoid arthritis and assessing destructive potential
- Differential diagnosis of inflammatory myopathies (dermatomyositis, polymyositis)
- Mechanisms of secondary osteoporosis development during glucocorticoid therapy
- Pathogenesis and clinical picture of primary antiphospholipid syndrome
- Features of the course of reactive arthritis after urogenital infections
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