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DOI: http://dx.doi.org/10.20534/ESR-17-3.4-65-67
Hamrayeva Nasiba Abdurasulovna, Samarkand State Medical Institute, Samarkand, Uzbekistan E-mail: hamrayevanasiba@gmail.com
The characteristics of articular manifestations systemic lupus erythematosus
Abstract: A typical pattern of articular syndrome in systemic lupus erythematosus was manifested in the form of arthritis of small j oints, which was characterized by symmetry, slight swelling and soreness of medium intensity. Arthralgia without signs of inflammation were often detected in large joints, had a migratory character, and was accompanied by symptoms of muscle damage. Keywords: systemic lupus erythematosus, arthralgia, arthritis.
Joint damage is an important clinical picture of systemic lupus erythematosus (SLE). Arthritis that affects two or more peripheral joints, manifested by pain, swelling and effusion is one of the main ACR criteria of SLE (1997), the severity of arthritis (heavy, medium, light - activity index on a scale ofBILAG (2004) and SELENA-SLE-DAI (2005) [1, 186-189; 6, 410-416; 7, 31 P.; 10, 720 P.; 12, 53-58].
E. L. Luchikhina (1998) [8, 15 p.] on the basis ofretrospective analysis of medical records (containing 80 parameters) in 228 patients with SLE in 80.5% of cases showed joint damage. In studies of T. A. Lisitsina (2014) [9, 32 p.] in patients with SLE compared to other diagnostic criteria that were most commonly diagnosed with arthritis (67.8%). However, in the works of E. A. Filatova et al. (2012) [13, 15 p.] a complex of symptoms, designated under convertional names "systemic inflammation", "the defeat of the cardiovascular system", "reno-parenchymal lesions" and "skin change" frequently (8-23%) than the defeat of the musculoskeletal system (6%). For Zhornyak, A. P., Ivanova M. M. (2005), Antipova, O. V. et al. (2007) in inflammatory lesions of SLE are very often localized in the interphalangeal, metacarpophalangeal and wrist joints, shoulder and knee joints are rarely affected, hip joints, spine and joints are caroleanne "with the exception of the joints" [3, 115-116; 5, 42-46].
Despite the large number of studies of joint damage in SLE, many questions to this problem to date remain controversial and require further study. In particular, very little is known about the destruction of medium and large joints in SLE, the role of the immune system affects the development of disorders of phosphorus-calcium metabolism, osteoporosis inter connection of lupus arthritis with other clinical and musculoskeletal manifestations of the disease.
The purpose of the study. To study the frequency and characteristics of articular manifestations in SLE, depending on the variant of its course and degree of disease activity.
Materials and methods. The study involved 80 patients with SLE (75 females, 5 males) were treated at Republican rheumatologic center at clinic No. 3 of Tashkent medical Academy, in rheumatology department of the hospital № 1 of Samarkand state medical institute and in the therapeutic department of the clinic of Andijan state medical institute. All patients were residents of the indigenous population.
Diagnosis of SLE is based on the presence of clinical manifestations and laboratory data. For confirmation of the diagnosis requires at least 4 of the 11 criteria of the ACR (1997) and SLICC criteria (2012), according to which the diagnosis of SLE must be 4 criteria, one of which must be immunological (any of: a-DNA, ANF, Sm, a-CL, C3, C4).
Examination ofpatients was carried out according to the Federal clinical recommendations on diagnostics and treatment of systemic lupus erythematosus FSBU "SRIR named after V. A. Nasonova" of RAMS (2014). A retrospective analysis of medical records in accor-
dance with specially designed research card. Onset of the disease is determined at the time of the onset of symptoms, significantly might be related to SLE. Disease activity was assessed using the scale SLEDAI-1 (Systemic Lupus Erythematosus Disease Activity Index, 1992).
All patients were indigenous (100%), dominated by females (1:9) employed in agriculture (30%) and with secondary education (75%). The average age of patients at the beginning of the disease was equal to 23.0±0.6 years, at the time of diagnosis was 25.3±0.8 years, currently to 32.1±0.9 years. Disease activity on a scale ECLAM at the time of the first and last hospital stay was, respectively, to 19.4±0.7 a 14.4±0.8 points. The frequency of skin lesions was detected in 100%, kidney - 85,0%, CNS - 33,8%, pneumonitis, pleurisy, pericarditis and vasculitis, respectively - 45,0%, 30,0%, 22.5% and 20.0% of patients. The acute course of SLE was detected in 30%, subacute - 48,8%, chronic - in 21.2% of patients.
The study of articular syndrome included determining the severity of the joint pain assessment by the patient (visual analogue scale - VAS), the index of exudation, manipulation ability of hands, the number of swollen and painful joints, the degree of functional insufficiency. Status of bone metabolism was judged by the concentration of serum total calcium (CA, mmol/l), phosphorus (P, Inmmol/l) and the activity of alkaline and acid phosphatase (ALP and KF, e/l).
To determine the bone density was used the method of computer tomography (CT), densitometry. The measurements were carried out with the use of CT apparatus of the American company "General electric", model bright Speed 16 of the Treasury, with application programs created on the basis of studies ofbone density in the United States. The program of examination of patients included osteodensitometry of vertebral bodies of the lumbar spine. Bone density was determined in units of Hounsfield (HU). The data obtained were compared to standard age and sex data. The degree of loss of bone density was calculated in arbitrary units in connection with the age and gender norm.
All patients underwent x-ray examination. If you suspect damage to the knee joints (35 patients) was performed by ultrasonography (US). With this survey, activlessons contours of the joint, of the joint space, cartilage, soft tissues (partial), cortical bone, capsules, volume of liquid in the joints and the joint capsule.
Statistical data processing was performed using software package statistica 6.0. The use of simple descriptive statistics, non-parametric correlation analysis by Spearman method.
Results and their discussion. SLE patients are the main forms of joint syndrome - arthralgia and arthritis was detected in 86.3% of patients.
In addition to activity stage and the duration of SLE nature of articular syndrome depends on the size of the affected joints. Inflammation is often detected in patients with moderate and high
Section 5. Medical science
disease activity, in acute and subacute SLE. Arthralgia without signs of active inflammation with low activity or chronic.
Bu localization arthritis more often developed symmetrically in small-metacarpophalangeal, proximal interphalangeal, talus-calcaneal, tarsal, metatarsophalangeal and wrist joints (ratio of arthritis/arthral-gia, respectively, amounted to - 1/9, 1/8, 1/8, 1/2 1/04). Migratory joint pain is often detected in large joints, mainly of the hip (ratio of arthralgia/arthritis - 5/9), shoulder joint (the ratio of arthralgia/ar-thritis - 2/6), spine, sternoclavicular (ratio of arthralgia/arthritis -2/6) and sacroilliac joint. In the middle joints (elbow, knee, ankle) the nature of the defeat was mixed, where there is arthritis and arthralgia (ratio of arthralgia/arthritis, respectively, 2/7 and 1/6 and 1/2).
Swelling, arthritis of small joints were unstable and were accompanied by moderate pain (for VAS 4.5±0.5 cm), slight limitation of motion. Arthritis of small joints of the indicators the patients age (36.3±4.6 years) and disease duration (135.6±7.6 months) was significantly higher than in patients with arthralgia (27.6±3.8 years; 102±5.2 month, P12 < 0.05). Quantitative indicators of joint syndrome: the pain intensity for VAS was 3.5±0.8 cm, the number of swollen joints 4.6±1.2, number of painful joints - 6.4±1.4 points, figure manipulation the ability brush - 85.5±7.8%, morning stiffness is 40.5±5.4 min.
The defeat of small joints is accompanied by other symptoms of SLE: Raynaud's syndrome (22.5%), "clean livedev" (17.5%) and erythema in the region of the joints (16.3%). In 11.3% of patients lose interphalangeal and metacarpophalangeal joints, especially the severity of atrophy of the interosseous muscles, severe pain, tendon and ligaments, the formation of pronounced deformations and fixed flexion of the fingers. There was a sharp decline in manipulative ability of the hands (on average 35.5±4.8%). This type of lesion met the criteria for D. Allarcon Segovia (1988) deforming arthropathy of the hands Jakku syndrome [3, 115-116; 5, 42-46; 11]. Arthropathy index Jakku (JAI, was calculated according to the severity of the deformation of the brush and the number of affected joints) in 6.3% of patients were less than 5 points (JAI < 5, moderate arthropathy), 5.0% — more than 5 points (JAI > 5, severe arthropathy). The average age of patients with deforming arthropathy of brushes made up of 30.6±3.2 years, duration of SLE - 98.4±8.4 months.
The degree of arthralgia of the shoulder, elbow and knee joints (22.5, 30.0 and 27.5%) were respectively 2.5 and 2.6 and 1,6 times higher the degree of arthritis (of 8.8, 11.3 and 17.5%). At patients with arthralgia of the knee was observed and a slight uniform thickening of the joint capsule (37.1%) and a moderate increase in the number of joint fluid (14.3%). Arthritis was visualized the uneven contours of the joint, the presence of free fluid in the cavity, considerable thickening of the joint capsule and irregularity of the cortical layer of the bone (34.3%). In 14.2% of cases, while ultrasound examination of the contours of the joints was smooth, the echogenicity of the cortical layer of the bones of the front and rear horns of the medial and lateral meniscus of the knee and joint fluid was homogeneous (normal levels).
In 3.8% ofpatients (all women, age was 26.3±3.2 years, the duration is 3.2±1.8 years) had severe SLE complications - aseptic necrosis of the femoral head. The characteristic symptoms of aseptic necrosis was a pain, uncertain localization and penchant for wide irradiation: in the lower back and buttocks, calves, groin and often into the region of the knee joint, as well as significant restriction ofmovement (patients avoiding active movements of the leg). When radiographic study of the femoral head was homogeneously darkened, the structure of the head lubricated. Height compared to the healthy side was reduced. The surface of the joint in places had the appearance of compacted
facets. There was a slight expansion of the joint space. For magnetic tomography study in the anterior part subchondral department heads have identified areas of osteonecrosis (1 to 3 pieces) ofvarying intensity, size 5-8 mm, limited by the periphery of the Crescent-shaped band of low intensity (symptoms of the II stage).
Articular syndrome in SLE was accompanied by signs of defeat of the muscles - myalgia, myositis, atrophy (43.8% ofpatients). Muscle pain was migratory in nature and often noted in the neck muscles, shoulder girdle, upper arm, forearm, interosseous muscles of the hands, the pelvic girdle and thighs. Atrophic changes occurred gradually and they had systemic character. At 66.3% of the detected failure ofbody mass index (calculated according to the formula: body mass index = body weight in kilograms/height in m 2): in 37.5% within 16.0-18.5 (insufficiency ofbody weight), 28.8% of less of 16.0 (significant deficiency).
To date there is no unified approach to the clinical interpretation of lesions of medium and large joints, spine, sedentary joints in SLE. This is probably due to the lack of diagnostic landmarks to the pain syndrome, the origin of which is with the activity of systemic inflammation is important to reduce mineral bone density and osteoporosis. An in-depth study of the mechanisms of decrease in mineral density of bone tissue, the timely diagnosis of osteoporosis in SLE will help early appointment of adequate therapy.
Diagnosis of osteoporosis was carried out according to the methodical recommendations of the Health Department of the city of Moscow (2007). Screening was conducted using the questionnaire of the International osteoporosis Foundation (all patients). A positive response to two or more questions was the reason for laboratory-instrumental investigations (second stage).
One survey question is positively answered to 17.5%, and two questions - 27.5%, on three - 35.0%, four - 20.0% of patients. Of laboratory tests at 18.8% of patients, the calcium content was in the range of 2.2 to 2.8 mmol/l (normal level), in 65.0% ofpatients were below 2.2 mmol/l (low content) and 16.2% were above 2.8 mmol/l (high levels). In patients with normal calcium content, a marker of bone resorption activity of KF was in the range of 5.5 and 6.4 IU/l, at low and high levels of calcium there was an increase in its activity - 6.0-7.8 IU/L. At normal calcium concentrations, the age of the patients amounted to 27.3±1.9 years, duration of illness from 2 to 68 weeks. At low and high concentrations of calcium the age of the patients amounted to an average of 27.3±1.9 years, duration of illness, from 26 to 960 weeks.
Computer tomographic intententionally (studied 30 patients) contributed to the identification of characteristics characterizing the I degree of osteoporosis in 40.0%, II degree - in 26.7%, III degree - in 33.3% of patients. The increase in the duration of the disease contributed to the increase in the frequency and worsening of osteoporosis. The degree of disease activity had an inverse correlation with the degree of decrease in density of a bone tissue: at low activity bone density amounted to 145.0±15.2, with an average - 129.0±10.1 and in high - 112.0±9.3 HU/cm2.
Assessment of the impact of therapy on the degree of reduction of bone mineral density showed that in patients treated with corticosteroids in supporting a dose of 10 mg/day (from 6 months to 8 years) bone mineral density averaged 132.0±12.9 HU/cm2, which is significantly higher than in patients treated with glucocorti-costeroids (GC) in a dose of20-40 mg/day. Statistically significant differences in mineral density of bone tissue in patients receiving and not treated with pulse therapy is not marked. These data confirm the relative safety of low-dose corticosteroids and pulse therapy in the development of osteoporosis.
It is known that the genetic predisposition to SLE (genotypic) stage becomes clinically expressed (phenotypic) under the influence of adverse environmental factors and climate [2, 21-24; 4, 57-62]. The climate of the greater part of Uzbekistan, where the research was conducted is sharply continental, there is a big range between day and night, summer and winter temperatures. The nature of arid, rainfall is not enough, the relative humidity is low (http://www.svali.ru:8101; http://www.advantour; http://www.poedem.ru). Most patients with SLE, in our study, the disease was associated with insolation (43.7%). While 13.8% ofthe cause of the disease was abnormal hot days in late spring, early or late summer when daytime temperatures exceed 40 0 C. On other climate change and weather are warming in the winter, the lack of «spring and autumn rainy days» and «snow winter days», as factors ofSLE, indicated by 8.8% ofpatients. From 13.8% the onset was associated with hypothermia (especially at night when there is a sharp decrease in temperature).
As the triggers of SLE, premature birth, abortion and held obstetric manipulations indicated 11.3% of the patients. Lupus has also provoked by psycho-emotional factors (7.5%), physical strain (5.0%), medications (3.8%) - TB (isoniazid), antifungal drugs (fluna) and antibiotics (tetracycline). 6.3% of patients were unable to indicate the cause of the disease.
Have 40.0% of patients arthralgia (ossalgia, myalgia) was observed before the development of SLE. The main part of this group of patients indicated that prodromal pain was intermittent. When the weather changes, especially in the summer and in the evening (26.3%) had increased pain. 16.3% of patients in anamnesis took place alarming symptoms of SLE, such as general weakness, wanton periodic low-grade fever (non-specific), pain in lymph nodes.
Thus, according to our data, in 86.3% of patients with SLE occurred articular syndrome, and in the pathological process involved all joints, particularly small joints ofhands and feet. The frequency of arthritis was higher among patients with medium and high activity of the pathological process in acute and subacute, the frequency of arthralgia — chronic disease course, with medium to low activity of the pathological process.
A typical pattern of articular syndrome in systemic lupus erythematosus was manifested in the form of arthritis of small joints, which was characterized by symmetry, slight swelling and soreness of medium intensity. Severe involvement of the small joints, deforming arthropathy Jakku were not registered often (11.3%), but in all cases contributed to the failure of joint function and permanent disability of patients.
Arthralgia without signs of inflammation were often detected in large joints, had a migratory character, and was accompanied by symptoms of muscle damage. Degenerative and atrophic changes in the muscles was gradually built, had system character, has led to general exhaustion and emaciation of the patients. Arthralgia and myalgia were the prodromal signs of SLE, as, pain and stiffness in bones and muscles were observed long before the development of the disease. Hypothermia, a change in the weather, sun exposure, physical activity, mental exposure provoked the appearance of prodromal signs.
In addition to the factors of SLE, pain in the middle and large joints were due to the violation of calcium-phosphorus metabolism and osteoporosis. In a laboratory study in 81.6% ofpatients discovered a change in the content of calcium and increased activity of KF (markers ofbone resorption), 60.0% of CT densitometry have contributed to identifying symptoms II and III degree of osteoporosis. The increase in the duration of the disease and increase in the degree of its activity had a direct correlation with the degree ofdecrease in density of a bone fabric. To prevent osteoporosis, along with observance of rules ofhealthy lifestyle, you must eat enough calcium and vitamin D, the desire to reduce the dose of GK by optimizing treatment of the underlying disease (in the morning, once in 1 dose).
The clinical picture of SLE also had a severe complication of arthritis of the hip — avascular necrosis of the femoral head, which contributed to a significant deterioration of the general condition of the patients. Therefore, examination of the patient with SLE, in addition to the general descriptive characteristics of the musculoskeletal and other systems should include quantitative and objective criteria of articular syndrome, radiographic, ultrasonic and densitometric studies to assess the nature of the lesion and the functionality of the joints.
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