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*Only for medical professionals to read for reference.
Look at the picture for diagnosis, it's even better with you! Because rheumatism can affect multiple systems throughout the body, if the diagnosis and treatment are not standardized, the deformity and disability rate will be greatly increased.
Therefore, in clinical practice, many doctors always have headaches in their diagnosis, but some patients with very typical signs are not helpful in diagnosing the disease.
It helps a lot
.
This time the editor summarized the typical signs of common rheumatism to help everyone have a better understanding of the disease
.
A type of rheumatoid arthritis (RA) RA is a systemic autoimmune disease characterized by synovitis of the joints.
The main clinical manifestation is joint disease.
Joints such as palms and wrists are the most common
.
Studies have shown that more than 90% of patients with RA first involve the hand joints, especially the proximal interphalangeal joints.
The advanced joints may have varying degrees of stiffness and deformity.
The most common ones are ulnar deflection, fusiform swelling, and "Swan neck" and "button pattern" like performance[1]
.
1.
Ulnar deviation: The patient's fingers are weak due to soft tissue, and the patient's other four points except the thumb are deviated in the direction of the little finger joint
.
Figure 1: Metacarpophalangeal joint ulnar deformity: atrophy of the extensor carpi ulnaris muscle, compensatory shift of the fingers to the ulnar side 2.
Fusiform swelling: most patients start with joint swelling
.
Swelling is caused by increased exudate in the joint cavity and inflammation of the soft tissue around the joint.
It is manifested as uniform swelling around the joint.
The fusiform swelling of the proximal knuckle of the finger is one of the typical symptoms of RA patients
.
Fusiform swelling refers to the swelling shape presenting a fusiform with a large center and narrow ends
.
Figure 2: Fusiform swelling of the proximal interphalangeal joint 3.
"Swan neck" deformity: metacarpophalangeal joint flexion, proximal interphalangeal joint hyperextension, distal interphalangeal joint flexion, looking like a swan neck from the side
.
Figure 3: The extensor tendons of the distal interphalangeal joint move down to both sides of the joint, causing flexion of the distal interphalangeal joint and hyperextension of the proximal interphalangeal joint For button fingers, the proximal interphalangeal joint has been kept in a flexed position due to the loss of the ability to actively straighten, while the distal interphalangeal joint is hyperextensive
.
This is the opposite of swan neck deformity
.
Figure 4: "Button flower"-like deformity: lateral ligament slippage and contraction to the volar side, leading to proximal interphalangeal joint hyperflexion and distal interphalangeal joint hyperextension.
SLE is a self-involving multiple organs.
Immune diseases, as many as 19%~73% of SLE patients can be complicated by lupus nephritis, which is a common cause of death in SLE
.
Butterfly erythema: Facial butterfly erythema is a SLE-specific skin lesion, seen in 40% to 85% of patients, and may be a sign of SLE disease severity and multi-system damage [2]
.
Figure 5: Facial lesions show a well-defined cheekbone rash, excluding nasolabial folds and eyelids [3] Triankylosing spondylitis (AS) AS is a chronic progressive inflammation of the spine, which is characterized by lesions often starting from the sacroiliac joints It begins to gradually spread upward to the spine, leading to fibrous or bony rigidity and deformity.
In the late stage, spine stiffness can cause flexion of the trunk and hip joints, and eventually kyphosis.
In severe cases, it can be forced to a 90-degree flexion position, and the vision is limited.
Take one step
.
In recent years, as the sources of information have become more and more extensive, more people have paid attention to such a type of people-folding people
.
Their heads are folded, their chests against their stomachs, their faces against their thighs, and the whole figure looks like a folding knife
.
For them, unable to walk upright, unable to eat, unable to lie down and sleep, this kind of life is really painful! Picture 6: Li Hua, the folding man, is really shocking when he sees the picture above! Li Hua is a rare "3-on folding person" in the world (the mandible is close to the breastbone, the sternum is close to the pubic bone, and the face is close to the femur)
.
From the age of 18 to 46, AS gradually "petrified" his body
.
Fortunately, after four "bone-to-bone" operations, he was knocked off his thigh, neck, and spine, and then replaced his hip joint.
He finally stood up
.
He was admitted to the hospital on June 13, 2019 and discharged on June 13, 2020.
This arduous process was also made into a documentary
.
Four gout Gout is a disease caused by the deposition of monosodium urate in the tissues.
It is directly related to the disorder of purine metabolism and hyperuricemia.
Monosodium urate can crystallize in vitro and cause repeated surrounding tissues.
Chronic granuloma-like reaction eventually forms chronic tophi consisting of monosodium urate crystals, inflammatory cells and fibrous tissue
.
Tophi deposits are the main pathophysiological cause of gout.
According to statistics, about 30% of patients with hyperuricemia will show signs of tophi deposits [4]
.
Tophi in different anatomical locations will have different clinical symptoms.
Tophi located in the joints and tendons can cause irreversible tendon, joint damage and bone destruction, and compression symptoms can occur in the peripheral nerves [5]
.
Some large tophis can directly affect joint function, and some tophis ulcerate, with lime-like exudates flowing out, and wounds at the ulcers are difficult to heal, leading to huge risks of toe or even amputation, which seriously affects normal life
.
Figure 7: Figures A and B show the deposition of tophi in the hand and its bone erosion (arrow); Figures C and D show the deposition of tophi on the elbow; Figure E and F show the deposition of tophi in the first metatarsophalangeal joint and its bone erosion.
Bone destruction [6] Five systemic sclerosis Systemic sclerosis (SSc), also known as scleroderma, is an autoimmune connective tissue disease of unclear etiology, with immune disorders, vascular disease, inflammation, skin and internal organs Excessive fibrosis of the organ is the main feature
.
The clinical manifestations of SSc are diverse, including Raynaud’s phenomenon, skin thickening, skin hardening, fingertip lesions, telangiectasia, nail fold capillary abnormalities, pulmonary hypertension and interstitial lung disease, gastrointestinal complications, renal complications, and cardiovascular complications
.
Clinically, SSc is mainly divided into limited skin type SSc and diffuse skin type SSc
.
Skin lesions are divided into: ① edema (or swelling): non-pitting swelling of the skin, swelling of the fingers and sausage-like swelling, swelling of the back of the hand, gradually spreading to the forearm; ②Sclerosis (or infiltration): thickening of the skin of the fingers, back of the hand, and forearm Like leather, it is waxy and shiny, and adheres to deep tissues, making it difficult to pinch
.
Facial skin damage causes the normal facial wrinkles to disappear, the face becomes rigid, the nose becomes sharp, the nose atrophys and softens, the lips become thinner and adducted, there are radioactive folds around the mouth, and the mouth opening becomes smaller; ③Atrophy: skin atrophy changes Thin as parchment paper, sometimes the subcutaneous tissues and muscles can also shrink and harden, the streak disappears, the hair falls off, the skin is smooth and thin, close to the bones, the fingertips and joints are prone to stubborn ulcers, and capillaries may also appear Dilation of blood vessels and calcification of subcutaneous tissue
.
Figure 8: Hardened skin on the face of patients with SSc, with radioactive folds around the mouth [3] Figure 9: Hardened fingers of patients with SSc, yellow and stiff skin, leading to skin atrophy and thinning (a) and signs of vasculitis, leaving scars on the fingers (B) [3] Hexomyositis dermatomyositis (DM) is a heterogeneous muscle disease characterized by symmetric proximal muscle weakness, often involving multiple organs, and easily complicated by tumors and other connective tissue diseases
.
Dermatitis is the most common first symptom of DM patients, and it can also be the only first symptom
.
For unexplained and stubborn dermatitis, DM needs to be considered, and relevant examinations such as muscle enzymes, electromyography, and immunology should be performed in time
.
Among the clinical symptoms, skin damage is most common with facial erythema combined with diffuse erythema and papules on the neck, limbs, front chest, and back
.
The skin characteristics of DM are divided into: ■ Specific skin lesions Specific skin lesions include upper eyelid edematous purplish red spots (Heliotrope rash), Gottron sign (elbows, knees, inner ankles and purplish red spots on the dorsal side of interphalangeal joints) Or atrophic spots), Gottron papules (purple or wine-colored flat papules on the dorsal side of the interphalangeal joints, elbows, and knees, which can then become porcelain white)
.
■ Non-specific skin lesions Non-specific skin lesions include dark erythema (mainly seen in the V-shaped area of the chest, trunk and limbs, and skin heterochromia), necrotizing vasculitis, Raynaud’s phenomenon, oral ulcers, photosensitivity, alopecia, and mesh Bleu, pulp and skin pimples and other calcium deposits
.
Figure 10: Gottron sign, papules on the interphalangeal and metacarpophalangeal joints (a), perithyroid erythema (with cuticle dystrophy and bleeding) (a, b), and purple erythema on the neck and chest V area (b) ) Figure 11: Gottron papules on the back of the fingers of the DM patient, painful purpura papules of palm ulcers (a), and ulcerative Gottron papules on the metacarpophalangeal joints have improved after treatment with mycophenolate mofetil (b) Summary: All of the above are rheumatism Although the skin manifestations of the disease can help clinicians diagnose the disease, it still needs to be combined with the patient's clinical manifestations and auxiliary examinations to further confirm the diagnosis! References: [1] Yao Fengxiang.
Modern Rheumatology [M].
Beijing: People's Military Medical Press.
1995:597.
[2]Boodhoo KD,Liu S,Zuo X.
Impact of sex disparities on the clinical manifestations in patients with systemic lupus erythematosus:A systematic review and meta-analysis[J].
Medicine(Baltimore),2016,95:e4272.
[ 3]Alves F,Gonçalo M,Suspected inflammatory rheumatic diseases in patients presenting with skin rashes,Best Practice&Research Clinical Rheumatology,https://doi.
org/10.
1016/j.
berh.
2019.
101440.
[4]ABHISHEK A,COURTNEY P,JENKINS W ,et al.
Brief report:Monosodium urate monohydrate crystal deposits are common in asymptomatic sons of patients with gout:The sons of gout study.
Arthritis Rheumatol.
2018;70(11):1847-1852.
Look at the picture for diagnosis, it's even better with you! Because rheumatism can affect multiple systems throughout the body, if the diagnosis and treatment are not standardized, the deformity and disability rate will be greatly increased.
Therefore, in clinical practice, many doctors always have headaches in their diagnosis, but some patients with very typical signs are not helpful in diagnosing the disease.
It helps a lot
.
This time the editor summarized the typical signs of common rheumatism to help everyone have a better understanding of the disease
.
A type of rheumatoid arthritis (RA) RA is a systemic autoimmune disease characterized by synovitis of the joints.
The main clinical manifestation is joint disease.
Joints such as palms and wrists are the most common
.
Studies have shown that more than 90% of patients with RA first involve the hand joints, especially the proximal interphalangeal joints.
The advanced joints may have varying degrees of stiffness and deformity.
The most common ones are ulnar deflection, fusiform swelling, and "Swan neck" and "button pattern" like performance[1]
.
1.
Ulnar deviation: The patient's fingers are weak due to soft tissue, and the patient's other four points except the thumb are deviated in the direction of the little finger joint
.
Figure 1: Metacarpophalangeal joint ulnar deformity: atrophy of the extensor carpi ulnaris muscle, compensatory shift of the fingers to the ulnar side 2.
Fusiform swelling: most patients start with joint swelling
.
Swelling is caused by increased exudate in the joint cavity and inflammation of the soft tissue around the joint.
It is manifested as uniform swelling around the joint.
The fusiform swelling of the proximal knuckle of the finger is one of the typical symptoms of RA patients
.
Fusiform swelling refers to the swelling shape presenting a fusiform with a large center and narrow ends
.
Figure 2: Fusiform swelling of the proximal interphalangeal joint 3.
"Swan neck" deformity: metacarpophalangeal joint flexion, proximal interphalangeal joint hyperextension, distal interphalangeal joint flexion, looking like a swan neck from the side
.
Figure 3: The extensor tendons of the distal interphalangeal joint move down to both sides of the joint, causing flexion of the distal interphalangeal joint and hyperextension of the proximal interphalangeal joint For button fingers, the proximal interphalangeal joint has been kept in a flexed position due to the loss of the ability to actively straighten, while the distal interphalangeal joint is hyperextensive
.
This is the opposite of swan neck deformity
.
Figure 4: "Button flower"-like deformity: lateral ligament slippage and contraction to the volar side, leading to proximal interphalangeal joint hyperflexion and distal interphalangeal joint hyperextension.
SLE is a self-involving multiple organs.
Immune diseases, as many as 19%~73% of SLE patients can be complicated by lupus nephritis, which is a common cause of death in SLE
.
Butterfly erythema: Facial butterfly erythema is a SLE-specific skin lesion, seen in 40% to 85% of patients, and may be a sign of SLE disease severity and multi-system damage [2]
.
Figure 5: Facial lesions show a well-defined cheekbone rash, excluding nasolabial folds and eyelids [3] Triankylosing spondylitis (AS) AS is a chronic progressive inflammation of the spine, which is characterized by lesions often starting from the sacroiliac joints It begins to gradually spread upward to the spine, leading to fibrous or bony rigidity and deformity.
In the late stage, spine stiffness can cause flexion of the trunk and hip joints, and eventually kyphosis.
In severe cases, it can be forced to a 90-degree flexion position, and the vision is limited.
Take one step
.
In recent years, as the sources of information have become more and more extensive, more people have paid attention to such a type of people-folding people
.
Their heads are folded, their chests against their stomachs, their faces against their thighs, and the whole figure looks like a folding knife
.
For them, unable to walk upright, unable to eat, unable to lie down and sleep, this kind of life is really painful! Picture 6: Li Hua, the folding man, is really shocking when he sees the picture above! Li Hua is a rare "3-on folding person" in the world (the mandible is close to the breastbone, the sternum is close to the pubic bone, and the face is close to the femur)
.
From the age of 18 to 46, AS gradually "petrified" his body
.
Fortunately, after four "bone-to-bone" operations, he was knocked off his thigh, neck, and spine, and then replaced his hip joint.
He finally stood up
.
He was admitted to the hospital on June 13, 2019 and discharged on June 13, 2020.
This arduous process was also made into a documentary
.
Four gout Gout is a disease caused by the deposition of monosodium urate in the tissues.
It is directly related to the disorder of purine metabolism and hyperuricemia.
Monosodium urate can crystallize in vitro and cause repeated surrounding tissues.
Chronic granuloma-like reaction eventually forms chronic tophi consisting of monosodium urate crystals, inflammatory cells and fibrous tissue
.
Tophi deposits are the main pathophysiological cause of gout.
According to statistics, about 30% of patients with hyperuricemia will show signs of tophi deposits [4]
.
Tophi in different anatomical locations will have different clinical symptoms.
Tophi located in the joints and tendons can cause irreversible tendon, joint damage and bone destruction, and compression symptoms can occur in the peripheral nerves [5]
.
Some large tophis can directly affect joint function, and some tophis ulcerate, with lime-like exudates flowing out, and wounds at the ulcers are difficult to heal, leading to huge risks of toe or even amputation, which seriously affects normal life
.
Figure 7: Figures A and B show the deposition of tophi in the hand and its bone erosion (arrow); Figures C and D show the deposition of tophi on the elbow; Figure E and F show the deposition of tophi in the first metatarsophalangeal joint and its bone erosion.
Bone destruction [6] Five systemic sclerosis Systemic sclerosis (SSc), also known as scleroderma, is an autoimmune connective tissue disease of unclear etiology, with immune disorders, vascular disease, inflammation, skin and internal organs Excessive fibrosis of the organ is the main feature
.
The clinical manifestations of SSc are diverse, including Raynaud’s phenomenon, skin thickening, skin hardening, fingertip lesions, telangiectasia, nail fold capillary abnormalities, pulmonary hypertension and interstitial lung disease, gastrointestinal complications, renal complications, and cardiovascular complications
.
Clinically, SSc is mainly divided into limited skin type SSc and diffuse skin type SSc
.
Skin lesions are divided into: ① edema (or swelling): non-pitting swelling of the skin, swelling of the fingers and sausage-like swelling, swelling of the back of the hand, gradually spreading to the forearm; ②Sclerosis (or infiltration): thickening of the skin of the fingers, back of the hand, and forearm Like leather, it is waxy and shiny, and adheres to deep tissues, making it difficult to pinch
.
Facial skin damage causes the normal facial wrinkles to disappear, the face becomes rigid, the nose becomes sharp, the nose atrophys and softens, the lips become thinner and adducted, there are radioactive folds around the mouth, and the mouth opening becomes smaller; ③Atrophy: skin atrophy changes Thin as parchment paper, sometimes the subcutaneous tissues and muscles can also shrink and harden, the streak disappears, the hair falls off, the skin is smooth and thin, close to the bones, the fingertips and joints are prone to stubborn ulcers, and capillaries may also appear Dilation of blood vessels and calcification of subcutaneous tissue
.
Figure 8: Hardened skin on the face of patients with SSc, with radioactive folds around the mouth [3] Figure 9: Hardened fingers of patients with SSc, yellow and stiff skin, leading to skin atrophy and thinning (a) and signs of vasculitis, leaving scars on the fingers (B) [3] Hexomyositis dermatomyositis (DM) is a heterogeneous muscle disease characterized by symmetric proximal muscle weakness, often involving multiple organs, and easily complicated by tumors and other connective tissue diseases
.
Dermatitis is the most common first symptom of DM patients, and it can also be the only first symptom
.
For unexplained and stubborn dermatitis, DM needs to be considered, and relevant examinations such as muscle enzymes, electromyography, and immunology should be performed in time
.
Among the clinical symptoms, skin damage is most common with facial erythema combined with diffuse erythema and papules on the neck, limbs, front chest, and back
.
The skin characteristics of DM are divided into: ■ Specific skin lesions Specific skin lesions include upper eyelid edematous purplish red spots (Heliotrope rash), Gottron sign (elbows, knees, inner ankles and purplish red spots on the dorsal side of interphalangeal joints) Or atrophic spots), Gottron papules (purple or wine-colored flat papules on the dorsal side of the interphalangeal joints, elbows, and knees, which can then become porcelain white)
.
■ Non-specific skin lesions Non-specific skin lesions include dark erythema (mainly seen in the V-shaped area of the chest, trunk and limbs, and skin heterochromia), necrotizing vasculitis, Raynaud’s phenomenon, oral ulcers, photosensitivity, alopecia, and mesh Bleu, pulp and skin pimples and other calcium deposits
.
Figure 10: Gottron sign, papules on the interphalangeal and metacarpophalangeal joints (a), perithyroid erythema (with cuticle dystrophy and bleeding) (a, b), and purple erythema on the neck and chest V area (b) ) Figure 11: Gottron papules on the back of the fingers of the DM patient, painful purpura papules of palm ulcers (a), and ulcerative Gottron papules on the metacarpophalangeal joints have improved after treatment with mycophenolate mofetil (b) Summary: All of the above are rheumatism Although the skin manifestations of the disease can help clinicians diagnose the disease, it still needs to be combined with the patient's clinical manifestations and auxiliary examinations to further confirm the diagnosis! References: [1] Yao Fengxiang.
Modern Rheumatology [M].
Beijing: People's Military Medical Press.
1995:597.
[2]Boodhoo KD,Liu S,Zuo X.
Impact of sex disparities on the clinical manifestations in patients with systemic lupus erythematosus:A systematic review and meta-analysis[J].
Medicine(Baltimore),2016,95:e4272.
[ 3]Alves F,Gonçalo M,Suspected inflammatory rheumatic diseases in patients presenting with skin rashes,Best Practice&Research Clinical Rheumatology,https://doi.
org/10.
1016/j.
berh.
2019.
101440.
[4]ABHISHEK A,COURTNEY P,JENKINS W ,et al.
Brief report:Monosodium urate monohydrate crystal deposits are common in asymptomatic sons of patients with gout:The sons of gout study.
Arthritis Rheumatol.
2018;70(11):1847-1852.
