Rheumatoid arthritis as a complication of chronic tonsillitis

Features of the disease

The peripharyngeal ring is a collection of lymphoid tissue, which is an important peripheral organ of the body's immune system. Pathogenic microorganisms that enter the body with food and water are retained in the oral or nasal cavity precisely by the tonsils of the peripharyngeal ring. As a result of the struggle between the body and the infectious agent, a local reaction of the tonsils occurs, which is expressed in increased production of lymphocytes and can lead to tissue inflammation.

Inflammation of the tonsils can also be caused by an internal infection of the body, namely diseases of the oral cavity or ENT organs: caries, sinusitis, rhinitis, otitis media, etc. When the body's immune defense is weakened due to illness or hypothermia, opportunistic microflora found in the growth or nasal cavity can provoke acute inflammation of the tonsils. Factors that provoke pathology are bad habits (smoking and alcohol abuse), diseases of the gastrointestinal tract, working in hazardous working conditions, and unhealthy diet.

The risk group for the disease includes pregnant women, the elderly and children, as well as people with chronic damage to the immune system.

Diagnosis of acute tonsillopharyngitis

If there are signs of streptococcal infection, the diagnosis is confirmed by a positive microbiological test (rapid test for the detection of GABHS antigen or a throat swab for GABHS). A test or smear should be performed before starting antibiotic therapy, as even a single dose of antibiotics can lead to a negative result.

Rapid tests for GABHS have a specificity of more than 95% and a sensitivity that varies between 70 and 90%. Given the high specificity and limited sensitivity of the available tests, a positive test for GABHS is sufficient to establish the diagnosis of streptococcal pharyngitis, but a negative test, in turn, does not exclude GABHS infection. Therefore, in a child or adolescent, in case of a negative result of the rapid test, it is necessary to perform a throat smear for GABHS. If the rapid test is positive, then subsequent bacteriological examination is not required.

In adults, with a negative rapid test in a standard situation, subsequent microbiological testing is not required.

A test for GABHS is indicated in the following cases:

• there are signs of acute tonsillopharyngitis (erythema, swelling and/or exudate in the tonsils) or a scarlet rash, but there are no symptoms of a viral infection;
• there was contact with a sick person whose diagnosis of streptococcal infection was confirmed (at home, at school);
• suspicion of acute rheumatic fever or post-streptococcal glomerulonephritis.

GABHS testing is not indicated for children and adolescents with manifestations of a viral infection. From 5 to 21% of children aged 3-15 years are carriers of GABHS, which can be mistakenly perceived as streptococcal rather than viral pharyngitis.

Timely treatment of GABHS in children and adolescents is primarily necessary for:

• prevention of purulent complications and acute rheumatic fever;
• preventing transmission of the disease to others, especially if the patient is in contact with a person who has had a history of an episode of acute rheumatic fever;
• reducing the duration and severity of symptoms of the disease.

Classification of the disease

Inflammatory pathology of the tonsils varies:

• by type of pathogen, can be bacterial, viral or fungal in nature;
• by the nature of the course - acute or chronic;
• according to the clinical picture - catarrhal, follicular or lacunar.

Sore throat can be primary (simple), which occurs when a bacterial infection penetrates, secondary, which occurs against the background of other diseases of the body, and also specific, caused by the action of a specific agent.

Material and methods

The study was carried out in patients with chronic decompensated tonsillitis who were admitted to the Department of Otorhinolaryngology of the St. Petersburg State Medical University named after. acad. I.P. Pavlova for planned surgical treatment. Group 1 included 23 patients aged from 20 to 43 years, who in the postoperative period received NSAIDs (Ketorolac) on demand for pain, as well as a homeopathic monocomponent herbal preparation Arnica Montana C9 (BOIRON) 5 granules 3 times a day for resorption from the 2nd day. The second (control) group of patients included 20 patients aged 19 to 42 years who received only on-demand NSAID therapy (Fig. 1).

Rice. 1. Distribution of patients in groups by age. The two study groups of patients were balanced by gender and age, thus, the studied differences between them reflect the effect of the drug Arnica Montana C9 (BOIRON). All patients underwent classical bilateral tonsillectomy under general anesthesia by the same operating team. In the early postoperative period, a number of criteria were assessed in all patients: body temperature in the morning after waking up and in the evening, the need to use NSAIDs, the amount of their use per day, pain assessment according to VAS, as well as changes in the pharyngoscopic picture and neck lymphadenopathy within 10 days after surgery.

The results of the study were entered into the developed computer database on a personal computer using Microsoft Excel tables. Using the application package Statistica for Windows v.10.0, analysis and statistical processing of the obtained data were carried out, and the parameters of descriptive statistics were determined.

Quantitative indicators were checked for compliance with normal distribution using the Kolmogorov-Smirnov test. For quantitative data having a normal distribution, the arithmetic mean ( M

) and standard deviation (
SD
), which are presented in the format
M
(
SD
); when describing indicators that differ from the normal distribution, medians (Me) were used in the Me format (Q1; Q3) and the lower Q1 (25%) and upper Q3 (75%) quartiles were used as an interval estimate. Qualitative indicators of the study are presented in absolute and relative values ​​(%).

To find differences between normally distributed indicators, t

-Student's t-test.

Formula t

-Student's test:

where M

1 - arithmetic mean of the 1st compared group,
M
2 - arithmetic mean of the 2nd compared group,
m
1 - mean error of the first arithmetic mean,
m2
- mean error of the second arithmetic mean.

Statistical processing of the study results in groups was carried out with determination of significance using the nonparametric Mann-Whitney U test.

Mann-Whitney U test formula:

where n

1 - the number of elements in the 1st sample,
n
2 - the number of elements in the 2nd sample, T
x
- the larger of the 2 rank sums,
nx
- the corresponding sample.

Indicators changing over time were analyzed using paired Student's t test (in the case of normal distribution) or using t

-Wilcoxon test.

To analyze qualitative indicators, the χ2 test with Yates' correction was used (in cases of absolute numbers less than 10); if it was impossible to use it, the Z-test was used for proportions with correction for end points.

The difference between groups was considered statistically significant at p

<0,05.

Symptoms of the disease

Sore throat or acute tonsillitis have a pronounced clinical picture. The incubation period lasts from 12 to 48 hours, after which clinical signs appear.

• Increased body temperature (above 39°C, less often 37-38°C). With a sore throat, it is difficult to lower a high body temperature with the help of antipyretics.
• Signs of intoxication are body aches and weakness, headache, chills, dizziness, pain in the chest and heart area.
• Pain and sensation of a lump in the throat. Pain when swallowing.
• Hoarseness of voice.
• Inflammation of regional lymph nodes.

On examination, swelling and hyperemia of the palatine tonsils are revealed. Depending on the type of inflammation, purulent plaque forms on the lacunae or all tonsils.

In some cases, the symptoms of the disease may not be expressed. The temperature may remain within the low-grade range or slightly elevated, accompanied by unpleasant and painful sensations in the throat.

Rheumatoid arthritis as a complication of chronic tonsillitis

Chronic tonsillitis is a general infectious-allergic disease with local manifestations in the form of persistent chronic inflammation of the tonsils, characterized by a recurrent course and occurring more often as a complication of infectious pathology.

Chronic tonsillitis is a condition of the palatine tonsils, in which their natural protective functions are lost and they become a chronic source of infection, intoxication and allergization of the body. Chronic tonsillitis can cause and maintain many diseases, such as rheumatism, myocarditis, glomerulonephritis, pyelonephritis, etc. Chronic tonsillitis either contributes to their development or negatively affects their course.

When studying the flora in the lacunae and on the surface of the palatine tonsils, more than 30 combinations of various forms of microbes were identified. The main causative agents of chronic tonsillitis are hemolytic streptococcus, viridans streptococcus, enterococcus, staphylococcus, and adenoviruses.

Rheumatism is a toxic-immunological systemic inflammatory disease of connective tissue with a predominant localization of the process in the cardiovascular system, developing in persons predisposed to it in connection with an acute infection caused by ß-hemolytic streptococcus of group A, mainly at the age of 7-15 years.

It has now been convincingly proven that the occurrence of rheumatism and its relapses are associated with ß-hemolytic streptococcus of group A (tonsillitis, pharyngitis, streptococcal cervical lymphadenitis).

In typical cases, rheumatism, especially during the first attack, begins in school and adolescence, 1-2 weeks after suffering an acute or exacerbation of chronic streptococcal infection (sore throat, pharyngitis). Then the disease enters a “latent” period (lasting from 1 to 3 weeks), characterized by an asymptomatic course or mild malaise, arthralgia, and sometimes subfebrile body temperature. In the same period, an increase in ESR, an increase in titers of ASLO, antistreptokinase, and anitstreptohyaluronidase are possible. The second period of the disease is characterized by a pronounced clinical picture, manifested by carditis, polyarthritis, other symptoms and changes in laboratory parameters.

More typical for primary rheumatism, it is based on acute synovitis. The main symptoms of rheumatic arthritis: severe pain in large and medium-sized joints (symmetrically), often in the knees and ankles, swelling, hyperemia of the skin in the joint area, severe limitation of movements, volatile pain, rapid relief of non-steroidal anti-inflammatory drugs, absence of residual joint effects.

Let us consider the clinical case of patient B., born in 1974, who was treated in the ENT department of the Central District Hospital in Zheleznodorozhny from February 6, 2008 to February 15, 2008. She was admitted with complaints of frequent sore throats (up to 5-6 times a year), constant sore throat, discomfort in the throat when swallowing, increased body temperature up to 37.5C, pain and stiffness in all joints of the upper and lower extremities, limitation of movements, difficulty opening the mouth , weakness.

From the anamnesis it is known that at the age of 6 months she suffered from a sore throat. Subsequently, sore throats recurred up to 6 times a year. He has been suffering from rheumatoid arthritis since the age of 2, for which he has repeatedly undergone courses of anti-inflammatory therapy with a short-term effect. The disease progressed, almost all joints were involved in the process. At the age of 15 she underwent synovectomy of the right knee joint, in 1990 - osteotomy of the left hip, arthroplasty, in 1994 - endoprosthetics of the left hip joint, in 1996 - left knee joint. In 1998 she underwent resection arthroplasty of the right elbow joint. She received systemic anti-inflammatory therapy. Examined by an ENT doctor, the diagnosis was made: Chronic decompensated tonsillitis, bilateral tonsillectomy was recommended.

On admission: condition of moderate severity. Body temperature is 37.2C. Moves with the help of crutches. ENT status: mouth opening is difficult due to arthritis of the maxillary joint. During pharyngoscopy: the mucous membrane of the oropharynx is moderately hyperemic. Palatine tonsils of the 1st degree of hypertrophy, fused with edematous palatine arches, the lacunae are wide, when pressed, abundant purulent plugs are determined.

In blood tests - ESR - 75 mm/h, ASLO - 250.0, CRP - 120.0, RF - 13 units/ml.

On December 12, 2008, a bilateral tonsillectomy was performed under local infiltration anesthesia with technical difficulties. The postoperative period was uneventful. She received general and local anti-inflammatory therapy. On the 2nd day after the operation, laser therapy was performed with a device. Examined over time after 3 months: there was an improvement in the general condition, normalization of body temperature, remission of rheumatoid arthritis, mouth opening improved, the palatine niches were clean, without signs of inflammation. Blood tests have stabilized to normal.

Chronic tonsillitis often leads not only to many somatic diseases, but also to disability of patients, as in our case.

Authors: D.M. Mustafaev, T.V. Kozyrkova, N.U. Adilkhanova, A.N. Yusupov

Treatment of the disease

In most cases, treatment is carried out on an outpatient basis. Patients are prescribed bed rest, warm, plenty of fluids, and food should be light and liquid. Treatment, depending on the type of sore throat, includes antibacterial therapy, antiviral drugs and local symptomatic treatment. Additionally, the tonsils are irrigated with anti-inflammatory drugs, gargling with herbal decoctions and antiseptic solutions. To reduce swelling and symptoms of intoxication, antihistamines are indicated. The course of treatment is 5-10 days.

Treatment of tonsillitis

The child should be provided with:

• peace and the opportunity to sleep as much as he wants;
• Drink plenty of fluids to relieve sore throats and prevent dehydration;
• air humidification;
• a sore throat can be relieved by both warm drinks and cold ice cream, especially popsicles;
• for a sore throat, it helps to gargle with a solution of table salt and soda - a teaspoon of salt and a small pinch of soda per 250 ml of warm water;
• Children over 4 years old can be offered lozenges for sore throats. Do not give candy to small children - they may choke;
• do not smoke when your child is sick, avoid strong odors that irritate the throat;
• A sore throat and fever can be relieved by medications containing paracetamol and ibuprofen. Don't give children aspirin; in rare cases, it can cause deadly Reye's syndrome.

Confirmed bacterial tonsillitis (usually streptococcal tonsillitis) is treated with antibiotics. It is dangerous to interrupt or stop the course because it increases the likelihood of infection spreading to the joints, heart, kidneys and other organs. Continue taking antibiotics even if your symptoms are completely gone.

Complication of the disease

Sore throat is dangerous because of its complications, which can be early, i.e. occurring immediately after inflammation of the tonsils or delayed, which appear 3-4 weeks after purulent inflammation. Complications can be single (affect one organ) or multiple and affect several organs.

Early complications of tonsillitis are otitis media, lymphadenitis, sinusitis, sinusitis, laryngeal edema, tonsil abscess, etc. Delayed inflammation provokes diseases of the heart muscle (rheumatism of the heart muscle, myocarditis, pericarditis), joint pathologies (rheumatism, arthritis), kidney diseases (glomerumetritis, pyelonephritis, renal failure).

In medical clinics, at any time convenient for you, they will provide timely and qualified assistance for any diseases of the ENT organs in patients of all age categories. The clinics are equipped with modern diagnostic equipment for diagnosing ENT diseases, and patients also have a modern diagnostic laboratory at their disposal, in which all necessary laboratory tests are performed.

Our otorhinolaryngology doctors have extensive experience in diagnosing and treating various diseases of the ear, nose and throat in adults and children, using both conservative and surgical methods. When the first symptoms of a sore throat or other pathologies appear, do not delay visiting a doctor and seek qualified medical help. You can make an appointment by calling the center or leaving a request on the website.

Complications of tonsillitis

• Labored breathing.
• Sleep apnea (holding your breath during sleep).
• Spread of infection to the tissue near the tonsils (peritonsillitis), peritonsillar abscess - accumulation of pus behind the tonsil.
• Acute cervical lymphadenitis is inflammation of the cervical lymph nodes.

Streptococcal tonsillitis can cause complications such as:

• acute rheumatic fever, affecting the joints, heart and other organs;
• glomerulonephritis (inflammation of the kidneys, which can lead to serious consequences, including kidney failure).

Treatment with antibiotics significantly reduces the likelihood of complications after streptococcal sore throat.

Conclusion

Based on the statistical analysis of the comparison of two groups of patients who underwent bilateral tonsillectomy, in patients who received, in addition to the anesthetic drug ketorolac, Arnica Montana C9 (BUARON) for resorption, 5 granules 3 times a day from the 2nd day, the recovery time was significantly reduced . This is indicated, in particular, by a faster time for normalization of body temperature, disappearance of pain and a decrease in the inflammatory reaction in the pharynx after tonsillectomy. This may have a positive effect on the quality of life in the early postoperative period of patients taking the drug Arnica Montana C9 (BOIRON).

The authors declare no conflict of interest.

The authors declare no conflicts of interest.