OVERVIEW

What is rheumatic arthritis?

Rheumatic arthritis is a common clinical condition caused by rheumatic fever, characterized by "migratory polyarthritis." It often affects large joints such as the knees, ankles, elbows, and wrists, manifesting as joint pain, swelling, and stiffness. The arthritis in each joint typically resolves on its own within two weeks without leaving sequelae but tends to recur frequently. The primary treatment for rheumatic arthritis involves antibacterial drugs, such as penicillin and cephalosporins^[1,2].

Rheumatic fever can occur in individuals of any age but is most common in children aged 5–15. With improvements in living standards, the incidence of rheumatic fever in China has significantly decreased, primarily occurring in rural and remote areas. Rheumatic arthritis is often accompanied by other manifestations of rheumatic fever, such as fever (above 37.5 °C), carditis (palpitations and shortness of breath after exercise), chorea (involuntary, purposeless movements of the limbs and trunk), subcutaneous nodules (small, painless, firm nodules under the skin near joints), and erythema marginatum (red, ring-shaped rashes on the arms, thighs, or trunk)^[3].

SYMPTOMS

What are the symptoms of rheumatic arthritis?

1. 1–6 weeks before the onset of rheumatic arthritis, patients often have a history of pharyngitis or tonsillitis, presenting with fever, sore throat, cough, swollen submandibular lymph nodes, etc.^[1].

2. Rheumatic arthritis mainly manifests as "migratory polyarthritis," which can sequentially affect multiple large joints such as the knees, ankles, elbows, and wrists. Symptoms include redness, swelling, warmth to the touch, pain, and limited mobility (joint stiffness, inflexibility, and difficulty in normal use). The arthritis in each joint can completely resolve within two weeks without leaving deformities or functional impairments, but it may recur^[1].

3. Rheumatic arthritis may also be accompanied by other manifestations of rheumatic fever, such as fever, carditis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum^[1,3].

   • Fever: Most patients experience irregular fever (axillary temperature above 37.5 °C), while a few may have mild fever (axillary temperature 37.2–37.5 °C) that may go unnoticed^[4].
   • Carditis: Patients may experience palpitations after exertion, shortness of breath, or discomfort in the left chest near the heart^[1].
   • Sydenham's chorea: This mostly occurs in children aged 4–7. Patients exhibit involuntary, purposeless movements of the limbs and trunk, along with facial expressions like frowning, blinking, puckering, or tongue protrusion^[1].
   • Subcutaneous nodules: Painless, slightly firm small nodules may appear under the skin near joints^[1].
   • Erythema marginatum: Red, ring-shaped rashes with pale centers appear on the arms, thighs, or trunk, fading within hours or 1–2 days^[1].

Which areas are commonly affected by rheumatic arthritis?

It often occurs in large joints such as the knees, ankles, elbows, and wrists, and occasionally in the hips, finger joints, jaw joints, or sternoclavicular joints^[4].

What diseases can accompany rheumatic arthritis?

Rheumatic arthritis usually resolves on its own within two weeks and typically does not cause other diseases. However, it may be accompanied by other manifestations of rheumatic fever, such as carditis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum^[1,5].

1. Carditis: Inflammation of the heart is the most severe manifestation of rheumatic fever and can include valvulitis, myocarditis, or pericarditis. Symptoms include palpitations after activity, shortness of breath, fatigue, chest discomfort, and edema. Heart damage from rheumatic fever may persist and progress, eventually leading to rheumatic heart disease.

2. Sydenham's chorea: This often occurs in children aged 4–7, presenting as involuntary, purposeless movements such as grimacing, shrugging, or tongue protrusion. Symptoms worsen with excitement and disappear during sleep, often accompanied by emotional instability. The condition usually lasts 1–3 months, though some children may retain varying degrees of neuropsychiatric sequelae (e.g., insomnia, restlessness).

3. Subcutaneous nodules: These are slightly firm, painless small nodules, 0.1–1 cm in diameter (similar in size to glass beads), appearing on the extensor surfaces of joints like the elbows, knees, or wrists, or on bony prominences such as the back of the head or spine.

4. Erythema marginatum: This rash appears as faint red ring-shaped patches of varying sizes with pale centers, typically on the trunk or proximal limbs. It emerges suddenly and fades within hours or 1–2 days.

Can rheumatic arthritis be fatal?

Rheumatic arthritis alone, with current effective treatments, is generally not fatal. However, if accompanied by other symptoms or complications of rheumatic fever, such as carditis, heart failure, or infective endocarditis, death is possible. Younger age at onset and more severe initial symptoms increase the risk of death^[6].

Does rheumatic arthritis leave sequelae?

Usually not.

Arthritis can resolve completely without lasting effects, though it may recur^[1]. However, if accompanied by other rheumatic fever symptoms like carditis or chorea, complications such as arrhythmias or rheumatic heart valve disease may occur.

CAUSES

What causes rheumatic arthritis?

1. Rheumatic arthritis is associated with pharyngeal infections caused by group A beta-hemolytic streptococci, typically occurring 1–6 weeks after the pharyngeal infection^[1].

2. Factors such as overcrowded living conditions, poor nutrition, and lack of medical care facilitate the reproduction and spread of streptococci, making rheumatic fever more common in developing countries, impoverished areas, and densely populated communities^[3].

Can rheumatic arthritis be caused by a damp environment?

Rheumatic arthritis is not directly caused by dampness.

Dampness itself does not cause rheumatic fever or rheumatic arthritis^[1]. The term "rheumatism" can be misleading. In reality, poor and underdeveloped areas with unsanitary, damp living conditions allow streptococci to thrive and spread, while inadequate medical care prevents complete eradication of streptococcal infections—these are the root causes of the high incidence of rheumatic fever and rheumatic arthritis. However, cold and damp environments may alter immune responses, potentially triggering the disease.

Is rheumatic arthritis hereditary?

Rheumatic arthritis may have a genetic component^[3].

Rheumatic fever (including rheumatic arthritis) appears to have a "genetic predisposition," possibly linked to multiple genes. Certain families are more susceptible to developing rheumatic fever after group A streptococcal infections than the general population, which is related to their genetic makeup^[3].

Is rheumatic arthritis contagious?

There is no evidence that rheumatic arthritis is contagious^[1,2,4].

However, the group A beta-hemolytic streptococci that cause rheumatic arthritis can spread between people. Not everyone infected with group A streptococci will develop rheumatic fever or rheumatic arthritis.

DIAGNOSIS

What tests are needed for rheumatic arthritis?

1. Throat swab culture: A sample is taken from the mucous membrane of the throat for culturing. In some patients, group A streptococcus may be detected^[1].

2. Blood tests: These include testing for antistreptolysin O (ASO), which becomes positive two weeks after streptococcal infection. Additionally, tests for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), IgM, IgG, and complement C3 are required. These markers are typically elevated in patients with rheumatic arthritis^[1].

3. Cardiac examination: This mainly includes electrocardiogram (ECG), echocardiography, myocardial nuclear imaging, and myocardial enzyme tests to determine whether rheumatic fever has caused carditis^[1].

Which diseases can rheumatic arthritis be easily confused with?

1. Rheumatoid arthritis: Both conditions may present with fever, joint pain, and swelling. However, rheumatoid arthritis primarily affects small joints, such as the fingers and wrists, symmetrically on both sides. Symptoms persist and do not resolve on their own, with significant morning stiffness. Laboratory tests show positive rheumatoid factor and anti-cyclic citrullinated peptide (CCP) antibodies, while imaging reveals noticeable bone and joint damage^[1].

2. Reactive arthritis: Symptoms like joint swelling and pain resemble those of rheumatic arthritis. However, reactive arthritis often follows intestinal or urinary tract infections and mainly affects the lower limbs. It typically presents with localized skin warmth, swelling, and joint tenderness. A positive HLA-B27 test helps differentiate it from rheumatic arthritis^[7,8].

3. Tuberculous allergic arthritis: Symptoms such as fever, joint redness, and pain are similar to rheumatic arthritis. However, patients have a history of tuberculosis infection, a positive tuberculin skin test, and poor response to nonsteroidal anti-inflammatory drugs (e.g., aspirin). Antituberculosis therapy is effective. Doctors usually perform a tuberculin test for differentiation^[4,9].

TREATMENT

Is it necessary to go to the hospital for rheumatic arthritis?

Yes, rheumatic arthritis is a common manifestation of rheumatic fever, which is often accompanied by carditis. If not treated promptly, it may lead to rheumatic heart disease, heart failure, or even death^[6].

Additionally, if rheumatic arthritis is not treated in the hospital to eradicate streptococcus, rheumatic fever may recur in the future^[1].

How is rheumatic arthritis treated?

1. General treatment: Patients should rest, avoid overexertion, and refrain from strenuous activities such as heavy lifting or long-distance running. Keeping warm and avoiding cold exposure is also important to prevent joint irritation^[1,5].

2. Anti-infective treatment: Regardless of whether the patient has pharyngitis at the time of consultation, antibiotics should be used to eradicate group A streptococcus. Penicillin is usually the first choice, but alternatives like amoxicillin or cephalexin may be prescribed. For patients allergic to penicillin or cephalosporins, azithromycin, clarithromycin, or clindamycin may be used^[5]. However, penicillin may cause adverse reactions such as chest tightness, pallor, chills, or sore throat, which can be life-threatening in severe cases. Therefore, doctors typically perform a sensitivity test before administration^[10].

3. Anti-inflammatory and analgesic treatment (anti-rheumatic treatment): Anti-inflammatory therapy can effectively relieve arthritis symptoms, with nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin commonly used. Treatment is discontinued once symptoms subside and inflammatory markers (e.g., ESR and CRP) normalize. Side effects of aspirin may include nausea, vomiting, or skin itching^[11], but patients need not worry excessively as not everyone experiences these reactions.

4. Treatment for other symptoms of rheumatic fever: If the patient has rheumatic arthritis accompanied by carditis, rash, or other conditions, the doctor will provide corresponding treatment.

Does rheumatic arthritis require hospitalization?

For cases without severe complications, outpatient treatment and active follow-up are sufficient. This includes anti-inflammatory therapy to relieve arthritis symptoms, antibiotics to eradicate group A streptococcus infection, and management of heart failure if present^[1,4].

Patients with carditis should rest in bed and gradually resume activities once their condition stabilizes^[1].

Can rheumatic arthritis be completely cured? How to prevent recurrence?

Rheumatic arthritis can be completely cured but often recurs^[1].

Simple rheumatic arthritis typically resolves within two weeks without sequelae but may recur^[1].

Preventing initial and recurrent episodes of rheumatic fever depends on controlling group A streptococcal pharyngotonsillitis. Patients with a history of rheumatic fever are at high risk of recurrence if they develop streptococcal pharyngotonsillitis. Notably, one-third of rheumatic fever cases involve group A streptococcal infection without initial pharyngotonsillitis symptoms.

Doctors usually prescribe appropriate antibiotic prophylaxis to prevent recurrence. Long-acting benzathine penicillin G (intramuscular injection) is the first choice, while clindamycin may be used for penicillin-allergic patients or those with worsening symptoms during penicillin therapy^[12].

Which department should I visit for rheumatic arthritis?

Rheumatology, cardiology, respiratory medicine (for more antibiotic expertise), or pediatrics.

1. Patients with joint redness, swelling, or pain should visit rheumatology.
2. Patients with joint symptoms accompanied by chest discomfort or suspected rheumatic heart disease should consult cardiology.
3. Patients under 14 years old should seek pediatric care.

DIET & LIFESTYLE

What should patients with rheumatic arthritis pay attention to in daily life?

1. Improve living conditions and avoid crowded environments (such as shared dormitories, hostels, etc.)^[3].

2. Maintain a balanced diet to prevent malnutrition.

   • Patients can supplement with high-quality proteins such as chicken, duck, and fish, and drink a glass of milk daily;
   • Consume fresh fruits and vegetables to replenish essential vitamins.

3. Prevent colds and avoid streptococcal infections; seek medical attention promptly for pharyngitis or tonsillitis^[13].

4. Wash hands frequently with soap or other cleansers^[13].

5. Cook food thoroughly, reheat leftovers properly, and use clean disposable gloves when handling food^[13].

Can patients with rheumatic arthritis work during treatment?

Patients with rheumatic arthritis are not advised to engage in strenuous work.

They should rest more and avoid labor-intensive tasks such as heavy lifting^[1].

If complicated by carditis, bed rest is recommended, and work or study burdens should be reduced during treatment, with leave taken if necessary^[1].

Does rheumatic arthritis affect fertility?

Rheumatic arthritis alone does not affect fertility.

However, if accompanied by other symptoms of rheumatic fever (such as carditis), especially rheumatic heart disease caused by recurrent rheumatic fever, it may impact fertility, primarily posing risks to maternal and fetal safety during pregnancy and childbirth^[14].

Does rheumatic arthritis affect daily activities such as exercise, high-altitude travel, or flying?

Rheumatic arthritis alone can fully recover without causing joint deformities or mobility impairments, so it does not affect daily activities.

However, if complicated by rheumatic heart disease, strenuous exercise or high-altitude travel should be avoided^[15].

PREVENTION

How to Prevent Rheumatic Arthritis?

The cause of rheumatic arthritis is relatively clear. Prevention involves avoiding infection with Group A streptococcus as much as possible. If a streptococcal infection occurs, the bacteria should be eliminated promptly to prevent rheumatic fever. If rheumatic fever has already occurred, measures must be taken to prevent its recurrence.

1. Methods to avoid Group A streptococcus infection include:

   • Improve living conditions and avoid crowded environments (e.g., college dorms, military barracks)^[3].

   • Prevent colds and avoid streptococcal infections; seek medical attention promptly for pharyngitis or tonsillitis^[13].

   • Wash hands frequently using soap or other cleansers^[13].

   • Cook food thoroughly, reheat leftovers properly, and use clean disposable gloves when handling food^[13].

2. Methods to promptly eliminate an existing streptococcal infection include:

   • After diagnosing streptococcal pharyngitis or tonsillitis, administer a full course of antibiotics such as penicillin, erythromycin, or azithromycin to reduce the risk of subsequent rheumatic fever^[1].

   • Close contacts of patients infected with Group A streptococcus should undergo throat swab cultures. Those with positive results, even if asymptomatic, should receive a full antibiotic treatment to eradicate the bacteria and prevent future rheumatic fever^[12].

   • Patients should actively comply with medication to prevent rheumatic fever recurrence.