Lesser chorea: causes, symptoms, treatment

Small chorea (Sydenham's chorea, rheumatic chorea, infectious chorea) is a neurological manifestation of rheumatic infection. The main symptoms of the disease are disorderly violent movements in the limbs and trunk, as well as psychoemotional changes. Small chorea affects mainly children and adolescents, sometimes there are relapses at a young age. The diagnosis of the disease is based on a combination of clinical symptoms and data from additional research methods. This article will help you become acquainted with the causes, symptoms, diagnostics and methods of treating small chorea.

Clinical symptoms were first described by the English doctor Sidengam in 1686. The most frequent small chorea affects children aged 5 to 15 years. The prevalence of the disease among girls is 2 times higher than among boys. It is believed that this is due to the hormonal characteristics of the female body, as this disproportion increases in the adolescent period.

Causes

As early as 1780, scientist Stol had suggested the infectious nature of the disease. To date, it has been reliably established that the cause of small chorea is the transferred infection of β-hemolytic group A streptococcus

This type of streptococcus most often affects the upper respiratory tract with the development of tonsillitis and tonsillitis. The body fights against the pathogen, producing antibodies against it, which destroy streptococcus. In a number of people, antibodies are produced simultaneously and to the basal ganglia of the brain. This is called a cross-autoimmune response. Antibodies attack the nerve cells of the basal ganglia. Thus, an inflammatory reaction occurs in the subcortical structures of the brain, which manifests itself as specific symptoms (hyperkinesis).

Of course, such a parallel development of antibodies to the basal ganglia does not occur in all. It is believed that some role in the development of small chorea is played by:

• hereditary predisposition;
• hormonal surges;
• presence of chronic infectious processes of the upper respiratory tract;
• untreated carious teeth;
• weak immunity;
• increased emotionality (tendency to excessive nervous system reaction);
• thinness, asthenic.

Since β-hemolytic streptococcus can cause the production of antibodies to other structures of the body (joints, heart, kidneys), becoming cause of rheumatic damage, then small chorea is usually considered as one of the variants of the active rheumatic process in the body in whole. At present, small chorea has become less common due to specific prevention of rheumatic processes (bicillin therapy).

Symptoms

Chorea may manifest as grimacing in the child and awkward movements.

Clinical manifestations appear, as a rule, several weeks after the transferred angina, or tonsillitis. Less often the disease manifests itself without preliminary signs of infections of the upper respiratory tract, which happens when β-hemolytic streptococcus settled in the body imperceptibly.

The duration of small chorea on average is about 3 months, sometimes prolonged for 1-2 years. In 1/3 of the people who have had the disease, after a puberty period and up to 25 years, relapses of small chorea are possible.

In its morphological nature, small chorea represents rheumatic encephalitis with damage to the basal ganglia of the brain.

The main manifestations of small trochee arechoreic hyperkinesis: involuntary movements. These are fast, irregular, randomly distributed, chaotic muscle contractions that arise in addition to the will of the person and, accordingly, can not be controlled. Choreic hyperkinesis can capture different parts of the body: hands, face, completely limbs, larynx and tongue, diaphragm, all torso. Usually, at first, hyperkinesis diseases are hardly noticeable (awkwardness of fingers, slight grimacing, which is perceived as a prank of a child), intensify with excitement. Gradually their prevalence increases, they become more pronounced in amplitude up to so-called "trochaic storm when paroxysmal uncontrolled movements occur in all body.

What kind of hyperkinesis can attract attention and alarm? Let's call them.

• Awkward movements in writing (drawing) - the child can not hold the pen or pencil (brush), sloppy writes letters (if it turned out exactly before), gets out of line, puts blots and blots in a larger amount than previously;
• uncontrolled display of the language and frequent grimaces (grimace) - many may consider this a sign However, if this is not the only manifestation of hyperkinesis, then it is worthwhile to think about another the nature of the process;
• restlessness, not the ability to sit still or hold the prescribed posture (during the lesson such children endlessly interfere with the teacher, when they are called to the board, the answer is accompanied by scratching, twitching themselves over different parts of the body, dancing and the like movements);
• shouting out different sounds or even words, which is associated with an involuntary contraction of the larynx muscles;
• blurred speech: associated with hyperkinesis of the tongue and larynx. That is, the speech of a child who did not previously have speech therapy defects suddenly becomes fuzzy, mumbling, inarticulate. In very severe cases, the choreic hyperkinesis of the language causes a complete lack of speech ("choreic" mutism).

If the main respiratory muscle (diaphragm) is involved in the process, then there is a "paradoxical breathing" (Cherney's symptom). This is when the inhalation of the abdominal wall is drawn in instead of bulging in the norm. It is difficult for such children to fix a sight, their eyes "run" all the time in different directions. For the hands the symptom of the "milkmaid's hand" is described - alternate movements of compression and relaxation of the fingers of the hand. With the growth of hyperkinesis, everyday everyday activities become very difficult: dressing, bathing, brushing teeth, eating and even walking. There is a Wilson saying that describes the child with a small chorea as accurately as possible: "A child with Sidengam's chorea will be punished three times before he is diagnosed correctly: once for restlessness, once for broken dishes and once for the fact that he "made faces" grandmother. " The involuntary movements disappear in a dream, but the period of retirement due to them is accompanied by certain difficulties.

• Decrease in muscle tone: usually corresponds to the severity and localization of hyperkinesis, that is, develops in those muscle groups in which hyperkinesis is observed. There are pseudo-paralytic forms of small chorea, when hyperkinesis is practically absent, and tone is lowered so much that muscle weakness develops, and movement becomes difficult to perform;
• psychoemotional disorders: they are often the most initial manifestations of small chorea, but the connection with a small chorea is usually established only after the appearance of hyperkinesis. Such children express emotional lability (instability), anxiety, they become capricious, restless, touchy and whiny. There is stubbornness, unmotivated disobedience, violation of concentration, forgetfulness. Children are difficult to fall asleep, restlessly sleep, often wake up, the duration of sleep decreases. Emotional outbreaks arise for any reason, which forces parents to turn to a psychologist. Occasionally, a small chorea manifests itself more pronounced mental disorders: psychomotor agitation, a violation of consciousness, the appearance of hallucinations and delusions. The following peculiarity of the course of small chorea was noted: in children with pronounced hyperkinesias, sharp mental disorders, in children with prevalence of muscle hypotension - lethargy, apathy, lack of interest in the surrounding world.

You should correctly evaluate the above changes. It does not mean at all that all children who suddenly behave badly, the teachers complain about, are sick with small chorea. These changes can be associated with completely different causes (problems with peers, hormonal changes and much more). To understand the situation will help a specialist.

There are several neurologic symptoms that are characteristic of small chorea, which the doctor will definitely check when examining:

• The phenomenon of Gordon: when checking the knee reflex, the shin for a few seconds seems to freeze in position extension, and then returns to the place (this is due to the tonic tension of the quadriceps muscle thighs). Also, the shin can perform several pendulum movements and then stop;
• "The language of the chameleon" ("Filatov's eyes and tongue"): the inability to keep the tongue sticking out of his mouth with closed eyes;
• "Trochaic brush with extended arms, a specific position of the hands arises, when they are slightly bent in the wrist joints, the fingers are thus unbent, and the large one is (brought) to the palm;
• a symptom of the "pronator if you ask slightly bent hands to lift over your head (like a semicircle, so that your hands are directly over your head), then your hands involuntarily turn outward;
• symptom of "flabby shoulders if a sick child is lifted by the armpits, then his head is deeply immersed in the shoulders, as if drowning in them.

In the majority of children with small chorea, vegetative disorders occur in varying degrees: bluish bruises and stop, marbling skin color, cooling of limbs, a tendency to lowered arterial pressure, irregularity pulse.

Since small chorea is part of an actively developing rheumatic process, signs characteristic of her, these children may have symptoms of heart disease, joints, kidney. In 1/3 of patients who underwent small chorea, subsequently because of the rheumatic process, heart disease is formed.

Duration of the disease is different. The tendency to a favorable course and relatively rapid recovery is noted in cases with rapid development of hyperkinesia and without a sharp decrease in muscle tone. The slower the symptoms are formed and the more pronounced the problems with the muscle tone, the longer the course of the disease.

Usually, small chorea ends in recovery. Relapses of the disease can be associated with repeated angina or exacerbation of the rheumatic process. After the transferred disease for a fairly long period, asthenia remains, and some psycho-emotional characteristics of the individual can remain for life (for example, impulsivity and anxiety).

For females who have undergone minor chorea, one should refrain from taking oral contraceptives, as they can provoke the appearance of hyperkinesis.

Diagnostics

To confirm the rheumatic process, the patient takes blood from the vein for analysis.

To confirm the diagnosis of small chorea, the role of an anamnesis of the disease with an indication of angina or tonsillitis, clinical symptoms and neurological examination data, as well as additional methods data research. The defeat of the heart, joints, kidneys (that is, other rheumatic manifestations) only prompt a diagnosis.

Laboratory methods confirm active rheumatic process in the body (markers of streptococcal infection - antistreptolysin - O, C-reactive protein, rheumatoid factor in the blood). There are situations when laboratory methods do not reveal rheumatic changes in the body, which significantly complicates the diagnosis.

Of the additional methods of investigation, electroencephalography is shown (reveals nonspecific changes in electrical activity, indirectly confirming disturbances in the brain), magnetic resonance imaging or computed tomography (also allow to detect nonspecific changes in the basal ganglia or in general the absence of such. The main purpose of using CT or MRI remains differential diagnosis with other brain diseases, for example, with viral encephalitis, Huntington's disease).

Treatment

Treatment of small chorea is complex and is directed, first of all, to the elimination of the rheumatic process in organism, that is, stopping the production of antibodies against the cells of one's own organism and combating streptococcus. Elimination of hyperkinesis plays an important role.

In an acute period, recommended bed rest, it is necessary to create conditions with minimal impact of stimuli (light, sounds). Food should be maximally vitaminized, with a small restriction of carbohydrates.

If small chorea is accompanied by pronounced changes in blood (increased ESR, high titres of antistreptolysin-0, an increase C-reactive protein, and so on) and the damage of other organs and systems, then such patients are shown antirheumatic therapy preparations. It can be non-steroidal anti-inflammatory drugs and glucocorticosteroids.

Among non-steroidal anti-inflammatory drugs use salicylates (Acetylsalicylic acid), Indomethacin, Diclofenac sodium. Of glucocorticosteroids are often used prednisolone.

Antibiotics penicillin series is usually not effective with a small chorea, since streptococcus by the time the onset of the disease in the body is no longer there.

To eliminate the active inflammatory process along with non-steroidal anti-inflammatory drugs or glucocorticosteroids are used antihistamines (Suprastin, Loratadin, Pipolphen) preparations. To reduce the permeability of blood vessels, Ascorutin is used. Multivitamin complexes are shown.

To eliminate hyperkinesia and pskhoemotsionalnyh disorders using neuroleptics (Aminazine, Ridazin, Haloperidol and others), tranquilizers (Clobazam, Phenazepam), sedatives (Phenobarbital, drugs valerian and others). Sometimes anticonvulsant drugs are effective: Valproate sodium and the like. Many of these drugs are potent, so they should only be prescribed by a doctor.

Separately, I would like to single out the work of children's psychologists. In most cases, medical intervention is not enough to cope with psychoemotional changes. Then psychologists come to the rescue. Their methods help very effectively combat behavior disorders, and also contribute to the social adaptation of children.

Postponed minor chorea necessarily requires the prevention of recurrence of the disease (as well as other manifestations of the rheumatic process). To this end, use bicillin-5 or benzathine benzylpenicillin. These drugs are prolonged forms of antibiotic penicillin series, to which β-hemolytic group A streptococcus is sensitive. The drugs are injected intramuscularly once in 3-4 weeks (for each of the drugs there is a scheme and dosage by age). The duration of application is determined individually by the attending physician and, on average, is 3-5 years.

Before the era of antibiotic use, angina often caused complications in the form of small chorea. The introduction of rational and timely antibiotic therapy and the use of bicillin prophylaxishas significantly reduced the number of new cases of small chorea, due to which the disease is less and less common now.

Thus, small chorea is one of the rheumatic lesions of the human body. Mostly children and adolescents are sick, and more often than girls. The first symptoms of the disease can be regarded as banal disobedience and pampering. The detailed picture of the disease consists of involuntary movements, psychoemotional disorders. Usually, on the background of treatment, small chorea has a favorable outcome in the form of complete recovery, although relapses are also possible.