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Systemic and Infectious Arthritis

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  • Systemic and Infectious Arthritis

    Systemic and Infectious Arthritis

    By: Arthur Huppert, MD
    Last Reviewed on: October 14, 2004
    The most well-known forms of arthritis are degenerative joint disease (osteoarthritis) or rheumatoid arthritis (see other article by same author). But there are many other forms of this common condition. Some, like rheumatoid arthritis, are a type of autoimmune disease. These different types of so called "systemic" arthritis are the result of immune system stimulation, which, in turn, results in clinically apparent inflammation of one or more sites including joint tissue. Systemic arthritis triggers the immune system and this result in inflammation of the body's tissues. Other forms of arthritis are infectious. These disorders result from infection of the fluid and tissues of a joint.

    Examples of Systemic Arthritises

    Systemic lupus erythematosus (SLE, lupus)
    Systemic lupus erythematosus, better known simply as "lupus", is an acute and chronic disease. People with lupus suffer from episodes of inflammation of their joints, tendons or other connective tissues and organs.

    Skin rashes and lesions are common symptoms of lupus. Lupus is considered a systemic disorder because it is usually accompanied by "constitutional" symptoms such as malaise, fever, anorexia, weight loss, and weakness. These symptoms may result from anemia, which often occurs with lupus. The most severe complications of lupus are those that threaten irreversible damage to internal organs including the brain, kidneys, lungs, heart, and less commonly but sometimes significantly portions of the GI tract. Despite the definite dangers of lupus, many people are able to keep the disease under control.

    The immune system of a person with lupus is overactive and produces abnormal antibodies that attack the body's own tissues. However, exactly what "triggers" this is not known. Clearly there are genetic, environmental, and hormonal factors that are involved. Diagnosis is often difficult, and is based on a combination of findings, including:

    a characteristic butterfly shaped red rash over the cheeks
    a skin rash in other sun exposed areas
    mouth and nose ulcers (often painless)
    arthritis in one or more joints
    kidney dysfunction
    nervous system problems (such as seizures, psychosis, impaired thought processes, and strokes)
    laboratory tests, including a positive test for antinuclear antibody (ANA)
    There are formal criteria for lupus, which are outlined by the American College of Rheumatology. These need to be reviewed when making scientific observations about patients with lupus, however clinicians may consider individual patients as having the disease even if they do not precisely fulfill the formal diagnostic criteria.
    Treatment depends on the severity of the disease. Regular medical care is vital, and drug treatment is tailored to each patient's circumstances. Mild symptoms, such as joint pain or fever, are often treated with acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs). For more severe symptoms, drugs called corticosteroids (prednisone and others) may be necessary. Unfortunately, long-term use of corticosteroids may result in serious complications, such as bone mineral loss, obesity, high blood pressure, diabetes, psychosis, and cataracts. For this reason, corticosteroid medications should not be used for prolonged periods of time. Other treatments which may slow the course of lupus include anti-malarials (hydroxychloroquine), and drugs that suppress the over-active immune system, such as azathioprine and cyclophosphamide.

    Psoriatic arthritis
    Psoriatic arthritis is an inflammatory arthritis that occurs in people who have psoriasis of the skin or nails. People with psoriasis suffer from an itchy, red and often "flaking" skin rash. In some people, psoriatic arthritis may result in rashes in only a few small areas of the scalp, trunk, or limbs. In more severe cases, patients may suffer from eye inflammation or tendinitis (inflammation at the bony sites of attachment of ligaments and tendons).

    An array of immune, genetic, and environmental factors have been implicated in psoriatic arthritis. Diagnosis relies on finding skin and nail changes. Bona fide psoriasis must be demonstrated before a diagnosis can be made with certainty. Treatment is identical to that used for rheumatoid arthritis. It starts with NSAIDs. Local corticosteroid injections may be helpful, but methotrexate may be needed for resistant cases. The antimalarial drug, hydroxychloroquine, may be effective, but it has been said to occasionally be associated with a flare of the psoriatic rash. Sulfasalazine, azathioprine, and cyclosporine may be used in severe and or refractory cases, but just as with rheumatoid arthritis patients must be monitored closely for side effects. As in most types of arthritis, proper exercise may be beneficial. Surgery may be required in certain circumstances.

    Anklyosing spondylitis (AS)
    Ankylosing spondylitis is one of several diseases that affect the joints of the spine. Pelvic arthritis and inflammation of the eyes, lungs, and heart valves may occur, typically in adolescents and young men. The feared outcome with AS is the development of a rigid immobile spine.

    Genetics play a key role in AS. The vast majority of people with AS have a gene named HLA-B27. Additionally, bowel or urinary tract infections may trigger episodes in susceptible persons. Diagnosis of AS is based on a combination of historical and examination features as well as laboratory tests, X-rays and bone-scan findings. No one laboratory test is specific for this disease.
    Early diagnosis, treatment with NSAIDs, and lifelong physical and rehabilitation therapy are all helpful in slowing progressive disability. Some patients require "disease modifying agents" (DMARDs), which are rapidly-acting agents which may safely halt the progression of arthritis. , the most used are sulfasalazine and methotrexate. Lifelong physical and rehabilitation therapy are key to maintaining posture and flexibility.

    Gout and pseudogout
    Gout, a problem described since biblical times, is still the most common cause of acute inflammatory arthritis in a single joint. It is still a leading cause of disabling chronic arthritis.

    Gout is called a "crystal induced" arthritic disorder. In afflicted individuals, there are usually above-normal levels of a blood chemical called uric acid. The sodium crystal of uric acid deposits around joints, within joints, under the skin and occasionally in other tissues. The Joint most commonly effected is the great toe, it is usually, hot, red, and exquisitely painful. Patients with gout are either over-producers or, more commonly, under-excreters of uric acid.

    The following things may contribute to elevated uric acid levels in the blood:

    Alcoholic beverages
    Foods high in uric acid-forming nutrients (including "organ" meats such as liver and sweetbreads, shellfish, sardines, dried peas and beans)
    Water pills and other medications
    Unfortunately, blood uric acid levels alone cannot determine if a person has gout. Many millions of people have elevated blood uric acid levels and never develop gout. Many other patients may have gout, but at the time of their attack, so much uric acid is deposited that the blood level at the time of an attack may actually be normal or even low. A definitive diagnosis can be made only by finding uric acid crystals in joint fluid during an acute attack.

    Acute gout may be treated using a medicine known for centuries for this purpose, colchicine; but due to it's side effect profile, NSAIDS such as Indomethacin (Indocin) may be a better choice, they provide relief of acute gout without causing GI disturbances ., it may also be treated with limited courses of corticosteroid medication. Despite their similarity to other NSAIDs, aspirin and aspirin-containing products are not effective for acute gout. Preventing gout flares relies on giving daily doses of colchicine while a program of uric acid lowering is undertaken.
    The similar disease called "Pseudogout" occurs when a specific type of calcium crystal (calcium pyrophosphate dihydrate) is deposited into joint cartilage. This is often visible on x-rays as whitish material in the area of joint cartilage. Like gout, pseudogout is diagnosed by finding crystals in joint fluid.However the main diffrence between the two conditions is that the shape of the crystals differ under the microscope and the components of the crystals are different aswell. Gout, involves uric-acid crystals where as pseudogout involves calcium-pyrophosphate crystals.Treatment generally consists of NSAID use; steroid injections are helpful in some. If an underlying disorder (such as hypothyroidism) is linked to the crystal deposits, then treatment of that disorder may help decrease the frequency of pseudogout attacks. Daily use of colchicine or an NSAID may also accomplish this.

    Examples of Infectious Arthritis

    Bacterial joint infections
    Bacterial joint infections are the only true arthritic emergencies. Bacteria can reach the joint through the bloodstream or through surgery, injection, or injury to the joint. A hot, red, intensely painful and swollen joint usually results. If unrecognized and not properly treated in 1-2 days, irreversible joint damage may occur. Prompt diagnosis by arthrocentesis (removal of joint fluid using a needle) and prompt antibiotic treatment are essential to preserving joint function.
    A related problem is an "immune complex" arthritis linked to an infection at another site. The body's efforts to fight the infection lead to the development of an inflammatory arthritis that does not include the offending bacteria in the involved joints. The most common example of this is the arthritis produced by gonorrheal infection. This is the most common type of acute arthritis in sexually active people. Another common offending microbe is chlamydia.

    Lyme disease
    Lyme Disease is a rare but widely feared cause of arthritis, Lyme disease is caused by a tick-borne organism, and can usually be diagnosed clinically and treated effectively. For more information on Lyme disease, see the current Healthology article on this topic.

    HIV-associated arthritis
    Musculoskeletal symptoms may affect up to 70% of patients with HIV. However, it is uncertain if HIV itself produces an actual inflammatory arthritis. Certainly, HIV patients are at higher risk for developing septic arthritis and arthritis related to venereally-spread infections such as those described above. In addition to painful joints, other syndromes, such as Reiter's syndrome (an AS-like disorder; see above) or psoriatic arthritis can also occur. Diagnosis is based on a positive HIV test accompanied by painful joints or other rheumatic illness. Most patients respond to NSAIDs and physical therapy. Some may be given immunosuppressive drugs, although their efficacy and safety has not been extensively studied in HIV-positive patients.

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