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About The Author Dr Manoj R.

kandoi is the founder president of Institute of Arthritis Care & Prevention an NGO involved in the field of patient education regarding arthritis. Besides providing literature to patient & conducting symposiums, the institute is also engaged in creating patients Self Help Group at every district level. The institute also conducts a certificate course for healthcare professionals & provide fellowship to experts in the field of arthritis. The author has many publications to his credit in various journals. He has also written a book The Basics Of Arthritis for healthcare professionals. The author can be contacted at: Dr manoj R. kandoi C-202/203 Navare Arcade Shiv Mandir Road, Opposite Dena Bank Shiv mandir Road, Opposite Dena bank Shivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501 State: Maharashtra Ph: (0251)2602404 Country: India Membership Application forms of the IACR for patients & healthcare professionals can be obtained from. Institute of Arthritis Care & Prevention C/o Ashirwad Hospital Almas mension, SVP Road, New Colony, Ambarnath(W) Pin:421501 Dist: Thane State: Maharashtra Country: India Ph: (0251) 2681457 Fax: (0251)2680020 Mobile ;9822031683 Email: drkandoi@yahoo.co.in Preface: Studies have shown that people who are well informed & participate actively in their own care experience less pain & make fewer visits to the doctor than do other people with arthritis. Unfortunately in India & many third world countries we do not have patient education & arthritis self management programs as well as support groups. This is an attempt to give a brief account of various arthritis, their prevention & self management methods which can serve as useful guide to the patients of arthritis. It would be gratifying if the sufferers of the disease knew most of what is given in the book. Acknowledgement\ I am thankful to Dr (Mrs) Sangita Kandoi for her immense help in proofreading & for her invaluable suggestions. The help rendered by Nisha Jaiswal is probably unrivalled. Thanks also to vidya, praveen, rizwana and parvati for their continous support throughout the making of the book. The author is grateful to his family for the constant inspiration they offered. The author alone is responsible for the shortcoming in this piece of work. He welcomes suggestions for improvement from the readers.

Infectious Arthritis:
Septic Arthritis: This is an arthritis caused by pyogenic organisms. It may be acute, subacute or chronic depending upon duration. Aetio-Pathogenesis: Etiological Agents: These include in decreasing order of frequency Staphylococcus aureus Streptococci Staphylococcus epidermidis Pheumococci Pseudomonos aeruginosa Haemophilus influenzae (commonest cause of arthritis in children below 2 years of age) Polymicrobial infection. Predisposing conditions: -Underlying chronic joint disease -Trauma -Joint involvement in RA -Diabetes mellitus -Steroid administration -Renal failure

-Malignancy -Immunosuppresive drug therapy -Parenteral drug abuse -Recent joint infection -Injection or Aspiration -Vascular insufficiency

Commonest joint involved: In decreasing order of frequency these are: I) Knee II) Hip III) Elbow IV) Shoulder V) Wrist VI) Ankle Methods of spread: The organisms reach the joint by one of the following routes: a) Haematogenous: This is the commonest route. There may be a primary focus of infection such as Septicemia, Skin infection, URTI etc. b) Secondary to Osteomyelitis: In joints of Hip, Shoulder etc. with intraarticular metaphysis spread to joints may occur from osteomyelitis. c) Penetrating wounds : e.g. Superficial joint injuries like knee joint. d) Latrogenic: This includes I. Intraarticular steroid injections II. Femoral artery punctures for blood collection Pathology Depending upon the evidence of organisms and individual body resistance, three types of exudation of fluid in the joint may occur: The serous type: Join is distended with clear serous fluid and is associated with mild inflammatory hyperaemia of vessels of synovial membrane and capsule

Prognosis

Complete recovery

Recovery followed by recurrence

Seropurulent arthritis

Purulent arthritis

Serofibrinous Arthritis: Here the synovial membrane is hyperaemic and inflamed with serofibrinous exudate covering the joint aspect. The cavity is filled with cloudy fluid containing a large number of polymorphs and a few large mononuclear cells. Since there is associated periarticular inflammation adhesions may occur. In early stages organisms may be demonstrated. Purulent Arthritis: The joint cavity is filled with pus containing large numbers of polymorphs, bacteria, RBCs and fibrin. The capsule and synovial membrane are infilterated with leucocytes and engorged and there may be small areas of focal necrosis or fatty degeneration. Pathology Fibrous or bony ankylosis Pannus with cartilage destruction Increased blood flow Arthritic advanced destruction Pannus with bony destruction Fluid accumulation and synovial Edema Radiographic Corelation Bony ankylosis Joint space loss Osteopenia Joint deformity Erosions Periarticular soft tissues swelling

Clinical Feature: Symptoms: 1. Continuous severe throbbing pain disturbing sleep 2. Swelling and redness of joint 3. Inability to use the joint 4. Fever is present in 50% of cases 5. Patient may present with pseudoparalysis 6. In subacute form, limp may be the presenting complaint.

NORMAL FIBROUS BONY JOINT ANKYLOSIS ANKYLOSIS

Signs: 1. Child is generally severely toxic with a high temperature and tachycardia 2. Joint is swollen and held in the position of ease

3. Palpation: local warmth, effusion and tenderness can be elicited 4. ROM: severely restricted and painful. Septic arthritis in animal bite: May occur due to bite by dogs, cats and rodents. Commonest organisms are pasturella multocida, staphylococcus aureus and streptococcus sp. etc. Treatment of p. multocida infection should include penicillin G. Polyarticular septic arthritis: Uncommon with an incidence of around 10%. Usually seen in immunosuppressed, immunodeficient, immunocompromised patients, rheumatoid arthritis, multiple arthroplasties. The mortality rate is approximately 25%. Investigations: A. Radiological examination: Early stage: Soft tissue shadows of joint swelling can be seen. Late stage: Joint space is narrowed with irregularity of joint margins. Ocassionally there may be a subluxation or dislocation of the joint. B. Haematological investigation: Neurophilic leucocytosis and raised ESR can be seen HIV if polyarticular or adult patient Blood culture may be positive in some cases. C. Joint aspiration: Synovial fluid examination Points Normal Non-Inflammatory Inflammatory Septic

Gross examination Volume (Ml) Often < 3.5ml Viscosity High Colour Colourless Examination in Lab Clarity Transparent

Often> 3.5ml High Straw Yellow Transparent

Often> 3.5ml Low Yellow Translucent

> 3.5ml Variable Variable Opaque

Examination in Lab WBC count < 200 200-2000 2000- 7500 PMN < 25% < 25% >50% Leucocytes Culture Mucin clot Firm Firm Friable Crystal examination may be done in suspected pseudogout.< 25 mg% of Glucose Equal to Nearly equal Level blood glucose to blood glucose blood glucose

> 10000 > 75% + Friable > 25 mg% of blood glucose

Role of specialized radiographic studies in septic arthritis: 1. Bone scan: a. Technetium bone scan: is often positive in 1-2 days but lacks specificity. b. Gallium scan: It is more specific but lacks sensitivity, gallium scan is more useful in children with growth plate abnormalities. c. WBC lebelled indium scan: It is more specific as it relies on migration of WBC to the site of infection. It is the preferred modality in joint replacement surgeries. 2. CT scan: It may be useful in S1 joint or sternoclavicular joint infection. 3. MRI: It provides early detection of soft tissue changes such as edema and effusion. It also demonstrates osteomyelitis. Acute monoarticular Chronic monoarticular Differential Diagnosis of Arthritis Syndromes: Arthritis arthritis Staphylococcus aureus Streptococcus pneumoniae hemolytic streptococci Gram-negative bacillae Neisserra gonorrhoea Fracture Haemarthrosis Osteoarthritis Monoarticular RA Crystal induced arthritis Ischaemic necrosis Mycobacterium tuberculosis Atypical mycobacteria Lyme disease Treponema pallidum Candida species Nocardia species Brucella species Legg calve perthes disease Osteoarthritis Polyarticular arthritis Neisseria meningitis Neisseria gonorrhoea Nongonococcal bacterial arthritis Bacterial endocarditis Candida species Poncet's disease Viral lesions Reactive arthritis Serum sickness Acute rheumatic fever Inflammatory bowel disease SLE RA/Still's disease Other vasculitides sarcoidosis

Organisms commonly found in different age groups of childhood septic arthritis: Neonates: - Staphylococcus Aureus (Hospital acquired) - Streptococci - Gram-negative bacilli Age < 2 year - Hemophilus influenzae - Staphylococcus aureus Age 2-15 years - Staphylocossus aureus - Streptococcus pyogenes

Differentiating features between gonococcal and nongonococcal septic arthritis: Gonococcal Personality of Pattern Tenosynovitis Skin Lesions Joint culture Blood culture Prognosis Young, healthy adults Migratory polyarthlgias/ arthritis ++ ++ Rarely positive Rarely positive good in > 95% Nongonococcal Infants, elderly, immuno-compromised. single joint Rare Rare +++ ++ (40-50%) Poor in half of the patients

Pseudoseptic arthritis: This term is used when synovial fluid WBC count is more than > 100,000 cells/mm3, with cultures and staining negative, Commonest type is poorly controlled rheumatoid arthritis which responds to increased carticosteroids dosage (not to antibiotics). Other DID include crystal induced arthrides and seronegative spondyloarthropathies, Diagnostic clues for septic arthritis coexisting with hemarthrosis: Failure of joint to resolve with factor replacement Raised WBC count HIV infection and other predisposing factors point towards septic arthritis Previous joint aspiration, surgery Underlying joint damage (chronic arthropathy).

Treatment protocol: Septic arthritis

Antibiotics based on -Age -Source of infection -Clinical presentation -Gram staining -Culture sensitivity

Aspiration and intra articular antibiotics (multiple aspirations several times a day)

Supporting therapy Immobilization Passive ROM after 48 hours Active ROM exercises once pain resolves Analgesic

Failure Surgical drainage (In indicated cases)

Absolute indications for drainage in a septic joint: 1. Infected hip joints and probably shoulder joints 2. Prosthetic joints. 3. Inability to remove purulent fluid by needle drainage because fluid is too thick or laculated. 4. Vertebral osteomyelitis with cord compression. 5. Anatomically difficult to drain joints e.g. sternoclavicular joint. 6. Arthritis associated with foreign body. 7. Delayed onset of therapy (more than 7 days) or failure to respond to therapy. 8. Associated osteomyelitis requiring surgical drainage. Initial antibiotic therapy based on gram staining report: Gram stain findings Gram positive cocci Gram negative cocci Gram negative bacilli Septic picture but No organism seen. Antibiotic of choice Nafcillin Ceftriaxone or cefotaxime Gentamicin Ampicillin plus Gentamicin Alternatives Vancomycin Ciprofloxacin Ceftazidime Vancomycin plus Ceftizoxime

Antibiotic treatment following culture report: Organism Staphylococcus aureus Methicillin resistant S. aureus Streptococci Enterococcus Enterobacteriaceae Haemophilus Influenza Antibiotic of choice Nafcillin vancomycin Penicillin Ampicillin plus Gentamicin Third generation Cephalosporine Ampicillin Alternatives Vancomycin

Pseudomonus

Aminoglycoside

Cefazoline Vancomycin Vancomycin Plus aminoglycoside Aminoglycoside ciprofloxacine Third generation cephalosporin Chloramphenicol Cefuroxime Ceftazidime

Role of serial joint aspiration in septic arthritis: Principle: 1. Mechanical debridement by saline lavage 2. To decrease intraarticuJar pressure

3. To reduce leukocyte enzyme activity 4. To instill antibiotics in the joint if required 5. To monitor response to medication Method: Preferable once daily as reaccumulation of fluid is very prompt Progression of disease and response to therapy can be monitored by serial synovial fluid WBC count which should reduce by atleast 50% by one wk. of therapy. Arthritis of tuberculosis: Tuberculous arthritis accounts for about 1 % of all cases of tuberculosis and for 10% of extrapulmonary cases. Types: 2 major groups

Monoarticular tuberculous arthritis

Atypical group

Poncet's disease

Polyarthalgias of Akt drugs

Atypical mycobacterial arthritis

Unusual forms of arthritis in tuberculosis: Poncets disease: It is a reactive symmetrical form of polyarthritis that affects persons with visceral or disseminated tuberculosis. No organisms can be seen in the joints and symptoms tend to resolve with AKT drugs. Polyarthralgias of AKT therapy: Polyarthlgias are known to occur with pyrazinamide therapy and tend to regress with the withdrawal of drug. These are less common with other AKT drugs. Atypical mycobacterial arthritis: Atypical mycobacteria found in water and soil may cause arthritis of digits, wrists and knees by direct inoculation during farming, gardening etc. Commonest etiological agents include M. marinum, M. avium intracellular, M. terrae etc. Haematogenous spread may occur in imunocompromised patients leading to involvement of joints by organisms such as M.kansasii, M. haemophilum etc. Diagnosis should be confirmed by biopsy and culture and treatment is based on sensitivity patterns. SYPHILIS OF JOINT: Types of syphilitic of joints: A) Joint lesions in congental syphilis: 1. Parots syphilic osteochondritis 2. Clutton's joint: symmetrical hydrarthrosis B) Joint lesions in acquired (early) syphillis: 1. Arthralgia 2. Hydrarthrosis SYPHILITIC OSTEOPERIOSTITIS

3. Plastic arthritis (very uncommon) C) Joint lesions in acquired (late) syphilis: Gummatous arthritis: 1. The synovial form. 2. The oseous form 3. Charcot's anthropathy. A. Joint lesions in congenital syphilis: Parots syphilitic osteochondritis: It is a juxtaepiphyseal inflammation involving growing ends of bone of more commonly upper limb. Occuring during the first few months of life the child presents with large and tender epiphyses and sometimes pseudoparalysis. Features similar to scuvry may be seen including seperation of epiphysis. Diagnosis is by strongly positive treponema immobilization reaction. Early and prompt treatment with antisyphilic therapy may produce complete resolution unless damage to growth cartilage has occured. Cluttons joint: Symmetrical hydrarthrosis: Children (between 8 to 16 years of age) may present with painless symmetrical hydrarthrosis of knee with ability to walk unaffected. Associated features such as eye changes & other stigmata congenital syphilis are present. It is a gradually progressive disease (with spontaneous recovery in few cases) responding slowly to treatment. B. Joint lesion in early acquired syphilis Arthralgia: Mild nocturnal arthlgia may occur in secondary stage before or after appearance of early rashes. Usually affecting one or more of larger joints there is good prognosis with respect of joint deformity or motion. Hydrarthrosis: Changes similar to clutton joint may be seen in later stages of secondary syphilis with abundant fluid & synovial membrane edema. Pain is moderate & gentle passive movements are painless. C. Joint lesions in acquired (late) syphilis (Tertiary syphililic arthritis): The gummatous arthritis occurs usually in insidous (rarely acute) form consisting of following variants: 1. Synovial form: The outer layer of capsule of joint becomes thickened with perivascular infiltration with abundant synovial effusion. Pain may or may not be present. Joints involved: Knee, ankle, elbow, shoulder & rarely IP joints. 2. Osseous form: Only knee joint in involved with feature of osteoarthritis & chronic synovitis present. Spine sometimes if affected resembles that of tuberculous spine. Diagnosis is by serological tests & should be preferably done in all cases of OA knee not responding to routine medication. . 3. Charcots joints: It usually occurs in acquired syphilis but may sometimes be seen in congenital syphilis. The features are similar to charcot's joint, diagnosis is mainly base on presence of locomotor ataxia (tabes dorsalis), associated neurotrophic features such as perferating ulcers may be seen.

Signs suggestive of syphilis are: 1. Joint disease without heat, pain or tenderness 2. Bilateral painless hydrops of knees 3. Pupillary changes or absent knee jerks 4. Rheumatic fever type picture not responding to salicylates 5. Positive VDRL test of Blood Diagnostic tests for syphilis: A. Nonspecific tests: Venereal Diseases Research laboratory (VDRL) test is widely used flocculation test as it is easy to perform False positive: Viral pneumonia, malaria, leptospirosis & following inoculation, certain chronic disorders such as Tuberculosis, collagen, vascular disorder. B. Specific tests: a) Fluorescent Treponemal Antibody (FTA) test b) Treponemal Hemagglutination test (TPHA) c) Treponemal immobilization test (TPI) Treatment: a. Benzathin penicillin > 6-9 mega units in divided doses b. P.A.M: 2-4 mega units stat then every 3rd day for 6-10 injections c. Erythromycin 500 mg qds for one month d. Tetracyclin 3 to 4 gm over 10-15 days. GONOCOCCAL ARTHRITIS It is an uncommon sequalae of gonorrhoea occurying in less than 1% of case. Usually it develops during the third week of infection but may also occur some months after the infection. Pathology: It is more common in young adult males. Mono articular involvement of large joints occur in 40% of cases, including knee, ankle, shoulder, wrist etc. Small joints of hands & feet may also be involved in polyarticular case.

Clinical Types: Acute cases: there are 4 types of presentation: 1. Arthralgia: One or more joints are painful with no detectable physical signs. 2. An acute infection with effusion in one or more of the larger joint. 3. Acute infection with effusion & erosion of cartilage. 4. Acute infection with purulent exudate with severe unceration & erosion of all cartilaginous surfaces. Subacute & chronic case: 2 types: 1. Synovial type: Features suggestive of chronic synovitis mainly involving knee joint

2. Mixed type: Polyarticular involving smaller joints, associated with fibroblastic & serofibrinous exudate. Proliferative fibroblastic changes in the periarticular region is noticeable.

Patterns of arthritis with gonorrhea Migratory polyarthralgia 70% Tenosynovitis 67% Purulent arthritis 42% Monoarthritis 32% Polyarthritis 10% .

Clinical Picture: Acute cases have presentation similar to acute pyogenic arthritis with associated pyrexia & chills or rigors. Chronic cases resemble that of chronic synovitis with associated inflammatory changes in tendons, tendonsheaths, bursae & the periosteum. More commonly tendons of wrist & ankle & retrocalcaneal bursae are involved. Most important diagnostic due for Gonorrhoea is tenosynovitis. Laboratory diagnosis: 1. Examination of urethral Dischange: a. Gram staining b. Cultural tests c. Sugar formentation d. Oxidase reaction Differential diagnosis: I. Acute Rheumatism II. Arthritis following pneumonia, dysentary, cerebrospinal infection, typhoid or scarlet fevers, acute tonsillitis & tuberculosis III. Reiter's Syndrome Differentiating features between Reiter's syndrome & gonococcal arthritis Features Reiters Gonococcal Migratory polyarthlgia + Enthesitis + Spondylitis + Uveitis + Differential diagnosis between acute rheumatism and gonococcal arthritis: Oral ulcers + Skin lesions Keratoderma, balanitis Pustules Culture Negative May be positive HLA B27 positive > 80% < 10% Arthritis Lower limbs Knees, Upper limb Response to penicillin +

Acute Rheumatism - No evidence of genitourinary disease - Marked pyrexia & constitutional symptoms

Gonococcal Arthritis -Mild to moderate signs and symptoms may be present -Except in purulent case, very moderate pyrexia and constitutional symptoms -Pain less intense

- Pain intense & increased by the slightest touch - Sweating very profuse with -Very little sweating except in acid odour purulent cases - Fleeting joint pain +ve -Absent - Tendon sheaths & periarticular -Very frequent tissues rarely involved IMP-TIPS: - Cardiac involvement with an -Very rare Gonorrhoea must always be excluded if there is an acute, subacute or chronic affection of active focus of tonsilitis a joint which is to salicylates - Responds well painful, persistent & associated periarticular changes. -Little effect on pain & swelling Prognosis: Prognosis

Acute

Subacute or chronic

Arthraligia recovery

Exudation

Exudation With mild erosion

Severe erosion with suppuration

Recurrences

Complete

Adequate treatment Fibrous ankylosis Good prognosis Treatment: a. Rest b. Physiotherapy c. Penicillin compounds d. Aspiration and injection of antibiotics in purulent type e. Rarely surgical debridement f. Patient should also be tested for syphilis and HIV Antimicrobial therapy:

1. Cefriaxone 1-2 gm im or IV per day till symptoms resolve followed by outpatient therapy for 7 days with cefuroxime (500 mg 1-1) or amoxicillin calvulanate (500 mg 1-1-1) 2. Alternatively ciprofloxacin or norfloxacin may be used 3. Doxycyclin (100 mg 1-1 x (7) days) must also be given for coexistent chlamydial infection. Parasitic arthritis: Guinea warm (Dracunculus medinesis): May sometimes cause destructive lesions in the lower extremities as migrating gravid female worms invade joint or may cause ulcer in the surrounding soft tissue which may become secondarily infected. Hydatid cyst (1 to 2% bone involvement caused by E granulosus): May sometime burst into joint from neighbouring bone involvement eg. Hip joint. Lymphatic filariasis: It may be associated with monoarticular arthritis in children and responds well to diethylcarbamizine treatment. Reactive arthritis: It may occur due to Hookwarm Strongyloides Cryptosporidium Giardia infestations Fungal arthritis Etiological agents: Candida species Aspergillus species Cryptococcus neoformans Blastomyces dermatitidis etc Methods of spread: Direct inoculation Disseminated hematogenous infection in immunocompromised patient. Differentiating Features: The synovial fluid usually contains 10,000 to 40,000 cells with about 70% neutrophilis. Stained specimen and cultures of synovial tissue should be done in cases of disseminated fungal infections to confirm diagnosis. Treatment: Drainage and lavage of joint Intra-articular installation of amphotericin - B Systemic therapy with antifungals (including amphotericin -B, flucanazole or itracanozole etc). Spirochaetal arthritis (Lyme disease): The disease caused by borrelia burgderferi may lead to arthritis in 70% of cases if left untreated.

Clinical presentation: 1. Monoarthritis or oligoarthritis : Commonest, involving knee and/or other large joints. The symptoms may wax or wane over period of months or years and spontaneous remission may also occur without treatment. 2. Waxing and waning arthralgias 3. Chronic inflammatory synovitis with erosion or destruction of the joint Treatment: Oral doxycyclin Oral amoxycillin plus probenecid, over a period of 3 to 4 weeks Parenteral cefriaxone Viral arthritis: Common viral disorder that may be accompanied by arthritis Hepatitis B Mumps Parvovirus B19 (fifth disease) Chickenpox Rubella Human immunodificiency virus (HIV) Arthritis of brucellosis: Clinical types include: 1. Arthralgias and ostealgias 2. Fibrositis 3. Hydrarthrosis 4. Acute arthritis 5. Chronic arthritis 6. Osteitis, osteomyelitis and osteoperiostitis Commonest presentation: Spondylitis resembling pott's spine is one of the commonest presentation and brucellosis should be kept in mind in those cases of pott's spine not responding to AKT. Etiopathogenesis: Arthritis of brucellosis

Acute type Invasion by microbes inside the joint Inflammatory arthritis Associated conditions: Psychic asthenia

Chronic type Usually due to an allergic inflammatory response of mesenchymal tissue

Autonomous nervous system disturbances Fever (mayor may not be present) Changes of the eight cranial nerve

Laboratory findings: Salient features are: 1. Positive intradermal reaction of bund 2. Anaemia with anisocytosis, leucopenia with neutropenia and lymphocytosis 3. Normal ESR 4. Positive agglutination titre to brucella of (SAT) > 80 5. Estimation of serum anti-brucella immunoglobulin (lgA, IgG, IgM) by radioimmunoessay or ELISA Treatment: Streptomycin 19m intramuscular daily and Chlortetracyclin 2gm daily x 3 wks. Steroids may be used to reduce inflammation Some authors reserve use of streptomycin (1 gm/day 1M) or gentamicin (6 mg/day IV /1M) for first 3 weeks of a 6 week course of chlortetracyclin in case of failure of response or relapse. Lymphogranuloma venereum Chronic process with acute flare-up & a tendency to relapse Usually polyarticular involvement including knees, ankles & wrists Swelling usually confined to periarticular tissues Associated conditions: a. Inguinal bubo b. Multiple discharging sinus in the inguinal region c. Rectal strictures in females d. Elephentiasis of genitalia Diagnosis: 1. Smear to identify HP inclusion bodies 2. PREI intradermal test Treatment: 1. Sulfonamides 1 gm qds for 7-14 days 2. Tetracyclin 250-500 mg 4 times daily for 15 days

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