Reactive arthritis
Refers to a form of peripheral non purulent arthritis, often accompanied by one or more extra-articular manifestations, that appear shortly after certain infections of the genitourinary tract or GIT
“The classical triad of Reiter’s disease constitutes non-specific urethritis, conjunctivitis and reactive arthritis”.
Incomplete form with just one (reactive arthritis only) or two of these features is more common.
Reactive arthritis can follow or triggered by:
· Bacterial dysentery. (Salmonella, Shigella, Campylobacter, Yersenia).
· Sexually acquired venereal infection with Chlamydia.
Reactive arthritis is considered a disease of young men, with ratio of male/female 15:1. HLA B27 is +ve in Reiter’s disease in up to 90% and when there is sacroiliitis, uveitis or balanitis. Peak incidence between age 16-35 years. Reactive arthritis become most common in people with AIDS.
Clinical features: Onset usually acute, with peripheral arthritis, which is usually, additive, oligoarticular, mainly joints of lower limbs, 1-3 weeks following dysentery or sexually acquired genitor-urinary tract infection. Dactylitis “sussage” digit can occur. Conjunctivitis and/or non specific urethritis occur in about 50%, or may be minimal or absent. Some times there is no history of dysentery.
In such cases, oligoarthritis mainly lower limbs, assymetrical, enthesitis may suggest of seronegative spondarthritis.
Extra-articular features:
· In addition to conjunctivitis, urethritis.
· Circinate balanitis and keratoderma blennorrhagica are considered a characteristic skin lesion and can give a clue for diagnosis in atypical cases.
· Nail dystrophy.
· Buccal erosion, painless, transient “only a few days”.
· Uveitis: Especially in recurrent type.
· Cardiac: Aortic incompetence, conductive defect, pleuro-pericarditis.
· Peripheral neuritis, CNS fits, meningo-encephalitis.
The first attacks usually self limited lasting several weeks.
While up to 60% of patient got recurrent attacks or run to chronic arthritis and it is not necessary to preceded by infection.
Some of them 15-20% develop progressive spondylitis with back pain and stiffness due to sacroiliitis.
Investigation:
ESR,CRP are raised. Normochromic normocytic anaemia. RF and ANF are negative.
· Synovial fluid, inflammatory containing gaint macrophage “Reiter’s cells”.
· Urethritis could determined by examinant of void specimen “two glass test”.
· Stool culture, apart from salmonella infection, usually negative.
· Previous bacillary dysentery could be tested by serum agglutinin test.
Radiographic changes:
· No changes in 1st acute attack apart of soft tissue swelling.
· In recurrent or chronic form: Periarticular osteopenia, j. space narrowing, marginal proliferative erosion.
· Periostitis of metatarsal, phalanges.
· Fluffy calcaneal spur.
· Sacroiliac involvement usually asymmetrical, unilateral.
Coarse asymmetrical, non marginal syndesmophyte.
Management:
· In 1st acute attack symptomatic treat. by NSAID.
· Joint aspiration, with intra art. corticost inj. “after exclusion of septic arthritis”.
· Intra-lesional corticosteroid in persistent enthesitis.
· In persistent cases sulfasalazine may beneficial and in severe progressive cases, and these with keratodermablenn may required DMARD with azathioprine or methotrixate.
“If the condition is not responed to these agents, TNF-alpha antagonist may be extremely effective”.
· Short course of tetracycline for treat. of chlamyd. Urethritis, this may reduce frequency of arthritis.
· Uveitis must be treated urgently by ophthalmologist.
Recurrent erosive arthritis, spondylitis, uveitis carry poor prognosis.
Psoriatic Arthritis
This term describes a variety of different patterns of arthritis and enthesitis seen in people with psoriasis or with family history of psoriasis.
5-8% of individuals with psoriasis develops psoriatic arthritis. It occurs mainly between age 25-40 years old. Sometimes the arthritis predate psoriatic lesion, nail psoriasis have strong association with arthritis than with skin lesion.
Clinical Features:
Five main arthritis patterns can be presented as psoriatic arthritis:
1. Asymmetrical inflammatory oligoarthritis: affecting lower and upper limbs.
Association of synovitis with periarticular tenosynovitis, enthesitis gives a characteristic appearance when affecting the digit “Sausage digit” or datylitis.
2. Symmetrical polyarthritis: especially in women, is similar to RA but absence of Rh. Nodules and extra-articular features of RA, persistent absence of RF, characteristic radiological features and typical DIP joint involvement, and may associated with spondylitis as well, in addition to presence of Ps. Skin and/or nail lesion, “all of these points are important to differentiate psoriatic arthritis from RA”.
3. Predominantly DIP joint: it is typical form of ps. Arthritis usually in men, mainly associated with nail psoriasis.
4. Psoriatic Spondylitis, either alone or associated with peripheral arthritis.
5. Arthritis Mutilans: erosive form, affecting mainly fingers and toes, causes severe bone and cartilage loss with bone shortening. The overlying skin invaginated, telescoped (so traction can pull the digit back to its original length).
Extra-articular Features:
· Psoriatic skin lesion.
· Psoriatic nail lesion.
· Eye: conjunctivitis, Uveitis mainly in patient with HLA-B27, especially with sacroiliitis and spondylitis.
Investigation:
ESR and CRP may be raised, especially in polyarticular.
· RF and ANF are generally absent.
· X-ray findings may be normal, or in persistent synovitis may show marginal proliferative erosions , sometimes give an appearance of “pencil in cup”, also the bone density is maintained and increased in bone sclerosis giving the appearance of “ivory phalanx”.
Radiological changes in spondylitis and sacroiliitis are mostly similar to that of axial involvement of reactive arthritis.
Management:
1. Symptomatic, simple analgesia, NSAIDs.
2. Intralesional or intra-articular injection of corticosteroid.
3. Prolonged resting the joint in splint should be avoided because this will increase the tendency of fibrous or bony ankylosis of the joint.
4. Similar advices and physiotherapy and exercise, in axial involvement as in AS.
5. For persistent progressive synovitis, sulfasalazine, methotrixate, azathioprine may be needed which have marginal, if not, affect on axial involvement. Methotrixate or Azathioprine also help in treatment of skin psoriasis.
6. Early studies suggest that anti TNF-? agent are highly effective for severe skin and joint disease.
7. Anti-malarial should be avoided because it can cause exfoliative reaction.
8. Retinoid Acitretin is effective in treatment of psoriasis as well as arthritis but must be avoided in young women because of its teratogenicity.
9. Photochemotherapy with methoxypsoraline and long wave UV “PUVA” which is beneficial with skin lesion and may be also beneficial with simultaneous exacerbation of arthritis.
Arthritis associated with Inflammatory Bowel Disease
Two patterns of arthritis are associated with ulcerative colitis and Crohn’s disease:
1. Enteropathic peripheral arthritis: 12% in ulcerative colitis and 20% in Crohn’s disease. Lower large joints are commonly affected, but the wrist and small joints of toe and finger can be affected also.
The arthritis follow the underlying bowel disease activity, so it usually appears with the exacerbation of bowel disease, also it cease after colectomy of U.C, “but arthritis may persist in controlled Crohn’s disease “.
Extra-articular features: aphthous oral lesion, iritis and erythema nodosum.
2. Axial(Sacroiliitis 16% and AS 6%) : especially in HLA-B27 patients, here it is independent of bowel disease activity.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .