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Chronic Infectious Arthritis

Arthritis is the condition in which the joints are inflamed. One of the main symptoms is the loss of mobility and eventual deformation of the affected area. It’s also known as septic arthritis. Chronic means that it is prolonged over time. The most affected places for any type of arthritis are joints, such as the knee or hip, but it also commonly affects the wrist and phalanges of the hands.

“Considering the cost of diagnosis; nonpharmacologic, pharmacological and surgical interventions; and lost productivity, arthritis is one of the most expensive and debilitating diseases in the United States. OA (Osteoarthritis) is most often seen in older individuals, but can occur in younger people following injury or repetitive stress. Obesity, lack of exercise, muscle weakness, and intense and traumatic physical activity are modifiable risk factors. […]

Rheumatoid arthritis (RA), the second most common form of arthritis, is a destructive and commonly debilitating systemic inflammatory disease. It affects women more frequently than men (5:1), has peak incidence between ages of 20 and 50, and affects 1.5 million Americans.

Optimal management of the individual with arthritis should include appropriate diagnosis and management of the underlying conditions when possible. The primary therapy for arthritis of almost any type includes pharmacological approaches, education, proper nutrition and weight loss, increasing physical activities, rehabilitation therapy and support. The establishment of effective patient/physician relationship is also crucial for optimal therapy.”1

Causes

Chronic inflammatory arthritis can occur in two ways:

  • A dirty trauma to a joint: By damaging and infecting, microorganisms will colonize and infect cartilage.
  • An infection anywhere else in the body. The microorganisms settled in another injured area, reached the bloodstream and eventually made it’s way to the joints.

There are some circumstances that predispose the individual to suffer from inflammatory arthritis. Some examples are people who go through artificial joint implants, arthroscopies, surgeries or any type of trauma to a joint. People with certain types of chronic diseases such as diabetes or who are taking drugs that inhibit the immune system are also more likely to acquire this condition. Folks who use drugs intravenously are also more likely to suffer from arthritis, because it is likely that the injected material contains microorganisms.

“Early recognition of symptoms and diagnosis is key to a more successful patient outcome. Early review allows faster initiation of treatment and suppression of inflammation. Studies have clearly demonstrated that response to DMARD therapy is related to duration of symptoms prior to diagnosis. The diagnosis of rheumatoid arthritis can be made with normal autoantibodies/inflammatory markers. Primary care physicians should not wait for investigation results prior to referral if rheumatoid arthritis is suspected. Early referral to a specialist rheumatology clinic has been associated with better results. […]

Primary care

When patients present with joint symptoms suggestive of inflammatory arthritis, initial treatment by primary care should focus on analgesia. This can include paracetamol, codeine or compound analgesics. Standard NSAIDs or selective COX-2 inhibitors are also options in primary care. Corticosteroids should only be initiated in secondary care after review.

Multidisciplinary care

The management of rheumatoid arthritis involves a multidisciplinary approach through a rheumatology clinic (occupational therapy, physiotherapy, psychology and patient support) along with patient education. The following professionals may be involved in the care of patients with rheumatoid arthritis as part of the multidisciplinary team:

  • Occupational therapist – Help with everyday activities; splints, wrist supports, pacing advice
  • Physiotherapist – Specific muscle/joint functioning, eccentric concentric exercise programs
  • GP – Assessment and management of co-morbidities including cardiovascular risk and consideration of bone health
  • Podiatrist – Foot care, appropriate footwear • Rheumatology nurse specialist – Practical advice and support
  • Orthopedic surgeon – Joint replacement surgery.”2

“Statistics show that arthritis and related diseases probably affect every family in the United States. Approximately 22 percent of U.S. adults (more than 50 million people) aged 18 years or older self-report doctor-diagnosed arthritis. In the United States, osteoarthritis affects 14 percent of adults aged 25 years and older and 34 percent (12.4 million) of those 65 years and older. It is estimated that 1.5 million U.S. adults have rheumatoid arthritis and 3.0 million U.S. adults are living with gout. Prevalence estimates for systemic lupus erythematosus range as high as 1.5 million. An estimated 294,000 U.S. children under age 18 (or one in 250 children) are diagnosed with arthritis or another rheumatologic condition. Arthritis kills people of all ages as the primary and associated cause of death. In addition, complications from treatment of arthritis can result in death. During the 20-year period of 1979-1998, 146,377 deaths were recorded with an underlying cause of arthritis and other rheumatic conditions. Deaths occurred among all age groups, including children; 12 percent of deaths occurred among persons aged 15–44. Age-standardized death rates were higher for women and blacks. Among rheumatic conditions, systemic lupus erythematosus has a relatively high mortality (15 percent of all rheumatic disease mortality in 1997). Using 10 categories of arthritis and other rheumatic conditions, three categories accounted for almost 80 percent of deaths: diffuse connective tissues diseases (34 percent; mostly systemic lupus erythematosus and systemic sclerosis), other specified rheumatic conditions (23 percent, mostly vasculitis), and rheumatoid arthritis (22 percent). During the 20-year period, an additional 585,446 people had arthritis and other rheumatic conditions listed as an associated cause of death. These estimates may not capture mortality from treatment-related adverse effects, such as nonsteroidal anti-infl ammatory drug induced gastrointestinal bleeds.”3

The most common microbes that produce chronic inflammatory arthritis are staphylococci and streptococci, Mycobacterium, tuberculosis and Candida albicans. Chronic inflammatory arthritis is more common in children. Some circumstances that promote chronicity are the age and health of the joint prior to the infection. The initial response to antibiotics and the severity of the infection also influence greatly.

When dealing with a chronic condition, there will always be some basic symptoms that will become more evident during the so-called ‘exacerbation periods’. The most usual and frequent symptoms are severe joint and bone pain and joint stiffness along with signs of infection in the area like swelling, loss of function, low-grade fever and fatigue.

Symptomatically, there are a few differences depending on whether the infection was caused by a virus or bacteria.

“Infectious arthritis is inflammation of a joint which has been caused by either bacterial, viral or fungal infection. Bacterial arthritis is defined as arthritis resulting from infection of the synovial tissues with pyogenic bacteria or other infectious agents.  In 95% of cases, acute infectious arthritis is caused by either bacteria or viruses.

Bacterial Arthritis (BA) can be categorized into two groups:

  1. Arthritis due to Neisseria gonorrhoeae or other Neisseria species (the most common).
  2. Non-gonococcal bacterial arthritis (Staphylococcusaureus being the most common bacteria).

The epidemiology and clinical features of bacterial arthritis have changed recently.  This can be attributed to factors such as longer life expectancy, increased frequency of methicillin-resistant (an antibiotic) Staphylococcus aureus isolates, increased use of arthroscopy, an increased proportion of individuals with prosthetic joints and the spread of the AIDS epidemic.”4

Bacterial infection

It is located in one or few joints and presents fever, chills, flushing and swelling and comes about very acutely. Inflammatory arthritis caused by bacteria are usually treated with antibiotics.

“The clinical presentation of a patient with one or more hot, swollen joints is common. The differential diagnosis is broad but the most serious potential cause is bacterial septic arthritis. The management of bacterial septic arthritis relies on early recognition, diagnosis and timely drainage of purulent material, together with prompt administration of antibiotic therapy. If the diagnosis is not made rapidly then the treatment of septic arthritis may be delayed, which can lead to substantial morbidity due to catastrophic joint damage, as well as significant mortality due to overwhelming septicemia. The differential diagnosis of bacterial septic arthritis includes inflammatory arthritis, crystal arthropathy, trauma, hemarthrosis and degenerative joint disease. Even in the hands of experienced physicians, the crucial diagnosis of septic arthritis can be a difficult one to confirm. Despite advances in laboratory techniques, efforts are still being made to find a synovial or serum investigation of sufficient sensitivity and specificity to clinch the diagnosis. In addition, the emergence of unusual and resistant organisms makes the management of septic arthritis an ongoing challenge.”5

Virus Infection

Affects multiple joints but pain and pronounced fever are commonly the only symptoms. Unlike their bacterial counterparts, viral infections begin gradually and are not cured with antibiotics, in the case of arthritis, symptoms usually disappear on their own.

“Viral infections are a well-recognized cause of acute arthralgia and arthritis with a large number of causative agents reported. The diagnosis of virally induced arthritis can be difficult to confirm but should be considered in all patients presenting with acute-onset polyarticular symptoms. In addition to serological testing for the causative agent there may be associated clinical features that point clinicians to a specific virus such as the typical ‘slapped cheek’ rash seen in parvovirus-associated arthritis or jaundice associated with acute hepatitis B (HBV) infection. In many cases however, these features may be subtle, absent or temporally distant from the joint symptoms making the diagnostic process difficult. Therefore when a virally mediated arthritis is suspected, serological testing should be based on both clinical and epidemiological data.”6

 

References:

(1) Vasudevan, S. V., Potts, E. E., & Mehrotra, C. (2003). Pain management in arthritis: evidence-based guidelines. WMJ-MADISON-, 102(7), 14-18. Available online at https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/7/14.pdf

(2) Tracey, G. (2017). Diagnosis and management of rheumatoid arthritis. Prescriber, 28(6), 13-18. Available online at https://onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1580

(3) Barr, W. G. Arthritis. Arthritis Foundation. Scientific Strategy 2015-2020. Available online at https://www.arthritis.org/documents/arthritis-foundation-scientific-strategy.pdf

(4) Pollard, H., Grangeer, S., Tuchin, P. (1999) Bacterial Arthritis, A Review. Available online at https://www.researchgate.net/publication/5859973_Bacterial_arthritis_A_review

(5) Lynn, M. M., & Mathews, C. J. (2012). Advances in the management of bacterial septic arthritis. International Journal of Clinical Rheumatology, 7(3), 335. Available online at https://pdfs.semanticscholar.org/0279/e564fbd0047a42b4dd3feb0c0b1ee1236a99.pdf

(6) Marks, M., & Marks, J. L. (2016). Viral arthritis. Clinical Medicine, 16(2), 129-134. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868140/

 

Robert Velasquez
13 October, 2018

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Hello everyone, my name is Robert Velazquez. I am a content marketer currently focused on the medical supply industry. I studied Medicine for 5 years. I have interacted with many patients and learned a lot...read more:

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