Every 3rd patient who comes to a rheumatologist with a complaint of joint inflammation, according to statistics, suffers from infectious arthritis. This disease requires immediate consultation with a doctor, because it can completely and irreversibly destroy a joint in a couple of days, and every 12th of those who are unlucky enough to get the disease die every year from its complications. But if you go to the hospital in a timely manner, 70% of patients get off with a “mild fright” - modern medicine allows you to save joints from deformation in most cases.
Let's look at the symptoms and treatment of infectious arthritis.
Infectious arthritis: causes, mechanism, complications
What is infectious arthritis? Infectious arthritis is an acute or chronic inflammation that occurs in the joint capsule due to bacterial or viral infection. Infection (gonococcal or non-gonococcal) can develop in the synovium, synovial fluid and soft tissue adjacent to the joint. The incubation period usually varies from several hours to several days (usually no more than 10).
Many pathogenic microorganisms produce so-called adhesive proteins and acids that help them attach to articular surfaces for further reproduction. These substances actually “eat away” the cartilage - the initial erosion develops into irreversible changes as the number of microorganisms increases. In addition to poor nutrition, the joint suffers from enzymes with which the human body tries to cope with bacterial agents - by “dissolving” foreign cells, these proteins damage the synovial fluid, ligaments and the cartilage itself.
What are the causes of the disease? The cause of the disease in children and adults is gram-negative and gram-positive bacteria - staphylococci, streptococci, gonococci, HIV, parvoviruses, spirochetes. Diseases such as rubella, mumps, hepatitis, dysentery, brucellosis, and borelliosis can provoke infection of the joint and an acute form of arthritis. Tuberculosis, mycosis and a number of other diseases often lead to a chronic, sluggish form.
People with rheumatoid and other types of arthritis and arthrosis, gout, joint prostheses, people over 60 years of age, and those addicted to injecting drugs or alcohol are especially susceptible to the disease. Risk factors also include recent surgery, immunosuppressive therapy, skin infections, the presence of bacteria in the blood (bacteremia), chronic diseases of the lungs, liver, kidneys (especially those requiring hemodialysis), cancer, diabetes, sexually transmitted diseases and a number of systemic diseases .
What complications occur with infectious arthritis? Almost a quarter of patients affected by infectious arthritis complain of partial or complete limitation of mobility in the affected joints.
Left untreated, this disease can provoke a purulent and even necrotic process in the bone and adjacent soft tissues. If the septic process spreads to the bone marrow, inflammation of the spinal column may develop. This is fraught with destruction of the vertebrae. The relatively high percentage of deaths in infectious arthritis is explained by severe intoxication of the body, septic shock and the possible development of respiratory failure.
Treatment of hip arthritis.
Pharmacotherapy is carried out taking into account the etiology of coxitis and may include the use of NSAIDs, specific chemotherapy (for tuberculous arthritis), antibiotic therapy (for infectious arthritis), etc. Intra-articular injections of corticosteroids are performed according to indications.
For purulent coxitis, a series of therapeutic punctures, lavage of the joint with antiseptic solutions, and flow-through drainage of the joint are performed. After relief of acute manifestations of arthritis of the hip joint, massage, therapeutic exercises and swimming, and physical therapy are prescribed). To facilitate movement, it is recommended to use canes, crutches, walkers and other devices.
If attempts at conservative treatment of arthritis are unsuccessful, in case of chronic pain and persistent limitation of joint function, the issue of surgical intervention is decided. Forecast and prevention of arthritis of the hip joint
The outcome of arthritis can be either mild stiffness or complete ankylosis of the hip joint. A complication of purulent arthritis can be infectious-toxic shock or sepsis. Timely and complete treatment allows you to minimize dysfunction of the hip joint and prevent the development of osteoarthritis.
Symptoms of infectious arthritis
Infectious arthritis is characterized by suddenness: pain appears unexpectedly, as if out of nowhere, and extremely intensely signals the onset of the disease. Almost immediately, stiffness sets in in movements - both active (using only muscles) and passive (produced with the help of hands or other aids). Typically, the first symptoms of infectious arthritis are observed in only one joint, with the possibility of spreading to others. But with blood diseases, viruses, gonococcal infections, polyarthritis is possible, in which symptoms are observed in several joints at the same time.
The main signs of infectious arthritis are:
- redness of the skin over the joint, local or general increase in body temperature;
- pain when touching the joint;
- accumulation of fluid in adjacent tissues caused by an inflammatory process;
- a sharp deterioration in mobility (the joint moves tightly, even if you bend it with your hand);
- fever, chills.
Specific symptoms and treatment for infectious arthritis vary depending on the pathogen. Gonococcal arthritis may be accompanied by ulcerative rashes on the skin and mucous membranes, in the mouth or in the genital area. If infection occurs through a bite, the lymph nodes usually become enlarged. Fungal infections of the joints can occur without fever or other systemic manifestations.
The disease is usually localized in the shoulder, elbow, wrist and interphalangeal joints, as well as in the knee and hip joints. Certain diseases can “select” specific joints - for example, borelliosis most often affects the knees.
Acute infectious arthritis
The acute form is observed in 95% of cases recorded by doctors. Unlike chronic arthritis, which affects people at risk, even absolutely healthy young people are not immune from it. Acute infectious arthritis, the most dangerous form of the disease, is characterized by severe swelling and heat in the affected joint. Erythrematous skin lesions against the background of other symptoms are a clear reason to call an ambulance.
You should also immediately consult a doctor if signs of arthritis are observed within 2-10 days after being bitten by dogs, cats, rats and other animals, as well as humans. Infections of the digestive tract are also dangerous. Nongonococcal reactive arthritis, which they can provoke, leads to joint destruction within the first hours after the onset of the disease!
Gonococcal infection, which is transmitted from mother to child, between sexual partners, as well as through household contacts, is less dangerous. However, the presence of concomitant diseases (for example, rheumatoid arthritis or systemic lupus erythematosus) significantly worsens the clinical prognosis in acute infectious arthritis.
Polyarthritis - symptoms and treatment
Most polyarthritis (rheumatoid, psoriatic, polyarthritis due to systemic connective tissue diseases, etc.) require long-term or lifelong therapy. Treatment of polyarthritis can be divided into “symptom-modifying” and “disease-modifying”.
Symptom-modifying treatment
Aimed at reducing symptoms (pain and joint stiffness) and improving the quality of life of patients. It includes:
1. Non-steroidal anti-inflammatory drugs (NSAIDs). Treatment of polyarthritis with NSAIDs is called first-line therapy. These drugs have analgesic and anti-inflammatory effects. Moreover, they relieve inflammation regardless of the cause of the disease. Therefore, NSAIDs are used for any type of polyarthritis [1][2][10].
2. Glucocorticoids (GC), for example Metypred, Prednisolone. These strong anti-inflammatory drugs are used as first-line therapy for active forms of systemic lupus erythematosus, rheumatoid arthritis with systemic manifestations, systemic vasculitis, etc. For reactive arthritis, they are prescribed if NSAIDs are ineffective.
3. Immunomodulators, for example aminoquinoline drugs [14]. They are used for mild rheumatoid polyarthritis.
Disease-modifying treatment
It influences the mechanisms of disease development, and in some cases (with infectious or reactive polyarthritis) - the cause of the disease.
1. Cytostatics (immunosuppressors) are basic drugs for rheumatoid and psoriatic polyarthritis. These include Methotrexate, Azathioprine, Cyclosporine, Arava (Leflunomide), etc. These drugs selectively reduce the activity of certain immune cells. Cytostatics also suppress the growth of synovial membrane cells and fibroblasts. As a result, laboratory parameters improve, symptoms decrease and the development of erosions is delayed.
However, cytostatics have many side effects. Nausea and vomiting occur very often, and sometimes stomatitis develops. Cytostatics can affect hematopoiesis and lead to the development of anemia, a decrease in the level of platelets and leukocytes. Sometimes they disrupt liver function: the level of liver transaminases (ALT and AST) may increase more than three times. This can lead to the development of nephropathy and kidney failure.
The drug of choice is Methotrexate due to less pronounced side effects. The clinically significant effect from the use of cytostatics develops relatively slowly (1–3 months), so at the beginning of treatment it is possible to use them in combination with NSAIDs or glucorticoids. That is, GC is prescribed for 1–2 months until disease-modifying drugs begin to “work”: Methotrexate, Arava, etc.
2. Genetically engineered biological drugs (GEBPs) are increasingly important in the treatment of polyarthritis (especially rheumatoid and psoriatic), ankylosing spondylitis, systemic vasculitis and connective tissue diseases. HIPB suppresses autoimmune inflammation and inhibits joint destruction.
Most often, these drugs are prescribed to patients with high laboratory activity of the disease, severe articular syndrome and damage to internal organs (for example, eyes). GIBP is also indicated for long-term arthritis that does not respond to treatment with basic drugs. There are works that prove the feasibility of using biologically active drugs in the early stages of the disease [14]. The effect of HIPB occurs quickly, so it is not advisable to use them in parallel with NSAIDs. To enhance the effect of GEBD and reduce their toxic effect on the body, Methotrexate may be prescribed.
Physical modulation methods
These methods include plasmapheresis, hemosorption, total irradiation of the lymph nodes and drainage of the thoracic duct. Purification of blood from circulating immune complexes using hemosorption and plasmapheresis is often used in clinical practice. Total irradiation of the lymph nodes and drainage of the thoracic duct are “therapy of despair” and are practically not used in clinical practice [2].
Drainage of the thoracic duct has a large number of complications. The percentage of unsuccessful operations on the thoracic duct, according to various authors, ranges from 10 to 50% [22]. And total irradiation of the lymph nodes reduces the number of lymphocytes and platelets so much that it threatens the patient’s life due to additional infections and bleeding.
Physiotherapeutic treatment
Physical therapy treatments can be used to reduce pain and inflammation. Electro- or phonophoresis with medications, exposure to currents of various frequencies, magnets and magnetic laser can be used.
Numerous clinical studies prove the effectiveness of using magnetic therapy, as well as low-intensity laser radiation on individual parts of the pathogenesis of arthritis (rheumatoid and osteoarthritis). As a result of exposure to these physical factors, patients experience an enhanced analgesic effect and an improved functional state of the joints [21]. Physiotherapeutic treatment should be prescribed for low laboratory activity, when ESR is less than 35 mm/h, CRP is less than 10–15 mg/l). Physiotherapy may increase the pain, but after 1–2 weeks the condition improves.
Infectious arthritis in children
Infectious arthritis occurs in every 5-10 children, girls are especially vulnerable to the disease. In patients under 16 years of age, the disease is often accompanied by loss of appetite, increased irritability, temperature from 37.1 to 38 ° C (sometimes higher), and there may be complaints that the limb is as if paralyzed. Sometimes the disease is hidden and makes itself felt only by minor pain, lameness, and allergic rashes, for which there are other explanations. If a child is atypically lethargic, losing weight, gets tired quickly, or “pulls” a limb, this is a reason for an immediate examination!
Infectious arthritis can result from congenital infections (eg, staphylococcal infections). Children under one year old become inactive, are not interested in food, and avoid putting stress on the affected joints. They behave more cautiously or, on the contrary, restlessly, and begin to whine when touching the sore joint.
More than half of children suffering from infectious arthritis are under 3 years of age—particularly vulnerable to bacterial, viral, and fungal infections.
In no case should you neglect vaccinating children against influenza (Pfeiffer bacillus) and pneumococcus - it helps reduce the risk of infectious arthritis several times. Young children are especially susceptible to staphylococci, streptococci and gram-negative bacteria.
Please note: infectious arthritis in children can develop due to hypothermia, high physical activity, taking glucocorticosteroids and other drugs, as well as post-vaccination complications.
If left untreated, infectious arthritis can leave a minor with lifelong disabilities, especially if there are genetic disorders of the immune system.
Treatment of infectious arthritis
Treatment of infectious arthritis depends on several parameters: the form of the disease, the causative agent and concomitant diseases. If necessary, treatment of complications is carried out.
Self-medication for this disease is strictly contraindicated, since it is impossible to determine the cause of arthritis without special laboratory tests - highly specialized drug therapy is required.
Diagnosis of infectious arthritis
Diagnosis relies on symptoms of infectious arthritis (eg, pathological changes in the tissue around the affected joint). Why does a doctor determine whether the infectious agent is actually in the joint, blood or adjacent tissues, and determines the infectious agent. This is necessary for the correct choice of antibiotic: if the bacterium or a specific strain turns out to be insensitive to the drug, precious time will be lost.
For example, an ultrasound examination of a joint helps a specialist determine the presence of effusion in the joint and lesions.
To identify the causative agent, leukocyte and bacteriological analysis of the joint fluid is performed, which makes it possible to determine the presence or absence of pathogenic microorganisms. After laboratory culture, with a high probability, the type of pathogen will be established - unless it is gonococcus, Borrelia spirochete or treponema (the causative agent of syphilis), since they are difficult to detect in joint material.
A general blood test (helps to detect bacteremia), ESR, PCR, and, less commonly, examination of urine, sputum or cerebrospinal fluid are also performed. To achieve this, minimally invasive interventions are performed - for example, taking blood from a vein or puncturing a joint. An x-ray is prescribed last - it allows you to evaluate the destruction of the joint and bone heads caused by the disease, determine the narrowing of the joint space and other deformities.
Taking an anamnesis plays an important role in determining the symptoms and treatment of infectious arthritis - it helps to establish the possible cause of the disease at the pre-laboratory stage and eliminate unnecessary studies.
Taking antibiotics to a patient (for self-medication or treatment of a primary disease) can significantly complicate diagnosis.
Drug treatment of infectious arthritis
Sometimes treatment with broad-spectrum antibiotics is prescribed even before the pathogen is identified (usually penicillin, cephalosporins). For children under 3 months of age, initial therapy is with antibiotics active against gram-positive bacteria.
The drugs are administered intravenously (2-4 weeks) and then orally (another 2-6 weeks). In urgent cases, injections directly into the diseased joint are possible. A combination of various antibiotics is possible (for example, for tuberculosis), as well as intravenous and oral use of various drugs simultaneously. With the correct selection of antibiotics, improvement is observed already in the first 2 days of treatment.
In case of fungal infection, antimycotic agents are prescribed. In case of parasitic - antiparasitic. For some diseases, special chemotherapy or antiallergic treatment is performed.
If the cause of arthritis is a viral infection, instead of specific treatment, symptomatic treatment is carried out, aimed at eliminating fever, pain (analgesics, non-steroidal anti-inflammatory drugs), maintaining cartilage tissue (chondroprotectors and other similar drugs). Immunostimulating therapy is possible only as prescribed by a doctor and is completely contraindicated in rheumatoid arthritis.
Non-drug treatment
In the presence of a purulent process, the accumulated exudate is removed using a drainage tube or pumped out through a needle once a day, sometimes rinsing with saline solution is carried out. In difficult cases, when it is impossible to remove pus in this way (for example, due to bone growths), surgical intervention is possible. If the joint is severely damaged, prosthetics are performed. In some cases, arthroplasty, arthrolysis, and synovectomy are prescribed.
To ensure that the joints do not lose mobility, patients undergo physical therapy (for example, medicinal electrophoresis, compresses, amplipulse, magnetic therapy), and are prescribed therapeutic exercises - strictly under the supervision of an instructor. The complex includes active and passive exercises that help avoid contractures. Strength exercises shouldn't hurt.
In the acute stage of the disease, massage and physical therapy are contraindicated. In the early stages of the disease, it is recommended to limit joint mobility using a splint or splint. Clinical recommendations for infectious arthritis include timely treatment of systemic and local infections, chronic diseases, as well as compliance with the rules for surgical interventions.
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Symptoms of hip arthritis
The most common forms of arthritis of the hip joint encountered in clinical practice are tuberculous and acute purulent coxitis. Other forms are observed much less frequently.
With purulent coxitis, there is a rapid onset of the disease with a predominance of symptoms of general intoxication: fever, weakness, sweating, loss of appetite, headache. Local changes are significantly pronounced: the skin over the joint area becomes tense, hyperemic and hot to the touch. There is a sharp pain (shooting, pulsating), which intensifies even more with movement. Due to inflammatory infiltration and the formation of purulent effusion in the joint cavity, the shape of the latter changes significantly.
Other forms of hip arthritis are characterized by gradual development. In the initial stages, dull, aching pain predominates in the groin area, on the outer side of the thigh, and buttocks, which limit the range of movements or make walking difficult. Due to the stiffness of the hip joints, movements become constrained, uncertain, and the gait becomes limping (Trendelenburg gait). Most often, pain and stiffness in the hip joint occurs after prolonged fixation in one position in an uncomfortable position, for example, when sitting or standing for a long time. Over time, patients may develop atrophy of the femoral and inguinal muscles, fibrous or bony ankylosis.
Psoriatic coxitis is accompanied by the appearance of a characteristic bluish-purple coloration of the skin over the inflamed joint, pain in the lower parts of the spine. In rheumatoid arthritis, the hip joints are affected symmetrically. Progressive dystrophic changes in the joint over time lead to the development of secondary coxarthrosis.