Arthropathy
The most common joint damage caused by hormonal imbalance is menopausal or ovariogenic arthropathy. Articular syndrome develops against the background of menopause or decreased ovarian function due to other reasons (surgical removal, radiation for a malignant neoplasm). Arthropathy most often affects overweight women. Usually the small joints of the feet are affected, less commonly the knee joints. Pain, stiffness, crunching and swelling occur. The configuration of the joints is disrupted - first due to swelling, then due to degenerative processes. In the initial stages, the X-ray picture is normal; MRI of the joints or during arthroscopy of the knee joint reveals some thickening of the synovial membrane. Subsequently, gonarthrosis and arthrosis of the foot joints are detected. After selecting effective replacement therapy, arthropathy decreases or disappears.
Diabetic arthropathy develops mainly in young women suffering from type I diabetes mellitus for 6 or more years, especially with irregular and inadequate treatment. The lesion is usually unilateral, affecting the joints of the foot. Less commonly, the knee and ankle joints are involved in the process, and even less frequently, the spine and joints of the upper extremities. Diabetic arthropathy is characterized by a clinical picture of rapidly progressing arthrosis. Radiographs reveal foci of osteolysis, osteoporosis and osteosclerosis, flattening of articular surfaces and osteophytes. Treatment of diabetes mellitus leads to a reduction in arthropathy, however, with severe arthrosis, therapy aimed at eliminating pain and restoring cartilage is necessary.
Hyperparathyroidism causes the resorption and subsequent restoration of bone tissue, while calcareous deposits appear in the articular cartilage, and articular chondrocalcinosis develops. Arthropathy manifests itself in the form of intermittent pain in the joints, acute mono- and polyarthritis. After correction of hyperfunction or removal of a parathyroid adenoma, articular symptoms usually disappear.
Hyperthyroidism, especially its severe forms, can also be accompanied by arthropathy. Both arthritis and arthralgia are possible, sometimes in combination with muscle pain. The X-ray picture is scanty; only symptoms of widespread osteoporosis are revealed. The diagnosis is made based on clinical manifestations. Therapy of the underlying disease leads to a decrease or disappearance of arthropathy.
Hypothyroidism is characterized by damage to large joints, most often the knees. Pain in the hip joints is also possible. Arthropathy is combined with myalgia, stiffness and muscle weakness. The X-ray picture is unchanged. With the development of hypothyroidism in childhood, rotation and displacement of the femoral head is possible with the development of flexion contracture of the hip joint.
When the function of the pituitary gland is impaired, damage to the spine and distal joints of the extremities is sometimes observed. In severe cases, kyphosis of the cervicothoracic region develops in combination with decalcification of the sternum and ribs. Limb deformities and joint looseness are possible. Arthropathy manifests itself as pain in the back and joints of the limbs. Contractures are uncommon.
Publications in the media
Microcrystalline arthritis is a disease of the joints associated with the deposition of microcrystals in them: sodium urates, calcium pyrophosphate, calcium hydroxyapatite, oxalates.
Statistical data. Chondrocalcinosis occurs in 1 in 10 people aged 60–75 years, 1 in 3 over 80 years, and only a small percentage develop clinical manifestations. The predominant age is over 60 years.
Pathogenesis • In early stages of pyrophosphate arthropathy, CPFCs are deposited in the articular cartilage. An acute attack of arthritis occurs when CPFC exits the cartilage into the joint cavity, which can be facilitated by hypocalcemia (causing leaching of pyrophosphate from the cartilage), destruction of the matrix (during enzymatic reactions in infectious or gouty arthritis), as well as significant biomechanical loads on the joint. Phagocytosis of crystals by neutrophils is accompanied by the release of Pg, collagenase, etc. The disease can be combined with hemochromatosis, hyperparathyroidism, hypothyroidism, alkaptonuria, Wilson-Konovalov disease, amyloidosis. There are also hereditary forms • Calcium hydroxyapatite crystals are deposited predominantly in avascular areas; Trauma and ischemia are considered trigger factors.
Classification • Gout - see Gout • Pyrophosphate arthropathy is a disease resulting from the deposition of calcium pyrophosphate crystals (CPPC) in joint tissues. The term chondrocalcinosis is used to designate radiological manifestations of the disease in the form of calcification of articular cartilage • Hydroxyapatite arthropathy - deposition of calcium hydroxyapatite crystals in joints, ligaments, fascia • Oxalate arthropathy - deposition of calcium oxalate crystals in joints, mainly in patients with chronic renal failure • Microcrystalline arthritis induced by drug administration , observed (rarely) as a side effect of intra-articular injection of GC.
Clinical picture • Pyrophosphate arthropathy can occur in several ways •• Acute arthritis, or pseudogout (25% of cases): pain, hyperemia, swelling of the joint, reaching a peak in 12–36 hours. In 50% of cases, damage to the knee joint is observed, although any different localization. The duration of the attack is several weeks. During the interictal period, the shape and function of the joints in typical cases are not changed •• Chronic (pseudoreumatoid) arthritis (5% of cases): morning stiffness, pseudorheumatoid deformities, a family history of joint diseases •• Pseudoosteoarthrosis occurs in patients with clinical and radiological signs of osteoarthritis, however, in contrast, patients exhibit radiographic evidence of chondrocalcinosis. More often than with osteoarthritis, flexion contractures and varus deformities of the lower extremities are observed •• Destructive arthritis of the type of Charcot arthropathy (tabes dorsalis): severe destructive lesions of the shoulder, knee or hip joints •• Lumboischialgia, reminiscent of the clinic of intervertebral disc prolapse •• Symptoms of polymyalgia rheumatica (see Polymyalgia rheumatica) •• Asymptomatic: no joint pain, pathology is detected only by x-ray • Hydroxyapatite arthropathy most often affects the shoulder and knee joints, rotator cuff, extensor carpi ulnaris, flexor carpi radialis. “Milwaukee shoulder”: effusion in the shoulder joint, damage to the biceps tendon.
Laboratory data • Examination of synovial fluid by light microscopy in polarized light is diagnostically valuable (one polarizer is placed in front of the light source, the other is placed between the smear of fluid and the eye; crystals that are birefringent glow with white light) •• sodium urate crystals are often needle-shaped or rods, are strongly birefringent •• calcium pyrophosphate crystals are diamond or rod shaped, weakly birefringent •• calcium oxalate crystals are bipyramidal in shape, are birefringent •• calcium hydroxyapatite crystals are coin-shaped or irregular in shape, are not birefringent • To detect calcium in synovial tissue As a screening liquid, a qualitative sample with alizarin red is used.
Instrumental data • X-ray examination •• Deposits of calcium salts in the form of focal or linear shadows in the articular cartilage, most often detected in the knee, shoulder, hip joints, pubic symphysis; in the acute period of arthritis there are no •• Calcification of tendons and ligaments in hydroxyapatite arthropathy.
TREATMENT
In general, the general tactics resemble those for acute gouty arthritis.
Regimen • Rest for the affected limbs, if the tendons are damaged - temporary immobilization using splints • Moist heat compresses on the affected ones.
Drug treatment • NSAIDs •• Indomethacin or diclofenac 150–200 mg/day for 12–14 days • Colchicine 0.6–1.2 mg/day for the prevention of exacerbations in recurrent cases. Side effects: impaired bone marrow function, deterioration of renal function, cholestasis.
Surgical treatment • Aspiration of synovial fluid • Large crystals, free cartilage fragments are removed surgically, incl. arthroscopically, by.
Flow. Acute attacks usually resolve within 10 days.
Synonyms • Pyrophosphate arthropathy •• Calcium pyrophosphate crystal deposition disease •• Pseudogout • Hydroxyapatite arthropathy •• Milwaukee shoulder •• Calcific tendinitis.
Reduction. CPPC—crystals of calcium pyrophosphate.
ICD-10 • M11 Other crystalline arthropathies
Reactive arthritis (arthropathy)
Treatment of reactive arthritis is carried out in two directions: 1. Antibacterial therapy. 2. Therapy of articular syndrome. Antibacterial therapy for reactive arthritis: - Duration of treatment is 7 days. — Patients with chlamydial infection should be screened for the presence of other sexually transmitted infections. - It is recommended to abstain from sexual intercourse for 7 days after completion of the 7-day course of treatment, as well as until all sexual partners of the patient have completed the appropriate course of treatment.
Recommended regimens: - Azithromycin at a dose of 1.0 g orally once (the effective concentration of the drug in the blood and tissues lasts 7-10 days) or - Doxycycline 100 mg orally 2 times a day for 7 days
Alternative regimens (equivalent): - Erythromycin 500 mg orally 4 times a day for 7 days, or - Ofloxacin 200 mg orally 2 times a day for 7 days, or - Roxithromycin 150 mg orally 2 times a day for 7 days, or - Clarithromycin 250 mg orally 2 times a day for 7 days
Additional drugs: - Amoxicillin 500 mg orally 3 times a day for 7 days or - Josamycin 750 mg orally 2 times a day for 7 days Erythromycin is less effective than azithromycin or doxycycline, and its side effects on the gastrointestinal tract often force patients to abandon this treatment regimen.
Roxithromycin and clarithromycin are alternative macrolide antibiotics with high tissue concentrations and are better tolerated by patients, as they are more favorable in terms of side effects.
Ofloxacin is similar in effectiveness to doxycycline and azithromycin, but is more expensive and does not have a dosing advantage. Other quinolones are not effective enough against chlamydial infection.
Doxycycline and ofloxacin are contraindicated in pregnant women. Josamycin is prescribed relatively rarely in Ukraine (accordingly, the probability of insensitivity of a microbial agent to the drug is less). Josamycin and amoxicillin can be prescribed to pregnant women.
None of the above regimens is highly effective, so repeat laboratory testing is recommended 3 weeks after completion of therapy. If test results are positive or urogenital symptoms recur, repeat the course of treatment with a change in antibiotic.
Therapy of articular syndrome The question of whether a short-term course of antibiotic treatment of acute urogenital infection affects the course of arthritis in reactive arthritis remains controversial. Long-term (3 months) antibacterial therapy has no effect on the course of arthritis. Therefore, treatment of articular syndrome in reactive arthritis is carried out with non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GCC), as well as basic drugs.
The choice of drugs and doses is dictated by the degree of inflammatory activity of the disease. In case of moderate pain, absence of a systemic inflammatory response (general malaise, fatigue, weight loss and fever), moderate increase in ESR (within 30 mm/h), NSAIDs and local administration of glucocorticosteroids are prescribed. There is no specific drug of choice; additional use of topical medications containing NSAIDs is advisable. In case of inflammation of the knee or ankle joints, intra-articular injections of GCC are possible. For intra-articular administration, the most powerful GCCs are preferred, such as dexamethasone or the long-acting combination drug betamethasone Diprospan. Depending on the size and degree of inflammation, 1-2 ml of these agents are injected into the joint. For achillobursitis, injection (subcutaneous) infiltration of the heel area of the GCC is indicated. For inflammation of small joints of the foot, the application of dimexide with dexamethasone is effective.
In case of severe pain, the presence of a systemic inflammatory reaction and a significant increase in ESR (> 30 mm/h), GCCs are systemically prescribed instead of NSAIDs; the drugs of choice are methylprednisolone and betamethasone. These drugs are taken in a dose of 40-60 mg/day of prednisolone equivalent, divided into 2 doses (morning and afternoon), for 5-7 days, followed by its reduction until the drug is discontinued as local and general inflammatory manifestations are eliminated. Against the background of systemic administration of GCCs, their local application is carried out according to indications. Simultaneously with the systemic use of GCC, a basic drug is prescribed.
Historically, sulfasalazine, gold salts, D-penicillamine, and azathioprine have been used to treat reactive arthritis. Currently, methotrexate should be considered the most suitable basic drug in the treatment of reactive arthritis.
The advantages of methotrexate over other basic drugs are: - rapid development of the maximum therapeutic effect (4-12 weeks from the date of prescription); - pronounced anti-inflammatory effect; — predictability of the most common (hematological) of the most serious side effects; — the ability to identify side effects at the preclinical stage with adequate laboratory monitoring of the patient; - minimal cost of treatment (methotrexate is the most inexpensive of all basic drugs).
Methotrexate is prescribed at a dose of 7.5-25 mg/week. The drug is taken 2.5 mg at intervals of 12 hours, 30-40 minutes before meals (nausea may occur when taken on a full stomach). Thus, if a patient is prescribed a dose of 20 mg/week, then starting on Monday morning, he will finish it on Thursday evening. This is followed by a break until Sunday inclusive, and the following Monday, methotrexate is resumed. The higher the weekly dose of methotrexate, the faster the maximum therapeutic effect develops. If oral administration of the drug is poorly tolerated (nausea), methotrexate is administered subcutaneously (the entire weekly dose is once).
The duration of use of methotrexate for reactive arthritis is determined by the course of the disease. If there are no relapses of arthritis during a year of treatment with methotrexate, then the drug can be stopped. In this case, the patient remains under the supervision of a rheumatologist for life, since relapse of the disease cannot be ruled out in the event of repeated urogenital infection.