Tuberculous arthritis

Posted onApril 13, 2020

Tuberculous arthritis is a chronic destructive form of septic arthritis caused by mycobacterium tuberculosis. It is more common in men over the age of 50-60. The combination of joint and lung damage is optional. The development of tuberculous arthritis is more often associated with the hematogenous spread of infection, the formation of the primary bone focus (osteitis) and the transition of a specific inflammatory process to the joint. The primary synovial form of tuberculous arthritis is much less common. As a rule, a large joint is affected – the knee, hip, ankle, and wrist. The affected joint is edematous, warm to the touch, moderately painful, movements in it are limited. In a number of patients, joint function is limited due to pain and reflex muscle contractures. Muscular atrophy may develop. When the wrist joint is affected, “carpal tunnel syndrome” often develops, which is clinically manifested by an infringement of the median nerve. Often, periarticular tissues are involved in the pathological process with the development of a “cold abscess”, that is, an abscess without pronounced erythema and tenderness on palpation. In the synovial fluid, the number of leukocytes (mainly neutrophils) exceeds 10,000, in about 20% of patients mycobacterium tuberculosis is sown from the synovial fluid. X-ray in the early stage of arthritis reveals diffuse osteoporosis, marginal bone defects, rarely a limited bone cavity with sequestration. In the late stage of arthritis, destruction of the articular ends of the bones, their displacement and subluxations often occur. For the diagnosis, seeding of a specific culture from the joint cavity, biopsy of the synovial membrane with the identification of characteristic tuberculous granulomas during its histological study, the detection of other tuberculous lesions in the body, positive reactions to tuberculin during skin tests (Pirke, Mantoux reactions) are important. Spinal tuberculosis (Pott disease) occurs mainly in children and young people (up to 30 years). In adults, the lower thoracic and upper lumbar are more often affected, in children – the thoracic spine. Specific bone changes are localized along the edges of the vertebral bodies, and one or two adjacent vertebrae are affected. As a rule, lysis and sclerosis of the bone with destruction of the articular cartilage are noted, as indicated by a narrowing of the joint space. As the destruction of the bones, the front of the adjacent vertebrae contracts, contributing to the formation of a hump. The process often goes to the intervertebral cartilage, paravertebral tissue, which is accompanied by the formation of paraspinal cold abscesses. Abscesses can spread along the spine or rib and reach the chest or sternum. When involved in the pathological process of the cranial nerves, severe neurological symptoms are often detected, up to paraplegia. Damage to the lumbar spine is observed less frequently and is clinically manifested, as a rule, by unilateral sacroileitis. For the diagnosis of spinal tuberculosis, X-ray examination and computed tomography are important. Also in the diagnosis of tuberculous arthritis, the final diagnosis is based on data from a bacteriological study of the contents of a cold abscess. Differential diagnosis is carried out with lesions of the spine in other infections, tumor metastases in the spine. Ponce polyarthritis is reactive arthritis that develops against the background of visceral tuberculosis. The defeat of small joints is characteristic. Clinically noted constant long-term pain in the joints and their swelling. Suppuration of joints and the formation of fistulas in them does not happen. There is a strict parallelism between the severity of the main process and the clinical manifestations of joint damage. With the subsidence of visceral tuberculosis, changes in the joints completely disappear. Differential diagnosis is carried out with RA. For tuberculosis of the osteoarticular system, as well as tuberculosis of the visceral organs, a long-term (usually at least 2 years) treatment is carried out with two bactericidal drugs, for example, isoniazid (tubazide) in combination with streptomycin, PASK or rifampicin or other anti-tuberculosis drugs. In addition, special orthopedic treatment methods must be widely used.

Brucellosis Arthritis

Brucellosis arthritis is relatively rare. It develops against the background of other clinical manifestations of brucellosis – wave-like fever with chills and heavy sweats, swollen lymph nodes, liver, spleen, changes in the nervous system, more often in chronic forms. It occurs in persons who have contact with animals suffering from brucellosis, or when using products from such animals. In acute brucellosis, arthralgia and myalgia are short-lived, quickly disappear with the appointment of antimicrobial therapy, and can pass on their own. Most often, brucellosis develops spondylitis and sacroiliitis, especially in the elderly with a severe course of the disease. Sacroileitis develops in the 1st month of the disease. It can be one-sided or two-sided. The lumbar spine is usually affected. Often an intervertebral disc is involved in the process, which is manifested by a narrowing of the intervertebral fissures; destruction of the vertebral bodies and calcification of the longitudinal ligaments at the level of the affected discs are observed (ossifying ligamentitis). Vertebral osteoporosis, periosteal thickenings, paravertebral abscesses can be detected. Damage to the intervertebral joints is not characteristic. The diagnosis is complicated. To establish it, an epidemiological history, specific tests for brucellosis – a Wright test in a titer of more than 1: 200, a skin test with brucellosis antigen (a positive Burnet reaction ) are necessary. Differential diagnosis is carried out with ankylosing spondylitis, tuberculous spondylitis, osteomyelitis. The most effective combined use of antibiotics: tetracycline 500 mg 4 times a day for 6 weeks and streptomycin 1 g intramuscularly per day for 2 weeks.

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