Infectious arthritis is an inflammatory joint disease of bacterial, viral, parasitic or fungal etiology. Disease can affect various joints and, in addition to local manifestations (swelling, hyperemia, soreness, restriction of movement in the joint), is accompanied by pronounced general symptoms (fever, chills, intoxication syndrome). The diagnosis of infectious arthritis is based on the data of radiography, ultrasound, arthrocentesis, synovial fluid examination, blood backseeding. Treatment includes immobilization and lavage of the joint, systemic and intra–articular administration of antibiotics, if necessary, arthroscopic rehabilitation or arthrotomy.
Meaning
Infectious arthritis is a group of arthritis caused by infectious pathogens (viruses, bacteria, fungi, protozoa) that penetrate directly into the tissues of the joint. In rheumatology and traumatology, arthritis associated with infection is diagnosed in every third case. Infectious arthritis more often affects the joints of the lower extremities experiencing a heavy weight load (knee, hip, ankle), as well as the joints of the hands. Pathology is registered in representatives of various age groups: newborns, preschool and school-age children, adults.
According to the etiological principle, infectious arthritis is divided into bacterial, viral, fungal, parasitic. Taking into account the nosological affiliation, septic (pyogenic, purulent), gonorrheic, tuberculous, syphilitic, brucellosis and other types of arthritis are distinguished. Due to the peculiarities of occurrence, post-traumatic arthritis is distinguished into a separate group.
When infection enters the articular tissues from the outside, they talk about primary arthritis. In the case of the spread of the infectious process to the joint from the surrounding tissues or distant purulent foci, secondary arthritis develops. The course of infectious arthritis can be acute, subacute and chronic. Joint damage can occur by the type of mono-, oligo- or polyarthritis.
Causes
Most often, with infectious arthritis, there is a metastatic pathway of joint damage, i.e. the penetration of infection into the joint cavity by a hematogenic or lymphogenic pathway, as a result of which the causative agent of the disease can be detected in the synovial fluid. A direct route of infection is also possible, for example, with open wounds and joint injuries, as well as the dissemination of microorganisms from closely located foci of osteomyelitis.
In newborns and young children, bacterial arthritis is more often caused by Staphylococcus, Enterobacteria, hemolytic streptococcus, Hemophilus bacillus. In adult patients, along with aerobes, anaerobic microorganisms are frequent causative agents of infectious arthritis: peptostreptococci, fusobacteria, clostridium, bacteroids. Acute bacterial arthritis can occur against the background of angina, sinusitis, pneumonia, furunculosis, pyelonephritis, infectious endocarditis, sepsis. In addition, there are specific infectious arthritis caused by tuberculosis, syphilis, gonorrhea, etc.
Fungal arthritis is usually associated with actinomycosis, aspergillosis, blastomycosis, candidiasis. Parasitic arthritis is usually associated with helminthic and protozoal infestations. Viral arthritis occurs in rubella, mumps, viral hepatitis B and C, infectious mononucleosis, etc. Post-traumatic infectious arthritis in most cases develops as a result of penetrating injuries of the joints. Iatrogenic infection is not excluded during therapeutic and diagnostic puncture of the joint, intra-articular injections, arthroscopy or endoprosthetics.
The category of persons with an increased risk of developing infectious arthritis includes patients suffering from rheumatoid arthritis, osteoarthritis, STIs, alcohol or drug addiction, immunodeficiency conditions, diabetes mellitus, obesity, vitamin deficiency; experiencing significant physical (including sports) loads, etc.
Symptoms
Infectious arthritis caused by nonspecific microflora (staphylococci, streptococci, Pseudomonas aeruginosa, etc.), have an acute onset with pronounced local and general manifestations. Local signs of purulent arthritis include sharp pain at rest, during palpation, active and passive movements; increasing swelling, changes in the contours of the joint; local redness and an increase in skin temperature. The consequence of a purulent-inflammatory reaction is a violation of the function of the limb, which takes a forced position. In most cases, acute infectious arthritis develops general symptoms – fever, chills, myalgia, sweating, weakness; in children – nausea and vomiting.
Septic arthritis usually occurs in the form of monoarthritis of the knee, hip or ankle joint. Polyarthritis usually develops in people receiving immunosuppressive therapy or suffering from joint pathology. In drug-addicted patients, there is often a lesion of the joints of the axial skeleton, mainly sacroiliitis. Infectious arthritis caused by Staphylococcus aureus can lead to the destruction of articular cartilage in just 1-2 days. With a severe course of purulent arthritis, osteoarthritis, septic shock and death may develop.
Infectious arthritis of gonococcal etiology is characterized by a skin-joint syndrome (periarthritis-dermatitis), characterized by multiple rashes on the skin and mucous membranes (petechiae, papules, pustules, hemorrhagic vesicles, etc.), migrating arthralgias, tenosynovitis. At the same time, the symptoms of primary urogenital infection (urethritis, cervicitis) may be erased or absent altogether. With gonorrheal arthritis, the joints of the hands, elbow, ankle, and knee joints are more often affected. Typical complications are flat feet, deforming osteoarthritis. Syphilitic arthritis occurs with the development of synovitis of the knee joints, syphilitic osteochondritis and dactylitis (arthritis of the fingers).
Tuberculosis arthritis has a chronic destructive course with the defeat of large (hip, knee, ankle, wrist) joints. Changes in articular tissues develop over several months. The course of the disease is associated with local synovitis and general tuberculosis intoxication. The mobility of the affected joint is limited by soreness and muscle contractures. When periarticular tissues are involved in the inflammatory process, “cold” abscesses may occur.
Arthritis associated with brucellosis occurs against the background of symptoms of a common infectious disease: wave-like fever, chills, torrential sweats, lymphadenitis, hepatomegaly and splenomegaly. Short-term myalgia and arthralgia, the development of spondylitis and sacroiliitis are characteristic.
Viral arthritis is usually characterized by a short-term course and complete reversibility of the changes that occur, without residual phenomena. There are migrating arthralgias, swelling of the joints, soreness of movements. The duration of the course of viral arthritis can range from 2-3 weeks to several months. Fungal arthritis is often combined with mycotic bone damage. The disease is characterized by a long course, the formation of fistulas. In the outcome of infectious arthritis of fungal etiology, deforming osteoarthritis or bone ankylosis of the joint may develop.
Diagnostics
Depending on the etiology of infectious arthritis, patients may need the advice and supervision of a surgeon, traumatologist, rheumatologist, phthisiologist, infectious disease specialist, venereologist. Ultrasound and radiography of the affected joints are among the priority measures for diagnosis. Radiologically, in infectious arthritis, osteoporosis, narrowing of the articular gap, bone ankylosis, bone erosions are determined. Ultrasound diagnostics reveals changes in periarticular tissues, the presence of intraarticular effusion. In the early stages, when radiographic signs of infectious arthritis are not yet detected, more sensitive methods can be used – CT of the joint, MRI, scintigraphy.
Important for the verification of the etiological factor are the data of diagnostic puncture of the joint, the study of synovial fluid (microscopy, cytology, culture on media). Of great diagnostic value in certain cases are enzyme immunoassay, bacteriological examination of blood and urethral discharge, a survey study of smears from the genital tract. The diagnosis of tuberculous arthritis is facilitated by a biopsy of the synovial membrane of the joint, the detection of other tuberculous foci in the body, positive tuberculin tests. Infectious arthritis is differentiated with rheumatoid, gouty arthritis, purulent bursitis, osteomyelitis.
Treatment
In the acute stage, the treatment of infectious arthritis is carried out inpatient. The limb is immobilized for a short period of time, followed by a gradual expansion of the motor mode, first due to passive, then active movements in the joint. In the event that an infection of the prosthetic joint has occurred, the endoprosthesis is removed. With purulent arthritis, daily arthrocentesis, lavage of the joint is performed, according to indications – arthroscopic rehabilitation of the joint or arthrotomy with flow-aspiration washing.
Drug therapy of infectious arthritis includes parenteral administration of antibiotics, taking into account the sensitivity of the identified pathogen (cephalosporins, synthetic penicillins, aminoglycosides), detoxification measures. With viral arthritis, NSAIDs are prescribed, with fungal infection – antimycotic drugs, with tuberculous arthritis – specific chemotherapy drugs. After the relief of acute inflammatory phenomena, a complex of physical therapy and physiotherapy, balneotherapy, massage is carried out to restore the function of the joint.
Prognosis and prevention
A third of patients who have had infectious arthritis have residual phenomena in the form of limited joint mobility, contractures, ankylosis. Septic arthritis poses a serious threat: despite the possibilities of therapeutic and surgical treatment, mortality in the complicated course reaches 5-15%. The unfavorable prognostic factors include rheumatoid arthritis, septicemia, old age, immunodeficiency conditions. Prevention of arthritis includes timely therapy of common infectious diseases, adequate physical activity, prevention of joint injuries, protection against STIs, compliance with the requirements of asepsis and antiseptics during surgical manipulations.