Arthropathy

Description:

Now reactive arthritis (arthropathy) is one of the most frequent rheumatological diagnoses. Usually reactive consider arthritis which does not meet diagnostic criteria of rhematoid or gouty arthritis and is not followed by extraarticular symptomatology, specific to general rheumatic diseases. Reactive arthritis represents group of diseases which are characterized by the same defeat of a musculoskeletal system.

Being not the heaviest, but, certainly, one of the most widespread rheumatic diseases, reactive arthritis generates ambiguity of opinions of specialists and essential distinctions in approaches to its treatment. Therefore it is reasonable to begin illumination of a problem of reactive arthritis with determination of its nosological essence.

Arthropathy symptoms:

Can include symptoms of reactive arthritis (arthropathy):
- characteristic joint syndrome;
- clinic of an urogenital infection;
- extraarticular defeats (skin and mucous membranes);
- damages of a backbone (usually sacroileitis);
- visceral defeats;
- system inflammatory reaction.

The joint syndrome (obligatory display of a disease) is characterized:
– an asymmetric oligoarthritis (an inflammation of 2-3 joints or joint groups) with damage of joints of legs (knee, talocrural, metatarsophalangeal and interphalanx) and a tendovaginitis (achillobursitis);
– the beginning of the first episode of arthritis during the period up to 30 days after sexual contact, with an average interval in 14 days between emergence of urogenital symptoms and arthritis;
– pain and rigidity with hypostasis or without it in the field of an attachment of muscles, sinews and sheaves, especially an Achilles tendon and a plantar fascia, to a calcaneus that often leads to difficulties when walking.

Clinical signs of arthritis.
1. Joint/joints pain:
- it is felt in all joint;
- it is connected with the movements and a day-night rhythm (at any movements, amplifies at rest and at night);
- it is accompanied by amplitude of movements in a joint (at the movements in all planes, accruing with increase in amplitude of movements);
- usually stupid, aching, unscrewing.

2. Constraint – subjective feeling of an obstacle to the movement which is, as a rule, most expressed right after awakening, the period of rest or inactivity. Constraint is caused by disturbance of outflow of liquid from the inflamed joint at rest, decreases or passes when resuming movements in a joint. Duration and expressiveness of constraint reflect degree of a local inflammation.

3. A swelling – passing increase in sizes and change of a contour of a joint, caused both by accumulation of exudate in a joint cavity, and hypostasis of periartikulyarny fabrics. Most clearly the swelling comes to light on extensor (back) surfaces of elbow and radiocarpal joints, on a brush, knee and ankle joints and foot.

4. Temperature increase of joints also is an inflammation sign. Is determined by carrying out the palm back by the surface of a joint.

5. Morbidity of a joint at a palpation confirms that joint pain is caused by its defeat, but is not reflected.

Radiological symptoms of arthritis at an early stage: circumarticular osteoporosis (the main sign), periartikulyarny hypostasis of soft tissues, expansion of a joint crack is possible (in small joints).

Clinic of an urogenital infection
Signs and symptoms of an urogenital infection are caused mainly by a cervicitis and an urethritis, and also their complications.

At women symptoms of an urogenital infection approximately in 30% of cases are:
- mucopurulent cervicitis;
- purulent discharges from a vagina;
- pain in the lower part of a stomach;
- post-coital or intermenstrual bleeding;
- dysuria;
- symptoms of an inflammatory disease of bodies of a small pelvis, chronic pain in the field of bodies of a small pelvis.

At men approximately in 75% of cases the urogenital infection is followed by the following symptoms:
- allocations from an urethra;
- dysuria;
- symptoms of an epididymite or prostatitis.

The symptoms characteristic both for men, and for women:
- anorectal allocations and discomfort;
- conjunctivitis.

Extraarticular defeats
1. Irritation of eyes with redness or without it, photophobia or easing of visual activity (conjunctivitis) take place at 20-25% of patients with reactive arthritis, the iritis is less widespread and comes to light only at 2-11% of patients. A keratohelcosis and a keratitis can seldom be observed, optical neuritis and a back uveitis are described.
2. Psoriasiform rashes in the form of typical plaques or tear-shaped psoriasis are noted at 12,5% of patients; dystrophy of nails – at 6-12%; the typical psoriasis centers on generative organs (a ring-shaped balanitis or a vulvitis) – at 14-40%; geographical language – approximately at 16%; pustular psoriasis on soles of feet (a keratoderm blennorragichesky) – at 33%. The last sometimes meets on palms of hands. Stomatitis and ulcerations of an oral cavity come to light approximately at 10% of patients.

Damages of a backbone
Lower back pain and rigidity are typical for a disease debut, sacroileitis signs (positive symptoms of Kushelevsky) are observed at 10% of patients. At the same time radiological signs of a unilateral sacroileitis come to light approximately at a half of patients.

Visceral defeats
1. Pathology of kidneys (a proteinuria, a microhematuria and an aseptic leukocyturia) is observed in 50% of cases and usually asymptomatically. The glomerulonephritis and an IgA-nephropathy meet seldom.
2. The ischemic centers in heart almost always of a bessimptomna, are possible tachycardia and occasionally a pericardis, and also defeat of the aortal valve. Disturbances of an ECG, including a conductivity delay, are registered at 5-14% of patients.
3. Rare manifestations include defeats of a nervous system (an encephalomeningitis and flaccid paralyzes).

System inflammatory reaction
System symptoms of an indisposition, fatigue, loss of weight and fever occur approximately at 10% of patients. Practical at all patients in clinical blood test the blood sedimentation rate (BSR) is raised.

Clinical current and forecast
1. At most of persons the disease has the self-limited character with an average duration of the first episode of arthritis of 4-6 months. Complications of reactive arthritis arise mainly owing to aggressive arthritis and are most probable if the patient has HLA-B27 gene.
2. Approximately at 50% of patients an arthritis recurrence through various intervals of time is observed.
3. Hronifikation diseases with a persistirovaniye of symptoms within more than one year is marked out approximately at 17% of patients.
4. Erosive damage of joints is especially characteristic of small joints of foot. Approximately at 12% of patients deformations of foot develop, however heavy deformation meets seldom.
5. In the absence of treatment or recurrent character the acute front uveitis can lead to bystry formation of a cataract.

Arthropathy reasons:

The reason of reactive arthritis is unknown. Presumably, genetically determined anomaly of immune system (the disease 50 times more often is diagnosed for HLA-B27 histocompatibility antigens carriers), which is implemented at infection with some microorganisms is the cornerstone of reactive arthritis.

Treatment of the Arthropathy:

Treatment of reactive arthritis (arthropathy) is carried out in two directions:
1. Antibacterial therapy.
2. Therapy of a joint syndrome.

Antibacterial therapy of reactive arthritis:
- Duration of treatment makes 7 days.
- Patients with a chlamydial infection have to be inspected on existence of other infections, sexually transmitted.
- It is recommended to abstain from sexual contacts within 7 days after end of a 7-day course of treatment and also until all sexual partners of the patient do not complete the corresponding course of treatment.

The recommended schemes:
- Azithromycin in a dose of 1,0 g orally once (effective concentration of drug in blood and fabrics remains 7-10 days) or
- Doxycycline on 100 mg orally 2 times a day during 7 days


Alternative schemes (equivalent):
- Erythromycin on 500 mg orally 4 times a day during 7 days, or
- Ofloxacin on 200 mg orally 2 times a day for 7 days, or
- Roksitromitsin on 150 mg orally 2 times a day during 7 days, or
- Klaritromitsin on 250 mg orally 2 times a day for 7 days

Additional drugs:
- Amoxicillin on 500 mg orally 3 times a day during 7 days or
- Dzhozamitsin on 750 mg orally 2 times a day for 7 days
Erythromycin is less effective, than azithromycin or doxycycline, and its side effects on digestive tract often force patients to refuse such scheme of treatment.

Roksitromitsin and кларитромицин are alternative makrolidny antibiotics with high concentration in fabrics and are transferred by patients better as are more favorable from the point of view of side effects.

Ofloxacin is similar by efficiency to doxycycline and azithromycin, but more expensive also has no advantage in a dosage. Other hinolona are insufficiently effective against a chlamydial infection.

Doxycycline and ofloxacin are contraindicated to pregnant women.
Dzhozamitsin in Ukraine appoint rather seldom (respectively, the probability of nonsensitivity of the microbic agent to drug is less).
Dzhozamitsin and amoxicillin it is possible to appoint pregnant.