Differential diagnosis of chronic urogenic arthritis

AIM: To investigate features of chronic urogenic arthritis (CUA) and its differences with psoriatic arthritis (PA) and ankylosing spondylarthritis (AS) with joint lesion. MATERIALS AND METHODS: CUA, AS, PA were diagnosed according to S. M. Sidelnikova et al., S. van der Linden and Agababova, respectively, in 94 patients. The disease ran for more than 3 years. Articular syndrome was examined in CUA, AS and PA. RESULTS: Articular syndrome in CUA remains for the most part monoarticular with affection of the joints of the low extremities. AS has clinical and x-ray signs of sacroileitis, affection of the spinal column and hip joints. PA runs with multiple arthritic lesions of the hand and foot joints. CONCLUSIONS: Chronic infection persists in all the CUA and PA patients. Its exacerbation coincides with arthritis aggravations. Only in CUA there is a chronological connection between acute or aggravated chronic urogenital infection and initial symptoms of joint disease.     

Reactive arthritis in young men in organized collectives]

The authors followed up 398 young males with reactive arthritis who had been admitted from organized collectives to hospital settings. Only one third of them could connect the development of reactive arthritis (ReA) with a survived infection: acute nasopharyngeal (26%), acute enterocolitis (7%), urethritis venerea (1%). Analysis of the clinical picture demonstrated that in case of indefinite ReA etiology together with the signs of myocardiac involvement one should not only exclude the presence of rheumatic attack but also to establish a possible relation of the disease with a prior survived poorly manifest intestinal infection. This fact should be taken into account if in the collectives, where from the patients were hospitalized, epidemic outbreaks of acute dysentery or cases of ReA and Reiter's disease etiologically connected with manifest intestinal infection were documented. Postenterocolitic origin of ReA could be suspected in patients with its continuous course and resistance to antiinflammatory therapy in whom arthralgia was preserved for a long time as was joint rigidity after a subsidence of joint changes due to the effect of acute inflammation. Besides, the detection of certain features of the articular syndrome and separate extraarticular signs characteristic of Reiter's disease and other conditions which comprised the group of seronegative HLA--B27-positive spondyloarthropathy are of high diagnostic value.     

Treatment of psoriatic arthritis with etanercept, a tumour necrosis factor antagonist

Psoriatic arthritis (PsA) is a chronic spondylarthritis that occurs in approximately 23% of plaque psoriasis sufferers. Traditional treatments for rheumatoid arthritis have been used as the first therapeutic approach to treat this inflammatory disease, which has both joint and skin manifestations. However, due to the inefficiency of current disease-modifying antirheumatic drugs and non-steroidal anti-inflammatory drugs in stopping the progression of the joint disease, biologics have emerged as a hopeful alternative to PsA therapy. Etanercept was the first approved tumour necrosis factor-alpha (TNF-alpha) inhibitor for reducing the signs and symptoms of PsA, as well as preventing the progression of the disease. Etanercept is a fully human, soluble, dimeric fusion protein that has the ability to bind to two molecules of TNF, thereby rendering them biologically inactive. Two clinical trials have demonstrated that etanercept is generally a safe, efficacious and well-tolerated biologic therapy for the treatment of PsA.     

The clinical and immunogenetic characteristics of reactive arthritis in children

Altogether 52 children suffering from reactive arthritis were placed under observation. In 45 patients arthritis developed after nasopharyngeal infection and was marked by a favourable course with a rapid positive dynamics. 7 children with a history of intestinal infection manifested Reiter's syndrome; in these children arthritis was characterized by a grave and prolonged course and by a high laboratory activity. HLA A10 (RR = 2.7), B27 (RR = 2.5) and DR2 (RR = 2.19) antigen were detected significantly more frequently in ReA patients who suffered nasopharyngeal infection. In children with Reiter's syndrome, the genetic markers of predisposition to the disease were HLA A10 (RR = 5.93) and B27 (RR = 149.1) antigens.     

The clinical aspects of the diagnosis of rheumatoid arthritis]

Altogether 212 patients aged 16 to 73 years with rheumatoid arthritis (RA) lasting 3 months to 32 years were examined. Of these, 78 patients had grade I, 111 grade II, and 23 grade III disease activity. 34 patients had stage I, 76--stage II, 56--stage III, and 24--stage IV disease. In 22 patients, roentgenography failed to reveal pathology of the joints. The reference group comprised 65 patients suffering from gouty arthritis, 46 having osteoarthrosis deformans with phenomena of secondary synovitis, 30 with Bekhterev's disease, 10 with systemic lupus erythematosus, 6 with Reiter's disease, 5 with psoriatic arthropathy, and 50 with non-rheumatic diseases. When trying the diagnostic criteria for ARA (revised in 1987), criteria 1-4 and 7 were found to be most sensitive (from 88.2 to 93.8%), criteria 5 and 6 appeared most specific (100 and 98.6%, respectively). The specificity of the remaining criteria ranged from 85.4 to 96.3%. The use of the revised criteria for ARA in clinical practice was dictated by the necessity of improving RA diagnosis.     

Role of arthroscopy in the diagnosis of chronic monoarthritis of the knee joint

The author analyzes the arthroscopy findings of 70 knee joints in 68 patients (35 men and 33 women) suffering from chronic monoarthritis of the knee joints with a disease standing from 3 months to 12 years. According to the x-ray data the overwhelming majority of the joints (54) showed stage 0-1, 15 stage II and 1 stage III of the pathological process. In accordance with the preliminary diagnoses 32 patients had synovitis of unclear genesis, 4 rheumatoid arthritis, 3 gonarthrosis deformans, 2 psoriatic arthritis, 5 patients were afflicted with Bechterew's disease, 1 with chondromatosis, and in 21 patients the diagnosis was doubtful. Arthroscopy promoted considerable improvement of the diagnosis, since rheumatoid arthritis including juvenile one was recognized in 12 patients, psoriatic arthritis in 8, reactive synovitis due to gonarthrosis in 16, Bechterew's disease in 12, Reiter's disease in 2, chondromatosis in 4, and pigmented villous-nodular synovitis in 3. The arthroscopic appearance of the disease remained unclear in 7 patients. Therefore, arthroscopy proved a highly effectual method that permits one to differentiate between reactive synovitis and genuine inflammatory diseases and to differentiate with a great probability between rheumatoid synovitis, psoriatic arthropathy and Bechterew's disease.     

Haptoglobin phenotype in patients with spondyloarthritis and healthy individuals

Haptoglobin (Hp) phenotype distribution was evaluated in 95 patients with seronegative spondylarthritis and 100 normal controls. The incidence of three Hp types was virtually the same in acute patients and controls. Reactive arthritis was associated with Hp2-1 type, psoriatic arthritis with Hp1-1 type, ankylosing spondylarthritis with Hp2-2 type. The authors suggest that the presence of Hp2-2 type is one of genetic factors of seronegative spondylarthritis.     

Immune disorders and sensitization to microbial antigens in seronegative spondylitis

A study was made of immunity in seronegative spondylarthritis. In ankylosing spondylarthritis, reactive arthritides and psoriatic arthritis, the decrease of T cells, T helpers and T suppressors was identified. Patients with ankylosing spondylarthritis and reactive arthritides manifested an increase of the B-lymphocyte count. Patients with ankylosing spondylarthritis were demonstrated to be sensitive to Klebsiella (52%), those with reactive arthritides to intestinal yersinia (44%). The phenotype of antigen-binding cells was examined. Of these, 39% appeared to be T lymphocytes, 29% B lymphocytes. The presence of Fc receptors in an appreciable portion of those cells suggests their functional maturity. The inhibition test demonstrated the participation of HLA-B27 in reception of Klebsiella antigens in ankylosing spondylarthritis.     

The clinico-echocardiographic characteristics of heart involvement in seronegative spondylarthritis (Reiter's disease, Bechterew's disease and psoriatic arthritis)

As many as 136 patients (76 with Bechterew's disease, 40 with Reiter's disease and 20 with psoriatic arthritic) and 35 practically healthy persons were examined by echocardiography combined with electro-, phonocardiographic and by clinical, x-ray and laboratory methods. 62 patients were examined over time (within a period from 1 to 4 years). Echocardiography was used to study in detail the central and intracardiac hemodynamics, the status of the valvular apparatus of the heart and of the aorta. The different clinical characteristics of the disease were established to make a concrete contribution to the development of cardial pathology. The disease duration is the most significant characteristics. A long-term prospective follow-up coupled with echocardiographic examinations made over time enabled one to specify the structure of heart damage in patients suffering from Bechterew's disease, Reiter's disease and psoriatic arthritis depending on the hypothetic nature of the damage.     

The typical features and clinical characteristics of Reiter's syndrome with a nonvenereal origin

Analysis of the clinical picture in 37 patients with Reiter's syndrome unrelated to venereal urethritis showed that in the majority of cases, it was preceded by acute intestinal infection which occasionally ran an unmarked course. The difficulties in diagnosing Reiter's syndrome were caused in some patients by the fact that in the disease debut, conjunctivitis and urethritis were little manifest and of short duration or occurred at the later stages, especially where the triad was preceded by the provoking factors, such as supercooling and nasopharyngeal infection. Also, in the acute phase of the disease, the patients demonstrated catarrh of the upper respiratory tract, the signs of myocardial injury and some symptoms characteristic of other rheumatological diseases. In this connection attention is drawn to the necessity of inquiring after the patients' health and sensations in doubtful cases, including the elucidation of the epidemiological anamnesis, thorough examination of the patients on admission to hospital and during the treatment to specify both the main and additional signs of Reiter's syndrome, and analysis of the disease course.     

Nosological diagnosis and outcomes of arthritis associated with streptococcal infection

AIM: To specify the course and outcomes of arthritides associated with streptococcal infection (AASI). MATERIAL AND METHODS: The trial comprised 60 patients with arthritis (mean age 26.8 +/- 14.0). The patients met the following criteria: arthritis, elevated (< 500 U) titers of antistreptolisin-0 in the absence of heart disorders detected at Doppler-echocardiography (2D-echoCG), urogenital infection, Yersinia infection, psoriasis. In addition to routine clinical tests, the following investigations were made: tests for alloantigen of B-lymphocytes D8/17 and antigen HLA-B27, antibodies to polysaccharide of streptococcus of group A, bacteriological test of laryngeal smears for streptococcal infection, prospective follow-up (mean 31.2 +/- 19.6 mon) with 2D-echoCG. RESULTS: Rheumatic arthritis was rejected in 33.3% patients. Other diseases were diagnosed: early rheumatoid arthritis (10%), seronegative spondylarthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, Still's disease, Konig's disease, sarcoidosis, gout, arthritis on the background of streptococcal nodular erythema. Acute rheumatoid fever (ARF) was diagnosed in 56.7% patients, poststreptococcal arthritis (PSA) in 10%. PSA differed from ARF by onset at the age of 36.0 +/- 10.2 years, short latent period (11.2 +/- 1.3 days), a significantly longer course of arthritis (95.0 +/- 3.9 days), recurrences. Alloantigen of B-lymphocytes was detected in 52.8% AASI patients (the difference from the control is highly significant (p < 0.001). Arthritis development was not associated with carriage of HLA-B27 carriage. CONCLUSION: In examination of AASI patients for diagnosis of ARV and PSA it is necessary to reject other diseases among which early RA (10%) is most frequent. It is recommended to make diagnosis of ARF in AASI patients with definition of risk factors (age 7-15 years, family history of rheumatic fever, carriage of alloantigen d8/17), 2.5-year and longer follow-up with 2D-echoCG. Diagnosis of PSA is made in rejection of ARF and in the presence of the following characteristics: development of the disease at the age 30-40 years, a short latent period of the infection, long-term persistent course of arthritis, insufficient effect of nonsteroid anti-inflammatory drugs, frequent affection of sacroiliac joints, recurrence, entezopathy.     

The characteristics of the course of inflammatory joint diseases in the inhabitants of an agricultural region]

The course of the main chronic inflammatory diseases of the joints was analyzed with special reference to the rural region of Georgia. 30 patients with rheumatoid arthritis (RA), 13 with ankylosing spondylarthritis, and 6 with reactive arthritis are registered and followed up by the rheumatologist. It is shown that the population of the region in question is characterized by a later onset of RA, a high percentage of the seronegative variety of the disease with involvement of the hand joints, and ankylosing of the carpal joints. The males demonstrate a low activity of the process. Since RA ran a benign course, the patients were only treated with nonsteroidal anti-inflammatory agents. The RA patients preserved work fitness for a long time. Ankylosing spondylarthritis was marked by the primary injury to the spine associated with the development of ankylosis and calcification of the ligamentous apparatus without a well-defined spinal deformity. Large-scale examination of the population of the region has shown the necessity of such measures for they permit identification of new cases of the disease to carry out early adequate treatment and specialized employment of the patients.     

Dissecting popliteal cyst: an unusual complication of Reiter's syndrome.

A case of Reiter's syndrome associated with a dissecting popliteal cyst mimicking deep vein thrombophlebitis is reported. The cyst was diagnosed by arthrography and responded to intra-articular injection of corticosteroids. The diagnosis of a dissecting popliteal cyst should be considered in a patient with arthritis of the knee joint from any cause and who develops signs and symptoms of thrombophlebitis.     

Evolution of seronegative arthritis

The paper is concerned with the results of a follow up of 67 patients with seronegative arthritis. The average duration of observation was 7.6 yrs. Diagnoses in 4 patients were established on a repeated clinicolaboratory and x-ray study: ankylosing spondylitis, Reiter's syndrome, Yersinia arthritis and gonorrheal arthritis. A picture of seropositive rheumatoid arthritis was noted in 16 patients (24%). In 47 patients arthritis remained seronegative. Of them in 30 patients a course of disease did not differ from that of seropositive rheumatoid arthritis. Considerable progression of disease was noted at the acute onset of disease with multiple involvement of the joints and a high inflammatory and immunological activity of a process. A morphological investigation of the synovial bioptates in 20 patients did not reveal a classical picture of rheumatoid synovitis even in a prolonged course of seronegative rheumatoid arthritis. The authors defined two variants of morphological changes in the synovial tissue in this group corresponding to a benign and progressive course of seronegative RA.     

Diagnosis of rheumatic disease. 1. Radiographs.

Radiographs are a clinician's most valuable tool in differential diagnosis of rheumatic disease and in assessment of its severity. The patterns of joint involvement and the specific bony changes characteristic of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome and psoriatic arthritis, gout, and systemic lupus erythematosus are discussed here.     

Blood serum and synovial fluid proteins in Reiter's syndrome

Individual proteins (transferrin, ceruloplasmin, alpha 2-macroglobulin, IgG, IgA and IgM) were examined in blood and synovial fluid of 11 patients with Reiter's syndrome. ARA-1981 was used as a diagnostic criteria. The control group included 40 patients with rheumatoid arthritis and 31 with osteoarthrosis of the knee joint. Statistically significant differences between the concentrations of individual proteins in patients with Reiter's syndrome, rheumatoid arthritis and osteoarthritis were only established in synovial fluid for IgM and for IgM index Csf/CS.     

Arthritis and the gut

The term "enteropathic arthritis" describes joint manifestations that occur in conjunction with gastrointestinal disease. Underlying causes include inflammatory bowel disease, reactive arthritis, iatrogenic disease. Whipple's disease, and other gastrointestinal diseases. A possible association between Reiter's syndrome and human immunodeficiency virus infection also has been reported. These arthritic syndromes can be treated symptomatically, but long-term therapy should be directed at the underlying cause. In most cases, prognosis for survival and joint function is good.     

The Clinical Features and HLA Associations of Reactive Arthritis Associated with Non-Gonococcal Urethritis

Fifty-seven patients with arthritis associated with non-gonococcalgenital infection have been studied. Synovitis characteristicallyaffected one or a few joints, especially the knee, ankle ormetatarsophalangeal joints and was accompanied by tenosynovitisand enthesopathies—each in about one third of the patients.A quarter of the patients had ocular, cutaneous, or mucous membranelesions (Reiter's syndrome). Although six patients developeda chronic or relapsing course, average duration of the acuteepisode in the majority was three to five months. Availableevidence strongly suggests that infection following sexual intercourse,usually but not always with a new partner, was instrumentalin the initiation of the disease. We have suggested the term‘sexually acquired reactive arthritis (SARA)’ toemphasize the mode of acquisition of the disease, and note thatsimilar syndromes are seen associated with gut infection. Weconsider that usage of the term Reiter's syndrome is correctlyapplied to only those cases which exhibited the characteristictriad of urethritis, arthritis and conjunctivitis with or withoutother cutaneous and mucous membrane lesions. Thirty-six of the54 patients who were HLA typed (67 per cent) possessed the antigenHLA-B27. Of 30 who presented directly to a rheumatology unit25 (83 per cent) were HLA-B27 positive. The other 24 patientsinitially attended a venereology clinic and only 11 (46 percent) of these bore the antigen. This appears to reflect diseaseseverity, HLA-B27 positive patients having a significantly longerduration of disease symptoms and a higher frequency of extra-articularmanifestations, than those lacking this antigen.     

The clinical features and HLA associations of reactive arthritis associated with non-gonococcal urethritis

Fifty-seven patients with arthritis associated with non-gonococcal genital infection have been studied. Synovitis characteristically affected one or a few joints, expecially the knee, ankle or metatarsophalangeal joints and was accompanied by tenosynovitis and enthesopathies--each in about one third of the patients. A quarter of the patients had ocular, cutaneous, or mucous membrane lesions (Reiter's syndrome). Although six patients developed a chronic or relapsing course, average duration of the acute episode in the majority was three to five months. Available evidence strongly suggests that infection following sexual intercourse, usually but not always with a new partner, was instrumental in the initiation of the disease. We have suggested the term 'sexually acquired reactive arthritis (SARA)' to emphasize the mode of acquisition of the disease, and note that similar syndromes are seen associated with gut infection. We consider that usage of the term Reiter's syndrome is correctly applied to only those cases which exhibited the characteristic triad of urethritis, arthritis and conjunctivitis with or without other cutaneous and mucous membrane lesions. Thirty-six of the 54 patients who were HLA typed (67 per cent) possessed the antigen HLA-B27. Of 30 who presented directly to a rheumatology unit 25 (82 per cent) were HLA-B27 positive. The other 24 patients initially attended a venereology clinic and only 11 (46 per cent) of these bore the antigen. This appears to reflect disease severity, HLA-B27 positive patients having a significantly longer duration of disease symptoms and a higher frequency of extra-articular manifestations, than those lacking this antigen.     

The peripheral joint syndrome in ankylosing spondylitis--one of the variants of reactive arthritis

In 75 patients with central (n = 37) and peripheral (n = 38) ankylosing spondylarthritis, EIA was used to detect serum antibodies to Klebsiella (IgG and IgA) and to the common enterobacterial antigen (CEBA) as compared to the level of the ESR, C-reactive protein and circulating immune complexes. Out of the 75 patients, 53 were examined for the intestinal microflora. Serum antibodies to Klebsiella were demonstrated more frequently in the peripheral form than in the central one, particularly in demonstrating Klebsiella coproculture. The presence of serum antibodies correlated with the disease activity. In the central form, enterobacteria without Klebsiella prevailed in the intestine. In both forms, antibodies to CEBA were demonstrated not so frequently (in 1/4 of the patients). In both forms, a large number of cases (74-80%) showed intestinal dysbacteriosis; in the peripheral form, however, it reached a greater degree. As to the central form, the etiological role of Klebsiella is not absolutely clear. It is more remarkable in the peripheral articular syndrome (reactive arthritis towards Klebsiella?) associated with ankylosing spondylarthritis.