Colitic arthropathies.

"Colitic arthropathy" is commonly used to describe the arthritis associated with ulcerative colitis or regional enteritis. The term also describes the acute sterile arthritis which infrequently follows infection of the intestinal tract with Salmonella, Shigella, or Yersinia. Sterile arthritis is the most common extraintestinal manifestation of Whipple's disease, in which an unidentified bacteria is present in greatest concentration in the small bowel. Although arthritis and intestinal symptoms are common in Behcet's syndrome, the arthritis is not usually thought of as a colitic arthropathy because of the prominence of other signs, such as oral and genital ulceration and eye involvement. Joint and intestinal manifestations may, however, appear first or overshadow for a time involvement of other systems. Arthritis and arthralgia also occur frequently after jejunocolic and jejunoileal bypass.     

Reactive arthritis. A clinical approach

What do conjunctivitis, urethritis/cervicitis, and arthritis have in common? These are all clues to the diagnosis of reactive arthritis. It takes a keen eye, a thorough history, a good physical examination, and a broad differential diagnosis to pull together the picture when sorting through seemingly unrelated clinical symptoms. Often a team approach is used when caring for patients with reactive arthritis. This article presents the diagnosis and treatment of reactive arthritis.     

Arthralgias and arthritis in viral infections.

Arthritis and arthralgias are common in many viral infections. They are particularly prominent with hepatitis B virus and rubella infection, where they may be the major presenting symptom. "Lyme arthritis" is also associated with a virus. Similar symptoms are occasionally seen with adenovirus, Coxsackie and echovirus infection. Joint lesions are due to the deposition of immune complexes and not direct viral infection. While the arthritis is usually transient and self-limited, the physician must consider viral infections as etiologic agents of arthralgias and arthritis.     

Lymphocyte subsets and mitogen induced proliferation in adjuvant arthritis. Part I. Migration and function of the peripheral T lymphocytes.

Adjuvant arthritis (AA) was used as an animal model of rheumatoid arthritis in this study. Seventy 10-week-old inbred female rats of both Long-Evans rats (LE, high responder of adjuvant arthritis) and Sprague-Dawley rats (SD, low responder of adjuvant arthritis) were inoculated with adjuvant. Using monoclonal antibodies, we demonstrated that redistribution, migration, or an imbalance of T lymphocytes rather than the change of total T cells are involved in the pathogenesis of AA. After the adjuvant injection, the lymphocytic proliferative responses of LE and SD rats to phytohemagglutin (PHA) had no significant difference, whereas the response of LE rats to concanavalin A (ConA) was significantly lower than that of SD rats. In addition, a highly significant positive correlation was found between the absolute numbers of helper T cells and the lymphocytic proliferative response to PHA, and between absolute numbers of suppressor T cells and the lymphocytic proliferative response to Con A. We postulated high responder strain LE would have a defect in suppressor T lymphocytes leading to severe arthritis, while in low responder strain SD, adjuvant-activated suppressor T lymphocytes might reduce the severity of arthritis.     

Treatment of rheumatoid arthritis. New thoughts on the classic pyramid approach.

Treatment of rheumatoid arthritis can be quite challenging. Toxicity profiles of the various anti-inflammatory agents are often unacceptable, mainly because of gastrointestinal intolerance or bleeding. In addition, epidemiologic data suggest that rheumatoid arthritis is a disease with substantial morbidity and increased mortality. Consequently, newer trends in therapy involve earlier use of remittive agents as well as use of low-dose steroids. These modifications of the classic pyramid approach and the investigation of other methods may significantly influence the future of rheumatoid arthritis therapy and improve quality of life in those with the disease.     

Rheumatic diseases. 2. Therapeutic considerations.

In the management of rheumatic diseases, the use of corticosteroids should be reserved for active arthritis. Phenylbutazone (Butazolidin) is probably the drug of choice for acute gout and is also effective in ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. Indomethacin (Indocin) also is useful in these conditions. Ibuprofen (Motrin) is only slightly more efficacious than aspirin. Aspirin is still the preferred treatment for rheumatoid arthritis and should be tried before ibuprofen. Osteoarthritis of the cervical or lumbar spine calls for a full program of physical therapy. Experimental procedures for total replacement of joints other than hip and knee show promise.     

Septic arthritis after ureteroneocystostomy.

Acute infectious arthritis is an uncommon disease that is most commonly caused by Neisseria gonorrhoeae or gram-positive cocci. Gram-negative bacteria are an infrequent and highly virulent cause of septic arthritis and most commonly enter the circulation through the urinary tract, as in this case after ureteroneocystostomy. The resulting arthritis carries a mortality of 25% and a morbidity of 80%. Early recognition and treatment with appropriate antibiotics and mechanical drainage is imperative. Needle drainage of the affected joint has been shown superior to open surgical drainage.     

Alternative therapies for arthritis treatment. Part 2

Although modern medicine has been successful in managing infection and saving victims of multiple trauma, healthcare providers have offered little relief to individuals with chronic diseases, such as arthritis. Many patients with arthritis are seeking help with disease management from alternative therapies. When used along with allopathic medicine, these therapies may, in fact, increase quality of life for patients with arthritis. This article, second in a two-part series on alternative therapies, returns to the seven fields of practice identified by the National Institutes of Health (NIH) to explore additional treatment options for individuals with arthritis. Part 1 in this series was published in the September/October 2003 issue of Orthopaedic Nursing.     

Autoimmunity to collagen in adjuvant arthritis of rats.

Arthritis can be induced in rats by intradermal injection of oil containing bacterial derivatives (adjuvant-induced arthritis) or cartilage collagen (type II collagen-induced arthritis). It was of interest, therefore, to determine whether collagen functions as an autoantigen in rats with adjuvant arthritis. Blood mononuclear cells from the majority of rats with adjuvant arthritis exhibited enhanced thymidine incorporation to homologous types I and II collagens, as well as to purified protein derivative of tuberculin. In contrast, cells from rats remaining nonarthritic after injection of adjuvant did not respond to collagen, although they did react to tuberculin. Similar results were obtained with a radiometric ear assay used to quantify intradermal delayed-type hypersensitivity in vivo. Using passive hemagglutination, autoantibodies to these collagens and their denatured alpha-chains were frequently detected in the sera of rats late in the course of adjuvant arthritis. Rats with inflammation of a hindlimb induced by turpentine did not acquire sensitivity to collagen. These data indicate that autoimmunity to collagen is a common feature of adjuvant- and collagen-induced arthritis, both of which are considered to be mediated by immunologic mechanisms.     

Corticosteroid therapy for rheumatoid arthritis. Benefits and limitations.

Oral corticosteroids, despite their potential side effects, have a select role in the treatment of rheumatoid arthritis. For articular disease, these drugs must be targeted to short-term goals, such as symptom relief. Close attention to the indications and potential hazards of steroid therapy may ensure optimal benefit and reduced risk. Intra-articular steroid injections can provide local symptomatic relief when only one or a few joints are swollen. Septic arthritis is most important to exclude before injection of a joint. Complications of intra-articular injection are few, and relief may be long-lasting.     

Juvenile rheumatoid arthritis.

Juvenile rheumatoid arthritis is a diverse group of diseases that includes systemic-onset, polyarticular, and pauciarticular types. Appreciation of the different types and their hallmarks is particularly important to accurate diagnosis, which is determined by exclusion of other known disease entities in children with chronic arthritis (more than three months' duration). Therapy should be directed at the arthritis per se (synovitis), at the extra-articular manifestations, and at the whole child. Salicylates provide the most satisfactory control of the arthritis per se and of the systemic manifestations in most cases. Iridocyclitis should be managed in consultation with an ophthalmologist. Patients should not be regarded as invalids or restricted needlessly. The prognosis for children with juvenile rheumatoid arthritis is good. In most patients, the disease remits without causing permanent joint damage.     

Oral steroids in rheumatoid arthritis. Helpful but not remittive

Although low-dose oral corticosteroid therapy cannot be considered remittive, it has earned a place in the therapeutic armamentarium for rheumatoid arthritis. Major clinical trials of a group using corticosteroid compared with a control group have not been done since the 1950s. One of these three large trials showed some slowing of the destructive joint changes of rheumatoid arthritis with use of low doses of corticosteroid. However, these agents have well-known side effects, especially when used long-term. Elderly patients or those who have features of the disease that indicate progression (eg, multiple joint involvement, elevated ESR, early evidence of erosion on x-ray films) are likely to benefit from carefully controlled doses of a corticosteroid. Because these drugs diminish bone formation and arthritis itself accelerates osteoporosis, supplemental calcium and vitamin D are useful adjuncts. A remittive agent and aspirin-like drug should be prescribed along with the corticosteroid. Abrupt withdrawal of even a very low dose of corticosteroids in rheumatoid arthritis patients causes a flare.     

Thrombotic thrombocytopenic purpura in a patient with rheumatoid arthritis treated by plasmapheresis.

Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by consumptive thrombocytopenia, microangiopathic hemolytic anemia, and neurologic symptoms. TTP is associated with many diseases and several therapeutic drugs. We report the rare case of a patient with rheumatoid arthritis who developed TTP that was not associated with drug therapy, 18 months after the onset of rheumatoid arthritis. She recovered from the TTP following daily sessions of therapeutic plasma exchange (TPE) with fresh frozen plasma replacement and glucocorticoid therapy. Recent pathogenic mechanisms are reviewed as they relate to von Willebrand factor. In this report of the rare association of TTP with rheumatoid arthritis, an immediate relationship is likely because both are of an immune nature. Awareness of the possible development of TTP in rheumatoid arthritis is important for early diagnosis and treatment.     

Complications of cervical arthritis.

Cervical arthritis can result in clinically important complications through a variety of mechanisms. The potentially most serious complication is spinal cord or nerve root compression, caused by either degenerative osteophytes or one or more of several subluxation patterns prevalent in inflammatory joint diseases. Disabling pain arising directly from the affected joints is more difficult to document but probably occurs often in the upper cervical spine, particularly in patients with rheumatoid arthritis. Limitation of head and neck mobility, with or without pain, commonly develops in inflammatory arthropathies, especially ankylosing spondylitis and juvenile rheumatoid arthritis. In the absence of neurologic signs or symptoms, most cases of symptomatic cervical arthritis should be diagnosed and treated conservatively.     

Different HLA-D associations in adult and juvenile rheumatoid arthritis.

HLA-D typing was performed in 126 patients with juvenile rheumatoid arthritis. HLA-DW4, the antigen found in previous studies to characterize adult rheumatoid arthritis, had a significantly lower frequency in children with arthritis than in normal controls (P less than 0.04). By contrast, in children the antigens HLA-DW7 (P less than 0.03) and HLA-DW8 (P less than 0.01) were increased compared to controls. The antigen TMo, detected with homozygous typing cells from a child with juvenile rheumatoid arthritis, was found to be related to the cross-reactive specificities HLA-DW7 and DW11. 46% of the patients with persistent pauciarticular arthritis of childhood typed for the antigen TMo, compared to only 1% of normal controls. Thus the relative risk for persistent pauciarticular arthritis in relation to the presence of TMo was 67.7 (P less than 0.0001). These results provide evidence of fundamental differences between adult rheumatoid arthritis and arthritis of childhood. The latter group appears to include a population distinguishable clinically and characterized in these studies by the HLA-D determinant TMo.     

Amelioration of collagen-induced arthritis by CD95 (Apo-1/Fas)-ligand gene transfer.

Both rheumatoid arthritis and animal models of autoimmune arthritis are characterized by hyperactivation of synovial cells and hyperplasia of the synovial membrane. The activated synovial cells produce inflammatory cytokines and degradative enzymes that lead to destruction of cartilage and bones. Effective treatment of arthritis may require elimination of most or all activated synovial cells. The death factor Fas/Apo-1 and its ligand (FasL) play pivotal roles in maintaining self-tolerance and immune privilege. Fas is expressed constitutively in most tissues, and is dramatically upregulated at the site of inflammation. In both rheumatoid arthritis and animal models of autoimmune arthritis, high levels of Fas are expressed on activated synovial cells and infiltrating leukocytes in the inflamed joints. Unlike Fas, however, the levels of FasL expressed in the arthritic joints are extremely low, and most activated synovial cells survive despite high levels of Fas expression. To upregulate FasL expression in the arthritic joints, we have generated a recombinant replication-defective adenovirus carrying FasL gene; injection of the FasL virus into inflamed joints conferred high levels of FasL expression, induced apoptosis of synovial cells, and ameliorated collagen-induced arthritis in DBA/1 mice. The Fas-ligand virus also inhibited production of interferon-gamma by collagen-specific T cells. Coadministration of Fas-immunoglobulin fusion protein with the Fas-ligand virus prevented these effects, demonstrating the specificity of the Fas-ligand virus. Thus, FasL gene transfer at the site of inflammation effectively ameliorates autoimmune disease.     

Managing arthritis with exercise.

Almost half of all older adults have arthritis, either degenerative or inflammatory. Regular exercise is an important therapeutic intervention for all types of arthritis. Specifically, regular exercise can prevent deconditioning of the muscles, keep the joints stable, improve joint function and flexibility, decrease pain, enhance aerobic fitness, improve balance, and decrease falls. A comprehensive exercise program should include stretching exercises followed by a range-of-motion program for joints, muscle strengthening, and aerobic exercise, if possible. Unfortunately, despite these known benefits, most older adults with arthritis do not engage in regular exercise. The Seven Step Approach was developed to provide a practical framework to help overcome barriers and improve exercise activity in older adults with arthritis.     

Differential roles of nitric oxide and oxygen radicals in chondrocytes affected by osteoarthritis and rheumatoid arthritis.

Osteoarthritis and rheumatoid arthritis are characterized by focal loss of cartilage due to an up-regulation of catabolic pathways, induced mainly by pro-inflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNFalpha). Since reactive oxygen species are also involved in this extracellular-matrix-degrading activity, we aimed to compare the chondrocyte oxidative status responsible for cartilage damage occurring in primarily degenerative (osteoarthritis) and inflammatory (rheumatoid arthritis) joint diseases. Human articular chondrocytes were isolated from patients with osteoarthritis or rheumatoid arthritis, or from multi-organ donors, and stimulated with IL-1beta and/or TNFalpha. We evaluated the oxidative stress related to reactive nitrogen and oxygen intermediates, measuring NO(-)(2) as a stable end-product of nitric oxide generation and superoxide dismutase as an antioxidant enzyme induced by radical oxygen species. We found that cells from patients with osteoarthritis produced higher levels of NO(-)(2) than those from patients with rheumatoid arthritis. In addition, IL-1beta was more potent than TNFalpha in inducing nitric oxide in both arthritides, and TNFalpha alone was almost ineffective in cells from rheumatoid arthritis patients. We also observed that the intracellular content of copper/zinc superoxide dismutase (Cu/ZnSOD) was always lower in rheumatoid arthritis chondrocytes than in those from multi-organ donors, whereas no differences were found in intracellular manganese SOD (MnSOD) or in supernatant Cu/ZnSOD and MnSOD levels. Moreover, intracellular MnSOD was up-regulated by cytokines in osteoarthritis chondrocytes. In conclusion, our results suggest that nitric oxide may play a major role in altering chondrocyte functions in osteoarthritis, whereas the harmful effects of radical oxygen species are more evident in chondrocytes from patients with rheumatoid arthritis, due to an oxidant/antioxidant imbalance.     

Immunoglobulin E-rheumatoid factor in the serum of patients with rheumatoid arthritis, asthma, and other diseases.

A solid-phase radioimmunoassay was developed to detect immunoglobulin (Ig)E antibodies that bound to human IgG. IgE-rheumatoid factor activity was found in the serum of 18 of 20 patients with seropositive rheumatoid arthritis, 1 of 4 patients with seronegative rheumatoid arthritis, 3 of 32 patients with seronegative rheumatoid arthritis, 3 of 32 patients with asthma, and in 1 patient with hypocomplementemic vasculitis and iodide sensitivity. Immunopathologic implications of IgE-rheumatoid factor are discussed.     

HL-A27 and arthritis.

In patients with recent inflammatory arthritis HL-A27 was seen in 6 out of 7 patients with ankylosing spondylitis, in 15 out of 18 patients with Reiter's disease, in 9 out of 12 patients with reactive postinfectious arthritis, in 22 out of 45 patients with rheumatoid arthritis, and in 2 out of 14 patients with other types of inflammatory arthritis. In two control series HL-A27 occurred in 46 out of 326 persons and in 3 out of 34 persons. The high frequency of HL-A27 in RA patients is in disagreement with previous results by other investigators. The explanation for this may be either that the diagnostic criteria do not apply at the early stage of the disease, or that there is a high prevalence of HL-A27 associated RA in Finland.