Associate Professor, Department of Faculty Therapy, Russian State Medical University
Candidate of Medical Sciences
“Post-infectious arthritis” or infection-associated arthritis, reactive arthritis is inflammation of the joint in patients who have suffered a urogenital infection. Extra-articular manifestations are typical in the form of damage to the urinary tract, mucous membranes of the eyes, oral cavity, skin damage, and damage to internal organs. Reiter's disease is a urogenic arthritis caused by chlamydial infection.
The duration of the disease in acute and subacute cases is 3-6 months, in protracted cases - up to a year. In 2/3 of patients, a primary chronic or recurrent course of urogenic arthritis is observed.
1. Direct hematogenous (through blood) introduction of infection into the joints. This option most often occurs in the disseminated form of gonococcal infection. Although some researchers recognize hematogenous introduction (through infected marophages) into the joints of chlamydia, herpes viruses, and ureaplasma.
2. An autoimmune mechanism in which the body begins to produce autoantibodies to its own tissues, in this case, to the cells of the synovial membrane of the joints. The term urogenic reactive arthritis is used to designate this form. It most often occurs in intracellular forms of parasitism of the pathogen - chlamydial infection (as a component of Reiter's syndrome) and genital herpes. Cases of reactive arthritis are also observed with mycoplasmosis.
The most significant etiological factor in the development of urogenic arthritis is currently recognized as chlamydia - Chlamydia trachomatis. This pathogen was found in scrapings from the urethra and cervical canal of patients with urogenic arthritis. In the presence of anogenital and orogenital contacts, chlamydia can be detected in scrapings from the rectum and pharynx. Currently, chlamydia is the most common sexually transmitted infection, especially among young people and adolescents. It is possible that chlamydia may be present for many years in the joint cavity and cause direct damage to the cells of the articular cartilage.
Another causative agent of urogenital infections is mycoplasma, and the most important among this class of microorganisms are Ureaplasma urealyticum and Mycoplasma genitalium, because The primary habitat of these microbes is the urinary tract and genitals.
Quite often, a chlamydial-ureaplasma association is found in people suffering from chronic urethritis. In urogenic arthritis it occurs in 10% of cases. A combination of gonococcal infection with chlamydial and ureaplasma is possible.
The danger of the infections discussed lies in their frequent asymptomatic course. As a rule, patients seek help with the development of complications such as inflammatory diseases of the pelvic organs, reproductive disorders, chronic prostatitis and epididymitis, eye lesions (recurrent conjunctivitis, iritis, iridocyclitis), lesions of the joints and periarticular tissues - arthritis, bursitis, tenosynovitis .
In this regard, there are two forms of chlamydia: complicated and uncomplicated.
Therapeutic tactics for these clinical forms vary.
Urogenic arthritis is a complicated form of urogenital chlamydia or ureaplasma infection. In the development of this complication, an important role is played by the characteristics of the immune response to bacterial antigens, which may be genetically determined.
The frequent combination of gonococcal infections with trichomonas, staphylococcal and viral infections has created conditions for the development of cross-forms of allergies, changes in the immunological reactivity of the body, which contributes to the occurrence of urogenital arthritis.
During arthritis, two phases are distinguished: infectious (early) and immunopathological (late). In the late phase of the disease, it is rarely possible to detect microbial antigens.
If there are contraindications, consult a specialist
• Involvement of the sacroiliac joints in the process.
- With urethritis. Urethritis is observed at the onset of the disease, preceding articular syndrome. Due to the fact that it occurs slowly, most patients do not seek medical help at this stage of the process. When the process becomes chronic, urethritis is complicated by chronic prostatitis and epididymitis. Women most often develop endocervicitis, which is manifested by scanty vaginal discharge. Women turn to a gynecologist only when complications arise, such as chronic adnexitis, menstrual irregularities, and infertility. A common manifestation of genitourinary infection is acute or recurrent chronic cystitis, chronic pyelonephritis.
- Conjunctivitis. Conjunctivitis may go unnoticed by the patient, because... lasts 1-2 days, is mild, manifests itself with slight redness, itching, and is usually regarded as allergic. At the same time, it should be noted that chlamydial conjunctivitis is prone to recurrence.
- Skin lesions. Damage to the oral mucosa: erosive or aphthous stomatitis, glossitis. Damage to the skin and mucous membranes is also manifested by recurrent balanitis, balanoposthitis. An important clinical syndrome is damage to the skin of the palms and feet of the keratoderma type, which is combined with changes in the nails.
• Generalized lymphadenopathy is considered as a systemic manifestation of urogenic arthritis. Enlargement of the inguinal lymph nodes should be regarded as a reaction to inflammation of the pelvic organs.
• Involvement of internal organs in the pathological process occurs during a long, persistent, highly active course of the disease. Heart damage can manifest itself as myocardial dystrophy, myocarditis, and in very rare cases, pericarditis and endocarditis, which can lead to the formation of aortic insufficiency. Neurological disorders range from autonomic disorders to rare cases of meningitis and meningoencephalitis.
2) Detection of antibodies to chlamydial or mycoplasma antigens (usually using ELISA).
3) Molecular genetic methods for detecting chlamydia and mycoplasmas: polymerase chain reaction (PCR) and DNA probes. These methods are very sensitive and specific, they can detect the presence of minimal concentrations of microbial antigens.
4) Study of scrapings from the urethra in men and from the cervical canal in women for chlamydia and ureaplasma.
5) To detect gonococcal infection, the Bordet-Gengou reaction, detection of gonococcus in the genitourinary organs, and the complement fixation reaction with the standard gonococcal antigen are used.
6) Detection of antigonococcal antibodies, immunoglobulins M, A, G in the blood of patients with gonorrhea and a decrease in their content after treatment indicate immunological disorders.
7) If there are symptoms of chronic prostatitis, a study of prostatic secretions is indicated.
8) In some cases, pathogens are found in smears from the conjunctival sac, in scrapings from the rectum, in the morning urine (usually in chronic urinary tract infections).
9) The detection of microbial antigens in synovial fluid is especially informative, but this study is only possible with significant exudation in the joint.
10) Laboratory examination reveals an acceleration of ESR, positive rheumatic tests (increased levels of C-reactive protein, seromucoids, a-globulins, fibrinogen). Rheumatoid factor is not detected.
11) X-ray changes can be detected only in the chronic course of the disease. An earlier radiological sign of urogenic arthritis is narrowing of the iliosacral joint.
1. Elimination of infection in the urogenital tract. Broad-spectrum antibiotics are used. Tetracyclines, macrolides, azalides, fluoroquinolones, and, to a lesser extent, chloramphenicol and rifampicin are active against chlamydia. Macrolides, azalides and tetracyclines are most active against ureaplasmas. The choice of antibiotic is dictated by the type of pathogen, individual tolerance, and cost-effectiveness.
It must be emphasized that sexual partners of patients with urogenic arthritis should also receive antibacterial therapy. Control tests for chlamydia and ureaplasma should be carried out monthly for 3 months. If pathogens are detected again, it is necessary to re-administer a course of treatment.
In addition, antibacterial therapy is recommended to be combined with immunomodulatory therapy (T-activin, thymalin, thymogen, thyoptin, immunoglobulin, interferon, interferon inducers).
2. Treatment of arthritis, including anti-inflammatory therapy, the use of basic agents, immunomodulators, and local therapy methods.
Pharmacotherapy of articular syndrome in urogenic arthritis should begin with the use of non-steroidal anti-inflammatory drugs. In the selection of a particular drug, individual sensitivity and tolerance play an important role. To reduce side effects, primarily NSAID gastropathy (stomach damage), local methods of administering NSAIDs are used - ointments, creams, gels, rectal suppositories.
Glucocorticosteroids (GCS) are prescribed when the activity of the process is high and the effectiveness of NSAIDs is low. It should be emphasized that GCS should be administered locally - intra-articularly or periarticularly. Internal corticosteroids are indicated only in the presence of severe systemic manifestations, such as carditis, meningoencephalitis, polyneuritis. However, it should be remembered that long-term use of GCS promotes the carriage of an infectious agent, and also leads to joint destruction due to a negative effect on cartilage.
In the chronic, recurrent course of urogenic arthritis, the prescription of basic drugs is indicated: aminoquinoline drugs, sulfonamides, gold drugs, immunosuppressants.
3.Physiotherapeutic methods, physical therapy, massage, sanatorium-resort treatment.
Chlamydial arthritis (urogenic) is an acute infectious lesion of the peripheral joints. It appears after a patient is infected with the bacteria Clamidia trachomatis. This disease belongs to the triad of Reiter's disease (Fissenger-Leroy-Reiter syndrome) and combines inflammation of the joints, eyes and genitourinary organs in the form of urethroprostatitis.
It is important to remember that the manifestation of all three symptoms at the same time (classic form of the disease) is not necessary; they often occur sequentially at long intervals (incomplete form of the disease).
The main category of patients are men and women of sexually active age (20-45 years), with rare exceptions children, adolescents and the elderly are affected.
Not only Clamidia trachomatis, but also many other bacteria that cause the following symptoms can awaken the chlamydial type of arthritis:
With urogenic arthritis, chlamydia does not penetrate the joint. This disease is classified as “sterile” and does not allow the virus to enter the joint cavity. The cause of the pathology is other factors.
A malfunction in the human immune system may occur, in which pathogenic microorganisms and one’s own cells become confused.
Since the receptors on the articular surfaces of bones and the receptors on the shell of chlamydia are similar to each other, an autoimmune process is launched in the body, in which microorganisms are its catalyst.
Under such conditions, antibodies together with antigens form a circulating immune complex that causes damage to the joint tissues.
Symptoms of arthritis are observed in 4% of patients with chlamydia.
Important! Even despite complete recovery from chlamydia (disappearance of urogenital signs of the disease), arthritis will not disappear without special comprehensive treatment, but will develop further.
Developing chlamydial arthritis is divided into 2 stages:
Several features can be identified in the development of urogenic arthritis.
Differences in degrees of FSI (functional joint insufficiency):
Chlamydial arthritis is the main attribute of Reiter's disease. It occurs within 1-3 months after the onset of urethritis. Most often, this type of arthritis affects several joints:
Usually one joint (monoarthritis) is affected; sometimes there may be two affected joints (oligoarthritis). If the signs of the disease are completely ignored and treatment is not timely, these types can affect several joints at once (polyarthritis). Classic is asymmetric inflammation (one-sided).
Small joints, such as the hands, can develop dactylitis. Such inflammation will lead to deformation of the fingers (they will begin to resemble sausages in shape).
Urogenic arthritis initially occurs in an acute form. Its main symptoms quickly appear - the joint quickly swells and increases in size, the skin over it becomes inflamed (hyperemic). The patient's general health gradually deteriorates, chills and fever occur, loss of appetite, weakness and increased fatigue occur.
The inflammatory process that occurs in the vertebrae (spondylitis) manifests itself in 40% of cases. The main clinical signs of its presence are back pain, both during physical activity and at rest.
The consequences of these diseases can be complete atrophy of the muscles surrounding the joint due to a decrease in the volume of muscle tissue.
In addition to the loss of muscle mass, the pathological process affects the joint capsules, which causes bursitis; tendons - tendonitis; fasciitis; periosteum - periostitis.
Urethritis occurs within 7-30 days after sexual intercourse. Its symptoms are poorly defined or absent altogether.
Often patients do not experience pain when urinating or excessive discharge; nothing bothers the patient. In rare cases there are:
In 30% of cases, patients develop prostatitis, pyelonephritis or acute cystitis. Pathologies manifest themselves in dysuric disorders:
External symptoms of Reiter's syndrome manifest themselves in the form of painless ulcers and erosions (aphthous stomatitis) on the skin and mucous membranes. Nail dystrophy, keratoderma (plaques on the skin similar to psoriatic plaques), balanoposthitis and balanitis (inflammation of the foreskin and glans penis) may also appear.
Eye symptoms are represented by the appearance of iridocyclitis, episcleritis, conjunctivitis and uveitis. The nervous system suffers in the form of peripheral polyneuropathy, radiculitis and encephalopathy.
For adequate treatment of chlamydial arthritis, all sexual partners of the patient should be checked and, if a source of infection is detected, they should be offered a set of antibacterial procedures.
Antibacterial therapy includes:
Taking various drugs based on penicillin and cephalosporins is undesirable, since they create resistance to chlamydia (Augmentin, Ceftriaxone, Ospamox, Cefazolin, Cefepime).
NSAIDs are used to reduce inflammation. The main drugs in this group are nimesulide (Nimesil, Nise), piroxicam (Revmoxicam), diclofenac sodium (Naklofen, Ortofen), celecoxib (Celebrex), ibuprofen (Nurofen, Ibuprom).
Such drugs exist in various dosage forms: injections (intra-articular and intramuscular); rectal (suppositories). Gels and ointments are produced for external use. For oral administration – dragees, capsules, tablets, powders.
When the disease has entered the chronic stage, doctors advise the use of adrenal hormones, in particular Diprospan, Prednisolone, Kenalog. At the same time, cytostatics and sala-derived drugs (Ftorafur, Sulfasalazine, Methotrexate) will be effective.
Chlamydia - gram-negative bacteria that reproduce only intracellularly and cause various diseases in humans - is currently considered the main pathogen that plays a role in the development of urogenic arthritis.
In 1973, Finnish scientist p. Ahvonen proposed the term “reactive arthritis” (ReA), which has become widespread. By “reactive” we mean aseptic (non-purulent) arthritis that developed in close chronological connection with any infection. At the same time, the putative etiological agent (microbe, virus) cannot be isolated from the synovial fluid, and the development of joint inflammation is explained from the position of as yet undeciphered immunological reactions. In recent years, this concept has been revised, since in a number of reactive arthritis (for example, yersinia, chlamydia), antigens and even whole intact cells of the putative causative microorganism have been detected in the joint using modern methods. In such cases, it would be more correct to talk not about “reactive”, but about “post-infectious” arthritis, which is more consistent with the existing classification of inflammatory joint diseases associated with infection (D. Dumonde, 1979). Nevertheless, the term “reactive” arthritis has been retained to this day in almost all classifications and guidelines on rheumatology.
The postenterocolitic variant is usually combined with the histocompatibility antigen HLA B27 and is considered within the framework of seronegative spondyloarthropathies.
There is no exact data on the spread of reactive arthritis. According to the Institute of Rheumatology of the Russian Academy of Medical Sciences and some foreign authors, patients with ReA make up about 10% of patients in rheumatology hospitals. At the Institute of Rheumatology in different years, 50–75% of all reactive arthritis were urogenic.
Currently, chlamydia is recognized as the main pathogen involved in the development of urogenic arthritis. Chlamydia are gram-negative bacteria, adapted only to intracellular reproduction (obligate parasites) and causing a wide range of diseases in humans and animals. There are 3 known types of chlamydia: C. trahomatis (cervicitis, urethritis, salpingitis, perihepatitis, proctitis, prostatitis, epididymitis, conjunctivitis, pneumonia, pharyngitis), C. psittaci (ornithosis and other numerous diseases of animals and humans), C. pneumoniae (interstitial pneumonia , upper respiratory tract diseases). Diagnosis of chlamydial infection is a rather difficult problem, since chlamydia does not grow on solid nutrient media. They are cultivated either in chicken embryos or in continuous cell cultures; these methods cannot be used in the practice of medical institutions. Chlamydia can be detected in scraping material of the epithelium of the genitourinary tract, conjunctiva, and respiratory tract using light microscopy of preparations stained according to Romanovsky-Giemsa, May-Grunwald-Giemsa, and Lugol's solution, but the sensitivity of these methods is not high. Microscopy of preparations stained with the immunoperoxidase method gives good results, but is not widespread. Most often, the direct immunofluorescent method using monoclonal antibodies is used to diagnose chlamydia in practical healthcare. According to the Institute of Rheumatology of the Russian Academy of Medical Sciences, more than 80% of cases of urogenic reactive arthritis are associated with chlamydial infection. Chlamydia can also be detected in patients with postenterocolitic reactive arthritis, especially with the development of Reiter's syndrome. This is probably due to the activation of latent urogenital chlamydia after an intestinal infection. However, chlamydia itself can cause intestinal disorders, in particular proctitis.
Urogenic arthritis usually occurs in young (under 40 years of age) sexually active people. In the chronic course of chlamydial infection, they are sometimes observed at an older age. The main contingent of patients are men, apparently due to a more vivid clinical picture, which facilitates the diagnosis of the disease. Urogenic arthritis occurs, as a rule, in people suffering from non-gonococcal (post-gonococcal) urethritis. Chlamydia infection is considered the most common form of sexually transmitted infections; it occurs 2–6 times more often than gonorrhea. Of all cases of non-gonococcal urethritis, it accounts for about 60%. According to English authors (A. Keat et al), from 1 to 3% of patients with non-gonococcal urethritis develop urogenic arthritis. The close association of urogenic arthritis with chlamydial infection has allowed a number of authors to identify a variant called “chlamydia-induced arthritis,” i.e., “aseptic” arthritis, which develops in the presence of a predisposition following a primary extra-articular infection caused by C. trachomatis. An acute infection or exacerbation of a chronic genitourinary infection immediately preceding articular syndrome is a prerequisite for a diagnosis of reactive arthritis. Most patients associate the onset of the disease with sexual contact with a new partner. However, a household route of infection is also possible (towel, linen, etc.). In men, urethritis, prostatitis, and less often cystitis are most often diagnosed; in women, cystitis, endocervicitis, and adnexitis are diagnosed. As a rule, urogenital inflammation is not as acute as, for example, with gonorrhea. In approximately a quarter of cases, signs of urogenital inflammation are detected only during laboratory testing: leukocyturia, sometimes gross hematuria, increased number of leukocytes in smears of the genitourinary tract, etc. Over time, signs of inflammation of the genitourinary tract may subside on their own. In this regard, it is very important to conduct examination at the earliest stages of the disease.
The clinical picture of articular syndrome in urogenic reactive arthritis is very peculiar and allows one to suspect it even in cases with asymptomatic genitourinary inflammation, to which the patient himself may not pay attention. Arthritis most often begins acutely, with pronounced exudative phenomena. Many patients have increased body temperature, up to febrile levels. Damage to the joints of the lower extremities predominates. Most often, the process involves the knee and ankle joints, small joints of the feet. A “sausage-shaped” deformation of the toes is very characteristic. The skin over the inflamed joints is often hyperemic, sometimes with a cyanotic tint. When the joints of the first toes are affected, a “pseudo-gouty” toe is formed. Almost any joint can be involved in the process. In acute reactive arthritis, joint damage is most often asymmetrical. The number of inflamed joints is usually small. There are both monoarthritis and oligo- and polyarthritis. The presence of enthesopathies (i.e., inflammatory changes in the area of attachment of tendons and aponeuroses to the bones), especially in the area of the heel bones, is very characteristic. Heel enthesopathies are difficult to treat and may be the only manifestation of damage to the musculoskeletal system. In approximately half of the patients, signs of inflammation of the iliosacral joints and spine are detected, but, unlike ankylosing spondylitis, spinal lesions, as a rule, recede into the background against the background of active peripheral arthritis. With a prolonged (6–12 months) and chronic (more than 12 months) course of the disease, the nature of the articular syndrome changes: the number of affected joints increases, the arthritis becomes more symmetrical, and the joints of the upper extremities and spine are more often involved.
With urogenic reactive arthritis, extra-articular manifestations characteristic of Reiter's disease (syndrome) may also occur, when conjunctivitis and/or damage to the skin and mucous membranes (balanitis, keratoderma) are added to urethritis and arthritis. Until now, the question of whether urogenic arthritis is considered synonymous with Reiter's disease is controversial. Some researchers believe that Reiter's disease can be spoken of only in the presence of a complete symptom complex that developed after enterocolitis, as described by Reiter. If the clinical picture is limited to urethritis and arthritis, then urogenic arthritis should be diagnosed. Others believe that the term “Reiter’s disease” is not correct at all, since it is not an independent nosological unit, but a syndrome that occurs in many, for example, intestinal infections. However, a number of observations confirm the dominant role of chlamydia in this pathology. Thus, research from the Institute of Rheumatology has shown that in the presence of signs of Reiter’s disease (syndrome) in the urogenitals, intestines, and even the conjunctiva, chlamydia is found in more than 60% of cases of postenterocolitic arthritis. The commonality of urogenic arthritis and Reiter's disease is also supported by the fact that conjunctivitis can appear at different stages of the disease. More often it develops in the first weeks of the disease, but sometimes only with repeated attacks or months later with chronic or protracted arthritis. The same can be said about damage to the skin and mucous membranes. At the same time, we have more than once observed cases where the first attack was characterized by a full set of symptoms of Reiter’s disease, which did not recur later.
Conjunctivitis in arthritis associated with chlamydial infection is usually short-lived, clinically not pronounced, and quickly relieved with antibacterial agents (drops, ointments). In some cases, conjunctivitis is diagnosed only by a doctor. More severe lesions of the organ of vision - iritis, iridocyclitis, uveitis - occur in 5-10% of patients with urogeinic arthritis and can lead to persistent loss of vision and even complete blindness.
Damage to the skin and mucous membranes occurs in approximately half of patients with urogenic arthritis. The most common condition is balanitis or balanoposthitis. Approximately 5% of patients experience a peculiar lesion of the skin of the palms and soles, keratoderma, which is clinically and morphologically very similar to pustular psoriasis. Keratoderma is often combined with nail changes such as onychia, onycholysis, onychodystrophy or paronychia. Occasionally, psoriasis-like plaques are observed on various parts of the body and scalp, which makes differential diagnosis with psoriatic arthritis difficult. In a number of patients, painless or slightly painful erosions of the oral mucosa, such as stomatitis or glossitis, can be detected, which often do not manifest themselves clinically and go unnoticed.
Among other extra-articular manifestations, it should be noted the presence of lymphadenopathy (especially inguinal lymph nodes), which occurs in a significant proportion of patients. Lymph nodes are usually moderately enlarged and painless. Inguinal lymphadenopathy, obviously, can be considered as a reaction of regional lymph nodes to infection of the pelvic organs. Many patients with urogenic arthritis quickly develop muscle atrophy, especially pronounced near the inflamed joints, which, according to some researchers, cannot be fully explained by physical inactivity of the limbs due to pain. Apparently, in these cases, neurotrophic disorders also occur. Neurological manifestations of urogenic arthritis are also common. The most common disorders of the autonomic nervous system are pronounced hyperhidrosis of the skin of the palms and soles. Less common are neuritis of peripheral nerves with sensory disturbances and even motor impairments. The literature describes cases of meningitis and meningoencephalitis, which can cause death.
In the chronic course of urogenic arthritis with high process activity, secondary amyloidosis can develop. Amyloid kidney damage is the most common cause of death in patients with urogenic arthritis.
Some patients experience changes in the ECG, pain in the heart area, less often shortness of breath, palpitations, which can be regarded as manifestations of myocardial dystrophy or myocarditis. In rare cases, signs of pericarditis or endocarditis are detected. In isolated cases, heart defects develop (usually aortic valve insufficiency). Laboratory testing reveals an increase in ESR, levels of C-reactive protein, α2-globulin, fibrinogen, seromucoids and other nonspecific indicators of inflammation. Rheumatoid factor is not detected. 80-90% of patients with urogenic arthritis are carriers of HLA B27. In the urine, especially at the onset of the disease or during its exacerbations, leukocyturia, microhematuria, and moderate proteinuria are detected, especially in the first portion of urine.
X-ray examination of the joints reveals epiphyseal osteoporosis, cyst-like clearing of bone tissue, narrowing of cracks and erosions, most often asymmetrical. The erosive process is usually localized in the area of the metatarsophalangeal and interphalangeal joints of the toes. With enthesopathies of the calcaneal bones, osteoporosis, erosions are found in the early stages, and in later stages - tendoperiostitis at the sites of attachment of tendons and ligaments and the so-called “loose heel spurs”. When examining the spine, just a few months after the onset of the disease, one can detect radiological signs of sacroiliitis, the frequency of detection and severity of which increase with the duration of the disease. In the chronic course of urogenic arthritis, single paravertebral ossifications or syndesmophytes can form.
The course of urogenic arthritis largely depends on how it is possible to sanitize the infectious focus in the urogenital tract. Among our patients, the majority were patients with the first attack of the disease. The duration of complete clinical remission varied from several months to 10 or more years. The duration of each exacerbation in 65% of patients did not exceed 6 months, in the rest it was 12 months or more. Relapses of the disease in some patients were associated with reinfection, in others with exacerbation of the urogenital focus of infection. With relapses, arthritis more often acquired a tendency to become chronic.
The basic principles of therapy for urogenic arthritis can be divided into three areas: rehabilitation of the infectious focus in the urogenital tract; (2) treatment of articular syndrome; (3) rehabilitation measures. To sanitize the infectious focus of chlamydia, tetracyclines, macrolides, and fluoroquinolones are used. Our experience has shown that 7-15-day courses of antibiotics used to treat uncomplicated urogenital chlamydia are ineffective in treating it in patients with arthritis. We use 28-30 day courses. At the same time, antifungal antibiotics are prescribed. The choice of antibiotic is determined by many factors: individual tolerance, time of year, as well as the cost of the drug and the convenience of taking it. In the summer, tetracycline antibiotics and fluoroquinolones should be used with caution due to the risk of developing photodermatitis. It is also necessary to take into account the composition of the microflora found in the urogenital tract, in addition to chlamydia. In case of chlamydia, one should refrain from prescribing penicillin antibiotics due to the possibility of chlamydia transforming into L-like forms and persisting infection. A control test for chlamydia immediately after finishing a course of antibiotic therapy usually gives negative results. Therefore, mandatory monthly examinations are required for 3 months. If chlamydia is re-diagnosed, it is necessary to repeat the course of treatment.
Multivitamin preparations are also indicated, especially those containing B vitamins. The administration of enzyme preparations such as lidase, trypsin, and chymotrypsin for chronic chlamydia improves treatment results.
Chlamydial arthritis is an acute autoimmune lesion of peripheral joints that occurs after a patient is infected with Clamidia trachomatis. Urogenic arthritis is part of the triad of Reiter's disease (or Fissenger-Leroy-Reiter syndrome) - a combined lesion of the genitourinary organs in the form of nonspecific urethroprostatitis, inflammation of the eyes and joints.
It should be noted that the simultaneous combination of all three syndromes is classic and rare. Most often they occur sequentially, at significant intervals (the so-called “incomplete” form of the disease).
The disease is more common in men and women of sexually active age (20-40 years), although cases have been described in children, adolescents, and the elderly.
In addition to chlamydia, the disease can be caused by:
The appearance of this disease does not mean that chlamydia has penetrated the joint. The disease refers to “sterile” arthritis, when no bacteria or viruses are found in the joint cavity. The reason for the appearance of pathology lies much deeper.
Our immune system sometimes confuses the body's own cells with pathogenic microorganisms. In this case, the receptors on the membrane of chlamydia and on the articular surfaces of bones are very similar. Microorganisms play the role of a trigger for the disease, therefore, under certain conditions (thymoma, excessive immune function), immune cells can become confused, and an autoimmune process occurs. Antibodies interact with antigens, and circulating immune complexes are formed that damage their own tissues.
Typically, arthritis occurs in 4% of people with chlamydia. Even if the patient is completely cured of chlamydia, his urogenital manifestations of the disease will disappear, but arthritis will flourish without special treatment.
The development of the disease can be divided into 2 successive stages:
By degree of activity:
According to the degree of functional joint insufficiency (FJ):
Arthritis is the main manifestation of the disease, it occurs approximately 1-3 months after the onset of urethritis. The favorite joints for the disease are peripheral:
Usually 1 (monoarthritis) or 2 (oligoarthritis) joints are affected. If the disease is not treated, the inflammatory process can spread to a large number of joints (polyarthritis). Inflammation is predominantly unilateral (asymmetric).
Small joints are characterized by the development of dactylitis (“sausage-shaped” defiguration of the finger).
Urogenic arthritis usually begins acutely, the joint quickly swells, increases in size, and the skin over it becomes hyperemic. The patient's condition progressively worsens, fever, chills, general weakness, loss of appetite, and increased fatigue occur.
Spondylitis (inflammation of the vertebrae) occurs in 40% of cases, clinically manifested as back pain during exercise and at rest.
The muscles surrounding the joint decrease in volume, up to complete atrophy. In addition to muscle mass, the pathological process involves: joint capsule (bursitis), tendons (tendinitis), muscle fascia (fasciitis), periosteum (periostitis). Over time, patients experience difficulty walking, lameness, and flat feet. In some cases, patients complain of “heel spurs” (enthesitis).
Urethritis usually occurs 7-30 days after sexual intercourse. It is mild or asymptomatic; most often, patients do not experience pain when urinating or excessive discharge. Patients may not be bothered by anything; occasionally, scanty mucous or mucopurulent discharge from the urethra, itching, the urge to urinate, and hyperemia around the external opening of the urethra occur.
Acute cystitis, pyelonephritis, prostatitis occur in 30% of cases. They manifest themselves as dysuric disorders (burning sensation when urinating, frequent urge to urinate), the appearance of white blood cells in the urine (leukocyturia), protein (proteinuria), and a small amount of blood (microhematuria).
Damage to the skin and mucous membranes manifests itself in the form of painless erosions and ulcers (aphthous stomatitis), keratoderma (the appearance of plaques on the skin similar to psoriatic ones), nail dystrophy, balanitis and balanoposthitis (inflammation of the glans penis and foreskin).
Changes in the eyes include conjunctivitis, episcleritis, uveitis, and iridocyclitis.
Damage to the nervous system causes radiculitis, peripheral polyneuropathy, and encephalopathy.
- thrombocytosis (increase in platelets);
- anemia (decreased number of red blood cells)
- proteinuria (the appearance of protein in it);
— leukocyturia (excretion of leukocytes);
- microhematuria (release of red blood cells)
- poor formation of mucin clot;
- increase in the number of leukocytes (more than 7 thousand/mm3), 70% of them are neutrophils;
- increase in protein content;
- bacteria or their remains are not detected
In order for treatment to make sense, it is necessary to check all the patient’s sexual partners and, if an infection is detected, offer them a course of antibacterial therapy.
It is not recommended to use penicillins (Augmentin, Ospamox) and cephalosporins (Ceftriaxone, Cefepime, Cefazolin), as they can cause the formation of resistance in chlamydia.
Anti-inflammatory drugs (NSAIDs) are used to reduce inflammation. The main representatives of this group include: diclofenac sodium (“Ortofen”, “Naklofen”), nimesulide (“Nimesil”, “Nise”), ibuprofen (“Ibuprom”, “Nurofen”), piroxicam (“Revmoxicam”), celecoxib ( "Celebrex")
These drugs can be used for external use (in the form of ointments, gels), injections (intramuscular and intraarticular), oral administration (tablets, powders, dragees) or rectally (rectal suppositories).
In chronic cases, it is recommended to use adrenal hormones (Prednisolone, Diprospan, Kenalog), cytostatics (Methotrexate, Ftorafur), and sala derivatives (Sulfasalazine).
Therapy for conjunctivitis includes the use of anti-inflammatory eye drops (Sofradex, Normax, Floxal) and eye ointments.
Skin lesions are treated with ointments containing glucocorticosteroids (hydrocortisone ointment, Elokom). For erosive processes in the mouth, rinses with a solution of furatsilin, potassium permanganate, sodium bicarbonate, and chamomile decoction are used.
Modern research is studying the role of biological agents (microorganisms specially bred using genetic engineering) for the treatment of advanced cases of urogenic reactive arthritis. These include TNF-inhibitors? (“Infliximab”, “Etanercept”, “Anakinra”).
But orthopedist Sergei Bubnovsky claims that a truly effective remedy for joint pain exists! Read more >>
There are several types of arthritis that fall under the term urogenic reactive arthritis. It is worth noting that this reactive arthritis is manifested by inflammation of the synovial membrane of the joints due to complications of a genital infection. Such complications develop extremely rarely, but if the approach to treatment is incorrect or untimely, they can lead to serious consequences, including disability.
Urogenic reactive arthritis is more common in men than in women. Statistics show that approximately 80% of cases of urogenic reactive arthritis occur among the stronger sex, while in women the incidence rates fluctuate at only 20%. This unequal ratio is explained by the difference in the microflora of the genital organs in men and women, which makes the fair sex more immune-resistant to a number of pathogenic infections that can cause the development of an inflammatory process in the joint capsule.
Considering the international classification, we can distinguish 3 main types of reactive arthritis, which may have a urogenic etiology. It is worth noting right away: despite the fact that the inflammatory process in the joints is caused by an infection of the genitourinary system, the location of the primary process can still be in different organs of the reproductive system. It is still unknown whether the location of the inflammatory process in the organs of the genitourinary system plays any role, but it is still believed that the greatest risk of developing concomitant reactive arthritis is observed after or during the course of urethritis. The types of urogenic arthritis and the frequency of their occurrence must be considered separately.
Regardless of the microorganisms that became the impetus for the development of reactive arthritis, the process of development of joint disease is similar, as are the clinical manifestations.
There is no general consensus in the scientific medical community regarding the etiology of this disease, but nevertheless, based on clinical studies, the main components of this process have been identified. The development of the disease is based on an autoimmune reaction, therefore, when examining the joint fluid, no bacteria or markers of their presence are detected. An autoimmune reaction is a failure in the immune system in which antibodies produced by the body to fight the initial infection located in the genitourinary system begin to identify synovial membrane tissue as foreign. In reactive arthritis, the mechanism of the autoimmune reaction is quite complex, since it is triggered by an extra-articular infection located far from the localization of the joints.
The reasons for such failures in the immune system have not yet been established, but there are 2 theories as to why antibodies designed to fight infection begin to attack healthy joint tissue. According to the first theory, the main problem in the development of such a reaction lies in the similarity of antigens secreted by the cells of the synovial sac and those secreted by certain types of pathogenic microorganisms to protect against the immune reaction. The second theory explains the development of an autoimmune reaction somewhat differently. A possible reason for the development of inflammation in the joint lies in the entry into the joint capsule of fragments of dead bacteria, which the immune system marks as foreign bodies. In this case, the body sends antibodies to the “address”, but since there are no pathogenic bacteria, a malfunction occurs and the antibodies begin to attack the joint tissue, which leads to a non-infectious inflammatory process.
There is also a theory of genetic predisposition to the development of reactive arthritis, which is also not without foundation, because in fact, in some patients, infections of the genitourinary system go away without a trace, without any complications, while in others such serious inflammatory processes of the joint tissue are observed. The development of an autoimmune reaction is associated with the presence of HLA group antibodies.
In addition, the theory is considered according to which pathogenic microorganisms, in the course of their life activity, modify antibodies that are initially produced by the body to fight them. Modified antibodies begin to attack healthy joint tissue, which may have some similarities with pathogenic organisms, but do not affect pathogenic bacteria. Modified antibodies are not recognized by the immune system as pathogenic, so the immune system does not prevent the destruction of healthy tissue.
Clinical manifestations of reactive arthritis begin to be observed approximately 30 days after infection of the body with pathogenic microorganisms. In some cases, manifestations of reactive arthritis are observed as early as 2 weeks after the onset of symptoms from infected organs of the genitourinary system. Two main stages of development of any type of reactive arthritis can be distinguished.
The most characteristic symptoms of joint damage in urogenic reactive arthritis are observed in the joints of the lower extremities, that is, in the knees and feet. It is possible to identify a number of clinical symptoms that accompany the development of urogenic reactive arthritis.
A certain percentage of patients experience complications of the disease with fasciitis, dactylitis and tenosynovitis. In rare cases, acute reactive arthritis may be accompanied by severe pain in the joints and soft tissues adjacent to them. For urogenic reactive arthritis, damage from 1 to 5 joints is typical. After a certain period of the disease, soft tissues located near the joints can also be affected. In this case, deformation of the finger joints occurs.
Under certain unfavorable factors, a number of complications of arthritis may develop. One of the most common complications is the appearance of chronic arthritis, which over time leads to the complete destruction of damaged joints and can cause the disease to spread to other elements for which no pronounced symptoms were previously observed.
The course of urogenic chronic arthritis is always accompanied by a period of exacerbations and remissions, so it is not always possible to completely cure this disease, even with the use of modern medical means. A common complication of these types of reactive arthritis is severe joint deformation and the appearance of contracture. Deformation of the joint leads to the fact that it can no longer perform its function during movement. In addition, such phenomena significantly reduce the strength of its individual elements, which can lead to complex fractures.
Contracture is a process in which there is chaotic contraction of ligaments or muscles located near the joint. If you have mild contracture, you may experience occasional leg twitching in different areas. With severe contracture, nerve twitching becomes more distinct and stronger. In some cases, chronic reactive arthritis completely destroys the joint, this leads to the complete loss of its motor ability and severe pain when trying to move the joint. The most rare complications of urogenic reactive arthritis include cataracts, which can lead to complete blindness.
There are 3 most important components of the treatment of reactive arthritis.
Diagnosis of urogenic reactive arthritis involves an external examination and history taking, and, in addition, a series of tests to identify an infection in the genitourinary system that has caused the development of an immunological response. After diagnosis, the doctor, based on the clinical picture, prescribes adequate treatment for this disease. Chronic urogenic arthritis may require additional funds to eliminate the inflammatory process.