Infectious mimics of rheumatoid arthritis.

Rheumatoid arthritis (RA) can have various infectious mimics. As immunosuppressive agents used in treatment can aggravate the underlying infections, correct diagnosis of RA and ruling out infections is important. Numerous viral infections (Parvovirus B19, Hepatitis B, Hepatitis C, Chikungunya and other alphaviruses, human immunodeficiency virus (HIV) and various other viruses), mycobacterial infections (Poncet's disease, tubercular septic arthritis, and leprosy), bacterial arthritis, brucellosis and Lyme disease are among common infections that mimic RA. Widespread travel and tourism, especially to exotic areas, high risk sexual behavior and widespread use of immunosuppressive and chemotherapeutic agents has led to numerous outbreaks of infections in areas where these infections were never reported before. Hence, rheumatologists all over the world should be familiar with musculoskeletal manifestations of infections. History of travel, comorbid fever, skin rash, genital ulcers, urethral discharge, the consumption of unpasteurized milk, lymphadenopathy, tenosynovitis, low platelet count, and positive Mantoux test can offer potential diagnostic clues. Serological testing, cultures, specific radiological signs and deoxyribonucleic Acid (DNA) amplification techniques often aid in diagnosis. Treatment mainly consists of antimicrobial agents, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs). However, immunosuppressive agents including steroids and disease modifying anti-rheumatic drugs (DMARDs) are needed occasionally in different refractory and prolonged illnesses. Most of the times, episodes of arthritis are self-limiting and respond to treatment of underlying cause. However, few infections like Chikungunya and Lyme's disease can lead to chronic arthritis as well.

Arthroscopic treatment of Mycobacterium massiliense septic arthritis outbreak after intra-articular injection: A case-series report and literature review.

ABSTRACT: Non-tuberculous mycobacteria (NTM) comprise mycobacteria, with the exceptions of Mycobacterium (M.) leprae and the M. tuberculosis complex. Septic arthritis caused by NTM is so rare that there is no standardized treatment.Between April and September 2012, 27 patients were infected with M. massiliense in a single clinic following injection of steroid in the knee joint. Clinical data of 9 patients who received arthroscopic treatment in Seoul Hospital of Soonchunhyang University were analyzed retrospectively.Arthroscopic irrigation and debridement were performed average 2.6 times (1-3 times). As 6 out of 9 cases (67%) had joint contracture of the knee joint, arthroscopic adhesiolysis, and brisement were performed. After surgical procedures, Hospital for Special Surgery and Lysholm knee score showed improvement compared before the surgery, but a radiographic result evaluated by Kellgren-Lawrence revealed that 6 cases got deteriorated to stage 4 in the 4-year follow-up.NTM septic arthritis had a higher recurrence and a higher contracture incidence than septic arthritis caused by tuberculous mycobacteria or other bacteria. Treatment was possible with repeated arthroscopic debridement and intravenous antibiotics.

Leprosy and rheumatoid arthritis: consequence or association?

Leprosy or Hansen's disease is a chronic granulomatous infectious disease caused by Mycobacterium leprae with a high prevalence in some developing countries however, it is rarely seen in non-endemic regions. Arthritis has been described in all types of Hansen's disease. Chronic arthritis is known to exist even in paucibacillary forms, resolved or treated disease and in patients without reaction, suggesting a perpetuated inflammatory process. In these cases leprosy can mimic some autoimmune diseases such as rheumatoid arthritis. When a patient with a history of leprosy presents with a symmetric, distal, polyarthritis the diagnosis may not be linear. Possibly it is a rheumatoid-like leprous arthritis with M leprae acting as the trigger element for the chronic process or it is an overlap condition, with a concomitant rheumatoid arthritis? A case report of a patient with a chronic inflammatory arthritis with 10 years of evolution is presented. The differential diagnosis between leprous and rheumatoid arthritis is discussed.

Leprosy-related joint involvement.

We estimate the prevalence and evaluate the clinical characteristics of leprosy related arthritis. One thousand, two hundred fifty-seven leprosy patients were attended at "Alfredo da Matta" outpatient clinic in the state of Amazonas, Brazil from July to October 2004. Among them, 115 patients were identified with articular pain and were referred for evaluation with rheumatologist. Blood samples were collected and radiological evaluation of the involved joints was performed. All patients with arthritis who continued to be followed up were reevaluated. One hundred fifteen leprosy patients (9.1%) were identified with articular involvement. The articular complaints were attributed to a defined rheumatic disease in 36 cases and excluded from further analysis. Twenty-four patients had arthralgia, and 55 (37 males and 18 females) had leprosy-related arthritis. The prevalence of arthritis was similar in both genders, and all patients with leprosy-related arthritis had lepromatous or borderline type. Most of patients had polyarticular and symmetrical arthritis and had completed the multidrug therapy and was under reaction treatment. The mean duration of articular symptoms at the time of study was 1.06 years (ranging from 5 days to 14 years). Ninety-one percent of patients with leprosy-related arthritis presented erythema nodosum leprosum or reversal reactions. Only five patients with arthritis had never presented reactions. Fifty percent of patients became asymptomatic during the mean 24 months of follow-up. Leprosy-related arthritis has a lower prevalence than previously reported. Most cases of leprosy-related arthritis were associated with reactional episodes, and in a large number of cases, the arthritis had a chronic course not responsive to the conventional therapy for reactions.

Arthritis as presenting manifestation of pure neuritic leprosy--a rheumatologist's dilemma.

OBJECTIVES: Leprosy classically presents with cutaneous and neurological manifestations. In diagnosed cases of leprosy, rheumatological involvement varies from 1% to 70%. A primary articular presentation without cutaneous manifestations is not yet known. Herein, we present our experience of five cases of leprosy that presented with predominant articular involvement in the absence of cutaneous manifestations. METHODS: The study was conducted in the Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences located in the state of Uttar Pradesh, one of the nine endemic states in India. Case records of patients with a definite diagnosis of leprosy were screened for the presenting manifestations, pattern of articular involvement, tenosynovitis, neurological signs and symptoms. Reports of nerve conduction study (NCS), nerve and synovial biopsy and other diagnostic tests were retrieved from laboratory records. Available radiographs were examined for evidence of juxta-articular osteopenia and erosions. RESULTS: Case records of 11,740 patients were screened, of which 28 had a diagnosis of leprosy. Twenty patients had presented with rheumatological complaints primarily. Five of the patients who presented with inflammatory arthritis with/without tenosynovitis (n = 4) and tenosynovitis alone (n = 1) had pure neuritic leprosy. All of these patients had thickened peripheral nerves and abnormal NCS. Sural nerve biopsy confirmed the diagnosis of leprosy in all these cases. CONCLUSION: A combination of tenosynovitis and thickened nerves in association with symmetric polyarthritis should raise a suspicion of leprosy even in the absence of cutaneous features.

Geographically specific infections and arthritis, including rheumatic syndromes associated with certain fungi and parasites, Brucella species and Mycobacterium leprae.

This overview is designed to introduce the reader to the broad spectrum of rheumatic syndromes associated with certain fungal and parasitic diseases, brucellosis and leprosy. Musculoskeletal disorders caused by fungi are uncommon and difficult to diagnose, particularly in the early stages. Deep fungal infections involve-in order of frequency-bone, soft tissues and joints. Rare but well-defined rheumatic syndromes occur in a variety of parasitic diseases. Brucellosis remains a major challenge to both human public health and clinical acumen in many countries today. The arthritis of leprosy deserves wider recognition and study as it contributes to disability and may hold clues to the mechanism of inflammation in other rheumatic disorders. All of the above may afflict residents in endemic areas and occasionally appear far from the source of origin in travellers or migrants, and usually cause diagnostic confusion.

Excision arthroplasty: an effective method in the management of plantar ulcers with metatarsophalangeal joint infection in anaesthetic feet.

The cases of 30 patients with septic arthritis of the metatarsophalangeal (MTP) joints as a complication of plantar ulceration in leprosy who underwent excision arthroplasty and primary closure of the plantar ulcer were reviewed. Twenty-two of these patients were male. The commonest site of MTP joint involvement was the first MTP joint. The average longitudinal diameter of ulcers was 2cm, and most ulcers were oval in shape. Diagnosis was made on the basis of signs of infection over the MTP joint, discharge from the ulcer and examination with a probe. Infection in the joint ranged from simple synovial discharge to seropurient or purulent discharge. Treatment involved excision arthroplasty of the MTP joint, excision of the ulcer with primary closure of the plantar incision and dorsal or lateral drainage depending upon the direction in which the infection extended. In two patients, the plantar wound could not be closed as it was too large. Healing of the plantar incision took 2 weeks in 12 patients and 3 weeks in 14 patients. In four patients, healing did not occur by primary intention. In a follow up of 1-2 years, there was no recurrence in 24 patients, while four patients had recurrent simple ulceration. Two patients were lost to follow up. Review of the results of this procedure dealing with septic arthritis of MTP joints secondary to plantar ulceration shows that primary healing of the plantar incision could be achieved in 3 weeks. With regard to recurrence, even though only four out of 28 ulcers treated by this procedure recurred, other contributing factors should be considered in a prospective control study to support the view that this procedure has contributed to non-recurrence.

Geographically specific infections and arthritis, including rheumatic syndromes associated with certain fungi and parasites, Brucella species and Mycobacterium leprae

This overview is designed to introduce the reader to the broad spectrum of rheumatic syndromes associated with certain fungal and parasitic diseases, brucellosis and leprosy. Musculoskeletal disorders caused by fungi are uncommon and difficult to diagnose, particularly in the early stages. Deep fungal infections involve-in order of frequency-bone, soft tissues and joints. Rare but well-defined rheumatic syndromes occur in a variety of parasitic diseases. Brucellosis remains a major challenge to both human public health and clinical acumen in many countries today. The arthritis of leprosy deserves wider recognition and study as it contributes to disability and may hold clues to the mechanism of inflammation in other rheumatic disorders. All of the above may afflict residents in endemic areas and occasionally appear far from the source of origin in travellers or migrants, and usually cause diagnostic confusion.

[How does one treat the osteitis and osteoarthritis of the extremities in older leprosy patients using granulated table sugar?]. / Comment guérir les ostéites et ostéo-arthrites des extrémités des anciens malades de la lèpre par le sucre cristallisé alimentaire?

A common problem of osteitis and septic arthritis is the recurrent bone infection after surgical debridement, a problem frequently encountered in patients with sequela leprosy. In these cases the authors propose the use of an ancient method of post surgical wound care based on the treatment with ordinary granulated sugar. The hyperosmolar climate created this way in the wounds inhibits the bacterial growth, enhances bacterial death and therefore permits the growth of granulation tissue in order to recover the debrided nude bones. At ILAD (Leprosy Institute of Dakar), 36 osteitis and septic arthritis were treated and healed during the last 2 years from March 1995 to March 1997 using this technic. All the wounds healed in the mean-time of 44 days. Only two of them needed a second debridement and healed afterwards. Up to now the method using ordinary sugar was applied in the treatment of infected wounds, eschars and postsurgical infections. Our experience shows that it also can be indicated to treat bone infections. This method is easy to apply also under often difficult field conditions and is very cheap.

Leprosy: an unusual cause of arthritis in children: report of two cases / Hanseníase: uma causa infreqüente de artrite em crianças: relato de dois casos

Os autores descrevem dois casos de adolescentes com mal de Hansen que tiveram o diagnóstico de artrite reumatóide juvenil devido ao comprometimento articular importante. O primeiro paciente, com idade de 12 anos, apresentava artrite de cotovelos e joelhos e eritema nodoso. O segundo paciente, com 17 anos de idade, queixava-se de artrite em metacarpofalangianas e metatarsofalangianas, além de rigidez matinal. Estes casos ilustram o envolvimento articular do mal de Hansen como causa pouco comum de artrite crônica na infância e adolescência, especialmente em áreas endêmicas

Streptococcal arthritis in Thai adults: case series and review.

The incidence, clinical spectrum, types of streptococci in Thai adults with streptococcal arthritis in Chulalongkorn Hospital are similar to Western reports. The most frequently found organism was group A Streptococcus and the second was group G. Most of the patients were elderly who usually had underlying medical and/or joint diseases. There were 3 patients with underlying lepromatous leprosy which has never been reported before, while mixed types of streptococcal infection in the same joint, mixed types of streptococcal infection in the same patient and a patient with group C lumbar spondylodiskitis were also found. The most reliable diagnostic test is synovial fluid culture. All streptococcal isolates in our review were sensitive to penicillin and the clinical responses correlated with antibiotic sensitivity tests. Intravenous antibiotics and adequate drainage are the treatment of choice. The duration of treatment ranged from 4 to 6 weeks and most patients responded well. The overall mortality rate depended on host factors, organism virulence and treatment administered.

Arthritis of leprosy.

An inflammatory polyarthritis has been previously described in leprosy but accounts of the clinical characteristics have varied. All patients with joint symptoms admitted to a leprosy centre over 5 months were examined by a rheumatologist. Of 48 acute admissions, 20 (42%) had a symmetrical polyarthritis affecting the wrists and fingers. This was strikingly similar to RA in appearance. The arthritis occurred exclusively in patients with reactions mainly during anti-mycobacterial treatment. The clinical features of the joint disorder were identical in Type I (associated with alterations in immune status) and Type II (erythema nodosum leprosum) reactions. Synovial tissue from one patient revealed no mycobacteria. Four of five hand X-rays suggested small erosions of the finger joints.

Evidence for B-lymphocyte mitogen activity in Borrelia burgdorferi-infected mice.

Borrelia burgdorferi produces a mitogen for murine B lymphocytes which can be measured in vitro by polyclonal stimulation of proliferation and immunoglobulin production (R. Schoenfeld, B. Araneo, Y. Ma, L. Yang, and J. J. Weis, Infect. Immun. 60:455-464, 1992). Sonicated B. burgdorferi cells also stimulated IL-6 production by splenocyte cultures. We have used the murine model for Lyme disease described by Barthold et al. (S. W. Barthold, D. S. Beck, G. M. Hansen, G. A. Terwilliger, and K. D. Moody, J. Infect. Dis. 162:133-138, 1990) to determine whether the B. burgdorferi B-cell mitogen is expressed during active infection. To correlate arthritic changes with immune events, we have studied two strains of mice injected with B. burgdorferi; one of them, C3H/HeJ, developed severe disease, and the other, BALB/c, developed only mild disease. C3H/HeJ mice displayed a persistent 10-fold increase in circulating immunoglobulin G (IgG) levels, a 2-fold increase in IgM levels, and a 15-fold increase in peripheral lymph node B-cell numbers, providing evidence of mitogenic activity. Infected BALB/c mice also had evidence for mitogen activity, since the IgG level in serum increased three- to fourfold. The bulk of the increase in circulating IgG levels was not directed against B. burgdorferi antigens, supporting the occurrence of polyclonal B-cell activation. Analysis of IgG isotypes pointed out a contrast between C3H/HeJ and BALB/c mice in that levels of all isotypes were elevated somewhat in both strains of infected mice but IgG2a levels were much more dramatically increased in the C3H/HeJ mice (28-fold) than in the BALB/c mice (4-fold). In this study, interleukin-6 levels were found to be persistently elevated in the serum of infected C3H/HeJ mice. Interestingly, interleukin-6 levels in serum were much lower in the infected BALB/c mice. These findings indicate that the B. burgdorferi mitogen is active in infected animals and may contribute to the inflammatory and immune response to infection.

Arthritis due to tuberculosis, fungal infections, and parasites.

Tuberculous, fungal, and parasitic infections infect millions of people throughout the world. While other problems usually overshadow their rheumatologic manifestations, nearly all these infections can involve bone or joints and may on occasion present with rheumatologic symptoms. The classic model of these diseases presenting as chronic monoarticular arthritis is still generally valid but other presentations, such as tenosynovitis with atypical mycobacterial infections, erythema nodosum with leprosy, coccidioidomycosis and histoplasmosis, and reactive arthritis with schistosomiasis and helminthic infections, are now well established. The most dramatic change in the epidemiology of tuberculous infections in recent years is the increasing incidence in patients with the acquired immunodeficiency syndrome (AIDS). Mycobacterium avium complex infections in particular have increased dramatically and are a major problem in the later stages of AIDS. Reports of septic arthritis and tenosynovitis due to M. avium are likely to increase over the next few years.