Clinical Manifestations and Outcomes in Disease-Modifying Antirheumatic Drug-Naive Adult Patients with Chronic Chikungunya Arthritis.

Most studies on chronic chikungunya virus (CHIKV) arthritis include patients treated with disease-modifying antirheumatic drugs (DMARDs), likely altering the expression of clinical manifestations and outcome. Therefore, we sought to evaluate the clinical features and correlates in DMARD-naive patients with chronic CHIKV arthritis. We conducted a case-control study in adult patients with serologically confirmed CHIKV infection in Puerto Rico. Demographic features, clinical manifestations, comorbidities, disease activity (per Clinical Disease Activity Index [CDAI]), functional status (per Health Assessment Questionnaire Disability Index [HAQ-DI]), and pharmacologic treatment were ascertained. Patients with and without chronic CHIKV arthritis were compared. Furthermore, a sub-analysis was performed among patients with chronic CHIKV who presented with mild disease activity versus moderate-to-high disease activity at study visit. In total, 61 patients were studied; 33 patients had chronic arthritis and 28 had resolved arthritis. Patients with chronic arthritis had significantly more diabetes mellitus, chronic back pain, and fever, tiredness, and myalgias on the acute phase. The mean (SD) HAQ score was 0.95 (0.56), and 57.6% had moderate-to-high disease activity. Patients with moderate-to-high disease activity had higher scores in overall HAQ-DI and HAQ-DI categories (dressing and grooming, arising, hygiene, reaching, and activities) than in those with mild activity. In conclusion, in this group of DMARD-naive patients with chronic CHIKV arthritis, nearly 58% had moderate-to-high disease activity and had substantial functional disability. Diabetes mellitus, chronic back pain, and some manifestations on acute infection were associated with chronic CHIKV arthritis.

Pro-inflammatory response resulting from sindbis virus infection of human macrophages: implications for the pathogenesis of viral arthritis.

Several viruses cause acute and chronic joint inflammation in humans, and among them, the alphaviruses are of special interest due to the increasing number of outbreaks in which they are the etiological factor. Sindbis virus (SinV), a member of the Alphavirus genus, is the most widely distributed of all known arboviruses. Although SinV causes arthritis in humans, the molecular and cellular factors that contribute to the pathogenesis of this disease are almost completely unknown. Despite the crucial role of macrophages in the development of arthritis, these cells have not been recognized as potential targets for viruses causing arthritis. In this study, replication of SinV in human macrophages was demonstrated. The infection promoted macrophage activation, leading to the release of macrophage migration inhibitor factor (MIF) from intracellular stores and inducing the expression and secretion of TNF-alpha, IL-1beta, and IL-6. Production of these cytokines was followed by the expression of matrix metalloproteinases (MMPs) 1 and 3, which could be involved in the articular damage that has been observed in disease induced by SinV. The use of different strategies to block MIF action, including an anti-MIF antibody, the MIF inhibitor ISO-1 and knockout mice for the MIF gene, showed that cytokine secretion and MMP expression during infection were regulated by MIF, suggesting that this cytokine acts in autocrine and paracrine manner upstream in the macrophage activation cascade. Thus, these are remarkable similarities between macrophage responses induced by SinV infection and those observed in rheumatoid arthritis, despite the different etiologies of infectious and autoimmune arthritides.

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.

Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children.

BACKGROUND: Septic arthritis is associated with residual dysfunction in 10 to 25% of affected children. Concentrations of cytokines detected in synovial fluid of children with bacterial arthritis correlate with the severity of inflammation. Treatment with dexamethasone decreased cartilage degradation in experimental Haemophilus influenzae b and Staphylococcus aureus arthritis. ENDPOINTS: To decrease the number of patients with residual dysfunction of the affected joint at the end of therapy and at 6 and 12 months and to speed clinical recovery by the administration of dexamethasone. METHODS: In a double blind manner we randomly selected 123 children with suspected hematogenous bacterial arthritis to receive dexamethasone or saline for 4 days. Antibiotic therapy was tailored according to age and the recovered pathogen. RESULTS: Of the 123 children enrolled, 61 were assigned to the dexamethasone group and 62 to the placebo group. Only 50 and 50 patients in each group were evaluable. The 2 groups of patients were comparable with respect to age, sex, duration of symptoms, pathogen, affected joint and therapeutic and diagnostic procedures. Staphylococcus aureus accounted for 67% of the isolates, Haemophilus influenzae type b for 13% and Streptococcus pneumoniae for 9%. Dexamethasone therapy reduced residual dysfunction at the end of therapy, P = 0.000068; at 6 months, P = 0.00007; and at 12 months, P = 0.00053 of follow-up and shortened the duration of symptoms (P = 0.001) during the acute phase. The 26% incidence of residual dysfunction in the control patients was similar to the 25% found in other series. CONCLUSIONS: A short course of dexamethasone reduced residual joint dysfunction and shortened significantly the duration of symptoms in children with documented hematogenous septic arthritis. These results suggest that a 4-day course of low dose dexamethasone given early benefits children with hematogenous septic arthritis.

Effect of long-term ketamine administration on vocalization to paw pressure and on spinal wind-up activity in monoarthritic rats.

The antinociceptive effect of long-lasting ketamine administration (mini-osmotic pump) was studied in monoarthritic rats by using hindpaw pressure testing and wind-up measurement in a C-fiber reflex paradigm. Chronic ketamine induced antinociception in the monoarthritic paw and significantly suppressed mechanical hyperalgesia during the 14-day treatment period. The treatment also reduced C-reflex wind-up in the monoarthritic hindpaw. After pump removal, vocalization thresholds and spinal wind-up scores from the monoarthritic paw returned to control values, while hyperalgesia developed in the normal paw. Results suggest that ketamine upregulates NMDA receptors upon long-term administration, resulting in hyperalgesic response in the normal paw after drug withdrawal.

La artritis septica y el medico general / Septic arthritis and the physician

Se hace una revisión global de la artritis infecciosa con una visión de educación continua para el médico general, teniendo en cuenta aspectos como: Fisiopatogenia, etiología, tanto gonocócica como no gonocócica factores predisponentes, clínica, ayudas diagnósticas y tratamiento. Todo lo anterior con sustento en un estudio nacional y artículos clásicos de la literatura internacional.

Artritis séptica: reporte de 65 casos / Septic arthritis: report of 65 cases

Se estudiaron 65 casos de adultos vistos en el Hospital de Especialidades del Centro Médico La Raza. En el 93 por ciento los factores predisponentes fueron metabólicos, neoplásicos y reumatológicos. El cuadro clínico fue con fiebre, inflamación y dolor. El inicio fue monoarticular en 60 casos y la localización más frecuente fue la rodilla (39 casos); en 5 pacientes la presentación fue poliarticular. La aceleración de la velocidad de sedimentación globular y la leucocitosis fueron los datos de laboratorio más comunes. La tinción de Gram tiene gran utilidad para el diagnóstico presuncional y fue positiva en 43 (69 por ciento) de los casos. El líquido sinovial mostró leucocitosis con predominio de polimorfonucleares. Los gérmenes aislados fueron: Staphylococcus aureus (33 por ciento), Salmonella enteritidis (15 por ciento), Eschirichia coli (10 por ciento), Pseudomona aeruginosa (7 por ciento), Klebsiella pneumoniae (7 por ciento), Streptococcus pneumoniae (5 por ciento). La artritis por Gram negativos fue más frecuente que la artritis séptica por Gram positivos y se presentó en pacientes inmunocomprometidos. Conclusiones: El tratamiento de antibiotecoterapia con punciones evacuadoras cotidianas fue tan efectivo con el tratamiento quirúrgico. Nueve de los 10 casos de artritis por Salmonella sp. tenían LES con terapia inumodepresora y requirieron manejo quirúrgico. Las secuelas en 31 pacientes estuvieron relacionadas con el retraso en el diagnóstico y consecuentemente con el inicio del manejo

Artritis infecciosa por Neisseria gonorrhoeae, productora de betalactamasa

Se presenta un caso de artritis infecciosa por N. gonorrhoeae penicilino-resistente. Se resalta la importancia del cuadro clínico para sospechar la infección por gonococo y como su torpida respuesta al tratamiento instaurado con penicilina cristalina nos hizo pensar que estuvieramos ante una cepa resistente. La importancia de esta publicación radica en que son pocos los casos descritos en la literatura mundial y en nuestro medio no encontramos ningun informe similar al que estamos describiendo. Consideramos que esta situación puede presentarse cada vez con mayor frecuencia y que por ende debemos tenerla en cuenta, obviamente para su confirmación es indispensable contar con un laboratorio de microbiología que ofrezca todas las técnicas necesarias para su detección.

Artritis piógena en el niño: presentación de 38 casos / Pyogenic arthritis in children: report of 38 cases

En 1978 se estudió fisiopatología y cuadro clínico de sujetos con artritis piógena que ingresaron al Hospital de Pediatría (Centro Médico Nacional) del Instituto Mexicano del Seguro Social. De 38 casos, 41% correspondió a niños menores de um año de edad. Con frecuencia se comprobó antecedente (septicemia, gastroenteritis y otros) que favorecía desarrollo de artritis, y en tres casos fue traumatismo. En los cultivos predominó Staphylococcus aureus; asimismo, en repetidas ocasiones se encontró afectada la articulación de la rodilla