Transcript Rheumatoid Arthritis

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Peripheral joints arthritis of
TB and BRUCELLOSIS
Azami Ahad. MD.
Rheumatologist
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TB Peripheral Joint
Arthritis
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EPIDEMIOLOGY:
 As many as 2 billion people are infected
with M. TB and 2 million people die each year
 Extra pulmonary TB accounted for 20% of TB infections in
2001
 Skeletal involvement with TB constitutes 1% to 3% of all cases
of tuberculosis
 Males and females are affected equally
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• TB incidence in Iran declined from 100
cases per 100,000 people in 1979 to 13
cases per 100,000 people in 2008
• TB prevalence in Iran of 1.3% in 2008,
down from more than 10% in 1979
Global health reporting.org [March 13, 2009]
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Risk factors:
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Microbiology:
 M. TB & M. bovis :are associated with significant
human disease.
 M. TB is the most common cause of TB.
 Aerobic, non-spore forming, non-motile &
slow -growing bacillus with a rod-shaped morphology
 Humans are its only known reservoir.
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1. Transmission: Inhalation of respiratory droplets →
bacillus deposited in alveolus. Engulfed by macrophages.
2. Infection, Proliferation, and Dissemination
Bacilli may survive and proliferate, kill macrophages → replicates
at primary focus and in lymphohematogenous metastatic foci
3. Host Response (Cell-Mediated Immunity)
Macrophages present antigens to T-cells (CD4 lymphocytes) →
lymphs proliferate, activate macrophages , secrete TNF-a ,
interferon-γ → microbicidal (cellular immunity) – get involution of
primary lesion / granuloma formation (epitheliod cells/Langerhans
giant cells are highly stimulated macrophages) (3-9 wks?)
4. Liquefaction and Proliferation: Reactivation with cavity formation
lymphohematogenous metastatic
or Bone
synovium
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Clinical patterns of
musculoskeletal TB:
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Spondylitis (50-60%)
Septic arthritis
Osteomyelitis
Tenosynovitis& bursitis
Soft tissue abscess
Reactive arthritis (Pancet's disease)
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Typical presentation:
• Chronic & insidious monoarticular arthritis &
polyarticular (Rarely)
• Large & medium joints:hip and knee (most commonly)
• SI, shoulder, elbow, ankle, carpal, tarsal joints(less
commonly)
• Cold joint
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Symptoms & Signs
Stage I is synovitis:
 Joint pain
 Joint swelling
 Flexion, abduction and external rotation of the hip
Constitutional symptoms (30%)
Stage I1 is early arthritis with osseous lesions:
Joint pain
Joint swelling
Most commonly flexion, adduction, and internal rotation of the hip
Apparent shortening of the affected limb
Limping gait
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Symptoms & Signs:
Stage 111 is the arthritic stage:
Articular surfaces destruction with loss of joint space
 True shortening of the limb occurs
 Movement of the joint is exquisitely painful
Stage IV is advanced arthritis: Albus tumor
Joint pain
Complete destruction of the joint space
Ankylosis
Draining cold abscess
Muscle atrophy
Duration for any stage: weeks to12 month
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Other joints arthritis:
knee:15%
Pain& swelling, limping gait, flex-contracture, muscle
atrophy, deformity
Foot & ankle:8-10%
Sacroiliac:7-10%
Unilateral (usually), pain, constitutional signs(frequent)
& severe SI tenderness
Elbow
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Poncet's disease:
Polyarthritis associated with E-pulmonary TB
with no evidence of bacteria in joint
More often in young people
Clinical findings: fever, malaise & polyarthritis
of large joints such as knees, ankles& at times
wrists
Arthritis can be destructive and persists until
anti-TB therapy is initiated
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Radiography:
Stage I : osteopenia & soft tissue swelling
epiphyseal
hypertrophy
 Stage I1:
Disease has progressed to produce epiphyseal or metaphyseal
erosions, but a normal joints space
 Stage I11: is frank arthritis & joint space narrowing
Stage IV:
Is advanced arthritic changes and disorganization of the joint
 Characteristic radiographic findings : (Phemister's triad)
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Sonography
CT-scans
MRI
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CBC
ESR
CRP
Are non-specific findings
HIV-test?
PPD-test
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SYNOVIAL FLUID
• Color
• WBC & diff:
10,000-30,000 cell/ml & PMN dominancy
(like to other chronic synovitis)
• Glucose, protein
AFB-smier (10-20% +)
Synovial fluid culture (79% +)
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Synovial biopsies :
Rice bodies, pannus, necrosis, caseating or
noncaseating granulomas ( 94% )
D.D:
fungal, atypical mycobacterial infections, brucellosis
& sarcoidosis
Synovial culture :
confirms osteoarticular TB in ( 94% )
PCR
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New Diagnostics:
 Interferon Gamma Release Assays
(IGRA’S)
 Rapid Molecular Amplification
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Diagnosis:
• The diagnosis of TB requires a high index
of suspicion
• Diagnosis rests upon a combination of
clinical presentation, pathologic findings,
and culture results
• In endemic area?
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Differential diagnosis?
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Peripheral Arthritis
Of
Brucellosis
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Brucellosis is a zoonotic disease of domestic
animals and humans.
The Many Names of Brucellosis:
 Malta Fever
 Undulant Fever
 Mediterranean Fever
 Gastric Fever
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History:
• 1861: Marston published description of
“Mediterranean gastric remittent fever”
• 1886: Sir David Bruce, microbe isolated from
a soldier with Malta Fever; named it
Micrococcus mellitensus
• 1897: Bernard Bang, first isolated B. abortus
from cattle
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Brucella species:
Four species can be pathogenic in humans:
B. melitensis, B. abortus, B. canis and B. suis.
 They are highly infectious, especially B.
melitensis and B. suis.
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BRUCELLA
 Non-motile
 Non-spore forming
 Intracellular
 Lack capsules
 Gram-negative coccobacilli
 Environmental persistence
 Temp, pH, humidity
 Frozen and aborted materials
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Pathogenecity:
Infection of non-phagocytic cells
Mechanism of invasion not clearly understood
Localize in rough endoplasmic reticulum
Infection of phagocytic cells
Invasion of PMN or MN cells by suppression of
bactericidal responses
S-LPS (smooth) plays major role in intracellular
survival; survive more effectively than rough
low toxicity for macrophages
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Pathogenecity:
Virulence
Elimination of virulent organisms depends on
activated macrophages and development of Th1 cellmediated response to antigens
Determinants
S-LPS is main antigen responsible for protection
Inhibition of phagolysosome fusion
Activation of myelo-peroxidase-halide system
Production of TNF
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Epidemiology:
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Worldwide, particularly Mediterranean, Africa,
Middle East, Latin America
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True incidence unknown
Endemic areas: >200/100,000
U.S.: <1/100,000
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In Iran, Brucellosis represents a major health problem
Iran J Radiol 2009, 6(1)
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TRANSMISSION:
• Oral entry - most common route
Ingestion of contaminated animal products (often
raw milk or its derivatives)
contact with contaminated fingers
• Aerosols
Inhalation of bacteria
Contamination of the conjunctivae
• Percutaneous :infection through skin
abrasions or by accidental inoculation
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Human Disease
• Incubation period:2-4 week
• Can affect any organ or organ system
• All patients have a cyclical fever
• clinical signs & symptoms:
 Headache
 Weakness
 Arthralgia
 Depression
 Weight loss
 Fatigue
 Liver dysfunction
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Human Disease:
Duration of disease?
days to months& year if untreated
Osteoarticular complications
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(In 20-60% of cases)
Reactive arthritis
Septic arthritis(38.8%)
Spondylitis (6.8%)
Sacroiliitis(46.6%)
Tendonitis&bursitis
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Sacroiliitis:
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Usually unilateral& nondestructive
Often Presents acutely& dramaticly
Severe low back& buttock pain
Difficulty in walking& standing
Fever(80%)
Direct tenderness on involve SIj
Bone scan is the most sensitive technique
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Peripheral arthritis:
• Often presents acutely (or subacutely)
• The most common cause is b.melitensis
• Particulary affected the large joints of lower
extremities
• Often monoarticular
• The most common are knee>hip>ankle
• Pain is predominant,
• Effusion frequently, no synovial thickening
• Tenderness& limitation of motion
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Reactive arthritis
 Sterile polyarthritis
 Non-destructive
 Intermittent & self-limited
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Paraclinics:
• WBC: NL or & lymph
• CRP, ESR:NL or
• Synovial fluid:
• WBC:10,000-15,000/ml & lymph-dominancy
• The yield of organism culture is low(50%)
• Plain x-ray is not diagnostic
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Diagnosis in Humans:
• Isolation of organism
– Blood, bone marrow, other tissues
• Serum agglutination test (wright test)
Titers?
– Fourfold or greater rise in titer
– Samples 2 weeks apart
• ELISA
• PCR
• Tissue biopsy: noncaseating granulomas
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