joint disease

Bursitis

Inflammation of a synovial bursa, the lubricating sac located over a joint or between tendons and muscles or bones, is called bursitis (or bursal synovitis). Bursas sometimes are affected along with the joints and tendon sheaths in rheumatoid arthritis and gout. Infectious agents introduced by penetrating wounds or borne by the bloodstream also may result in bursitis, but this is unusual. The prepatellar bursa, located on the lower part of the kneecap, is especially subject to involvement in brucellosis (undulant fever).

The cause of most cases of bursitis appears to be local mechanical irritation. Often the irritation is of occupational origin and occurs in the shoulder region, at the knee, or near the hip. The inflammatory reaction may or may not include deposition of calcium salts. The border between bursitis and other painful rheumatic conditions of the soft tissues is indistinct in many instances.

The most common form of bursitis affects the subdeltoid bursa, which lies above the shoulder joint. Bursitis in this circumstance is not the primary abnormality but results from degeneration and calcification of the adjacent rotator tendon. Direct injury is not usually the cause of calcium deposits and inflammation in the tendon; indeed, heavy labourers are less frequently affected than persons employed in less-strenuous occupations. The bursa proper is affected only when debris from the tendon extends into it, this intrusion being the principal cause of an acutely painful shoulder. The condition occurs most often in middle age and is infrequent among young children. Women are twice as likely to have the condition as men. The onset may be sudden and unprovoked. Pain and tenderness are great, and there is difficulty in raising the arm. Resting the arm and use of analgesics tend to lessen the discomfort; corticosteroids may reduce inflammation; and carefully graduated exercises may be used to lessen the possibility of lasting stiffness of the shoulder. Many months may pass before complete recovery is attained. Chronic inflammation of the bursa at the side of the hip joint—trochanteric bursitis—has a similar course.

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The more clearly traumatic forms of bursitis are exemplified by “beat knee,” a bursitis that develops below the kneecap because of severe or prolonged pressure on the knee. Bloody fluid distends the bursa and, unless removed early, may cause the walls of the bursa to become thickened permanently. Treatment, which involves protection from further irritation to the extent that this is possible, is otherwise similar to that for subdeltoid bursitis. A fair proportion of these lesions become infected as a consequence of injury to the overlying skin.

Infectious arthritis

Joints may be infected by many types of microorganisms (bacteria, fungi, viruses) and occasionally by animal parasites. There are three routes of infection: by direct contamination, by way of the bloodstream, and by extension from adjacent bony infections (osteomyelitis). Direct contamination usually arises from penetrating wounds but may also occur during surgery on joints. Blood-borne infections may enter the joints through the synovial blood vessels. Commonly, however, foci of osteomyelitis occur first in the long bones near the end of the shaft or next to the joint. The infection then extends into the joint through natural openings or pathological breaches in the outside layer, or cortex, of the bone. Characteristically, hematogenous (blood-borne) infectious arthritis affects one joint (monarthritis) or a very few joints (oligoarthritis) rather than many of them (polyarthritis) and usually affects large joints (knee and hip) rather than small ones. Infections of the joints, like infections elsewhere in the body, often cause fever and other systemic indications of inflammation.

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Joint cartilage may be damaged rapidly by formation of pus in infections by such bacteria as staphylococci, hemolytic streptococci, and pneumococci. Tuberculosis of the joint can result in extensive destruction of the adjacent bone and open pathways to the skin. Tuberculous spondylitis, also known as Pott disease, is the most common form of this infection. It occurs mostly in young children. Treatment is with the antibiotic streptomycin and with antituberculous medications such as isoniazid and rifampin. A frequent fungal infection in the United States is caused by Coccidioides immitis, an organism indigenous to the arid regions of the southwestern United States. As in tuberculosis, seeding from the lung to the bone usually precedes involvement of a joint. Brucellosis, like tuberculosis, has a particular affinity for the spine. Brucella suis is the most likely brucellar organism to cause skeletal disease. Deformities and destructive changes in the joints in leprosy (Hansen disease) arise from infection of the nerves by the leprosy bacillus or from infection by other bacteria.

Among the better-recognized viral infections that can cause joint discomforts are rubella (German measles) and serum hepatitis, both of which usually are of short duration and have no permanent effect. Several tropical forms of synovitis are also viral. Dranunculiasis (Guinea worm disease) is an infection caused by the Guinea worm, a parasitic nematode that affects persons in tropical countries, and may involve the joints.

Infectious arthritis complicates several sexually transmitted diseases, including gonorrhea. Early treatment with penicillin may provide a prompt cure and may prevent the marked destruction of the joint that could otherwise ensue. Reactive arthritis (Reiter disease), which may occur after food poisoning or infection with some sexually transmitted diseases, usually improves spontaneously over the course of several months. Characteristically, reactive arthritis involves inflammation of the joints, the urethra, and the conjunctiva of the eyes. Syphilis appears not to infect the joints directly except in the most advanced stage of the disease and in congenital syphilis. The latter frequently causes destructive inflammation in the growing cartilaginous ends of the bones of newborn infants. Untreated, it leads to deformity and restriction of growth of the involved part, but early treatment with penicillin may result in complete recovery. Clutton joint is another type of congenital syphilitic lesion. It is a true inflammation of the synovial membrane that occurs in children between ages 6 and 16; although it causes swelling of the knees, it is a relatively benign condition. Lesions characteristic of tertiary syphilis sometimes occur in the joints of children who have congenital syphilis. Yaws, a nonvenereal infection by an organism closely related to that causing syphilis, leads to similar skeletal lesions. The condition has largely been eradicated but still affects persons in tropical areas.

Rheumatoid arthritis and allied disorders

In several types of arthritis that resemble infectious joint disease, no causative agent has been isolated. Principal among these is rheumatoid arthritis. This disorder may appear at any age but is most usual in the fourth and fifth decades. A type that affects children is called juvenile rheumatoid arthritis. Rheumatoid arthritis typically affects the same joints on both sides of the body. Almost any movable joint can be involved, but the fingers, wrists, and knees are particularly susceptible. The joints are especially stiff when the affected person awakes. Rheumatoid arthritis is not only a disease of the joints; fatigue and anemia indicate that there is a more generalized systemic involvement. A slight fever may sometimes be present. Lesions also occur in sites outside the joints. Involvement of bursas, tendons, and tendon sheaths is an integral part of the disease. Approximately one of five affected persons has nodules in the subcutaneous tissue at the point of the elbow or elsewhere. Inflammatory changes also are found sometimes in small arteries and the pericardium—the membrane enclosing the heart.

The course of the disease varies greatly from person to person and is characterized by a striking tendency toward spontaneous remission and exacerbation. With continuing inflammation of the joints, there is destruction of the joint cartilage. The degree of articular (joint) disability present in rheumatoid arthritis depends in large measure upon the amount of damage done to this cartilage. If the injury is severe, large areas of bone may be denuded of cartilage, so that adhesions form between the articular surfaces. Subsequent transformation of these adhesions into mature fibrous or bony connective tissue leads to firm union between the bony surfaces (ankylosis), which interferes with motion of the joint and may render it totally immobile. In other instances, the loss of cartilage and bone, coupled with the weakening of tendons, ligaments, and other supporting structures, results in instability and partial dislocation of the joint. In a small minority of cases, the disease pursues a rapidly progressive course marked by relentless joint destruction and evidence of diffuse vasculitis (inflammation of blood vessels). Many affected persons are benefited over the course of several months by rest, analgesic medications, and therapeutic exercises. In approximately one-third of the instances of the disease, it progresses and causes serious incapacity. In the absence of proper physical therapy, the joints may become greatly deformed and ankylosed.

There is now convincing evidence that immunologic reactions play an important role in the causation of rheumatoid arthritis. The blood of approximately 80 to 90 percent of persons with rheumatoid arthritis contains an immunoglobulin called rheumatoid factor that behaves as an antibody and reacts with another class of immunoglobulin. This immunoglobulin is produced by plasma cells that are present in sites of tissue injury. There is evidence that suggests that this agent may be one or more viruses or viral antigens that persist in the joint tissues.

Although there is no cure, corticosteroid medications and nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful in reducing pain and inflammation. The effectiveness of corticosteroids generally diminishes with time, and there are definite disadvantages in their use, such as a greater susceptibility to infection and peptic ulcers. In some persons, corticosteroid injection directly into joint tissues may even worsen joint damage. Disease-modifying antirheumatic drugs (DMARDs) may slow the progression of the disease by inhibiting further joint damage. Surgery is often of value in correcting established deformities. A mild dry climate seems to be beneficial in some cases, but the improvement is generally not sufficient to justify a move that would disrupt the affected person’s life.

There is at times a close association between rheumatoid arthritis and seemingly unrelated disorders. In about one-third of the cases of Sjögren syndrome, there is also rheumatoid arthritis, and high levels of rheumatoid factors are usually present in the bloodstream. In Felty syndrome, rheumatoid arthritis coexists with enlargement of the spleen and diminution in the number of circulating blood cells, particularly the white blood cells. Removal of the spleen restores the number of blood cells to normal but has no effect on the arthritis.

Several other types of polyarthritis resemble rheumatoid arthritis but characteristically lack the rheumatoid factors in the bloodstream. Psoriatic arthritis, associated with the skin disease psoriasis, differs from rheumatoid arthritis insofar as it has a predilection for the outer rather than the inner joints of the fingers and toes; furthermore, it results in more destruction of bone. Another type of arthritis is associated with chronic intestinal diseases—ulcerative colitis, regional enteritis, inflammatory bowel disease, cirrhosis, and Whipple disease. Ankylosing spondylitis, also known as Marie-Strümpell disease or Bechterew disease, affects some of the peripheral joints, such as the hip; but its principal location is in the spine and sacroiliac joints. In the spine the small synovial joints and the margins of the intervertebral disks are both involved. These structures become bridged by bone, and the spine becomes rigid. Ankylosing spondylitis affects approximately eight times as many men as women. The age of onset is lower than that of rheumatoid arthritis. The general management of the two disorders is much the same, but phenylbutazone is more effective in ankylosing spondylitis than in rheumatoid arthritis.

Collagen diseases

The collagen diseases are so called because in all of them abnormalities develop in the collagen-containing connective tissue. These diseases are primarily systemic and are frequently accompanied by joint problems. One of these diseases, systemic lupus erythematosus (SLE), may affect any structure or organ of the body. An association with rheumatoid arthritis is suggested by the fact that one-quarter of those with SLE have positive serological tests for rheumatoid factor, and perhaps as many patients with rheumatoid arthritis have positive lupus erythematosus tests. In another collagen disease, generalized scleroderma, the skin becomes thickened and tight. Similar changes occur in other organs, particularly the gastrointestinal tract.

Rheumatic fever often is classified with the collagen diseases. It has certain similarities to rheumatoid arthritis, as the name suggests, but the differences are more notable. In both conditions, arthritis and subcutaneous nodules occur, and inflammation of the pericardium is frequent. Nevertheless, the joint manifestations of rheumatic fever typically are transient, while those of rheumatoid arthritis are more persistent. The reverse is true of cardiac involvement in the two disorders. There is no compelling evidence that streptococcal infection is an important causative factor in rheumatoid arthritis, but it appears well established in rheumatic fever.

Arthritis more or less resembling rheumatoid arthritis occurs in roughly one-fourth of children who lack gamma globulins in the blood. In this circumstance there is a deficit in the body’s mechanisms for forming antibodies.

Miscellaneous arthritides

Several types of arthritis appear to be related to a hypersensitivity reaction. Erythema nodosum is a skin disease characterized by the formation of reddened nodules usually on the front of the legs. In the majority of cases, pain may arise in various joints, and sometimes swelling appears. Lymph nodes at the hilus of the lung (the site of entrance of bronchus, blood vessels, and nerves) are enlarged. The synovitis disappears in the course of several weeks or months. Many cases of erythema nodosum are associated with drug hypersensitivity, with infections such as tuberculosis, coccidioidomycosis, and leprosy, and with sarcoidosis, a systemic disease in which nodules form in the lymph nodes and other organs and structures of the body. Synovitis of this sort occurs in 10 to 15 percent of patients with sarcoidosis.

Palindromic rheumatism is a disease of unknown cause that is characterized by attacks that last one or two days but leave no permanent effects. Nevertheless, palindromic rheumatism rarely remits completely, and approximately one-third of cases result in rheumatoid arthritis. Polymyalgia rheumatica, a relatively frequent condition occurring in older people, is characterized by aching and stiffness in the muscles in the region of the hips and shoulders, but the joints proper do not seem to be involved. There does seem to be some relationship to a type of arterial inflammation called giant cell arteritis. Polymyalgia rheumatica is not usually accompanied by serious systemic abnormalities and is treated with corticosteroids or NSAIDs.