Oligoarthritis

Oligoarthritis - inflammation of 2-3 joints - is typical for a large number of diseases. To confirm the inflammatory nature of oligoarthritis, the study of cerebrospinal fluid with detection of high cytosis (> 1000 in 1 μl) and the absence of radiological changes characteristic of various non-inflammatory joint diseases (osteoarthrosis, ischemic necrosis of bones) is crucial. X-ray changes typical for oligoarthritis develop slowly, within months, the first of them appears near-joint osteoporosis. The only exception is purulent arthritis (periarticular osteoporosis and signs of destruction of cartilage in the form of a narrowing of the joint gap can appear in a few days).

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What causes oligoarthritis?

Oligoarthritis accompanied by fever (> 38 ° C)

Discussion of the question of the septic nature of oligoarthritis is necessary only in rare cases (with sepsis monoarthritis prevails). Oligoarthritis can occur with staphylococcal sepsis, gonorrhea and brucellosis. The main diagnostic significance is the history, general symptoms of intoxication (fever with chills, severe weakness, headache), very severe pain in the affected joints (including at rest), detection of the entrance gate of infection and characteristic "extra-articulate" symptoms (for gonorrhea - vesicular or a papular rash with hemorrhagic contents). Crucial for the diagnosis are the results of a study of cerebrospinal fluid (cytosis> 50 000 with neutrophil prevalence); bacterioscopy with Gram stain and a positive seeding result.

Non-infectious diseases, which are always or in some cases accompanied by fever, include Still's disease, reactive oligoarthritis, microcrystalline arthritis (gout and calcium pyrophosphate precipitation disease of calcium). RA, ORL, as well as oncological diseases that occur with paraneoplastic manifestations in the form of oligoarthritis.

Adult Sick Adult Disease

The main differential diagnostic value is a peculiar rash (non-judicious, mostly spotted, salmon colors, occurs at the peak of fever), significant leukocytosis and peripheral blood and cerebrospinal fluid, a high concentration of ferritin and a normal level of procalcitonin in the blood.

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Reactive oligoarthritis

A clear chronological connection (within 1-3 weeks) with a clinically pronounced acute intestinal or urogenital infection (caused mainly by Chlmydia trachomatis) is characteristic; asymmetric oligoarthritis of large and middle leg joints; entesite; dactylyte; sometimes also sacroiliitis, spondylitis, keratoderma, conjunctivitis. In some cases, fever may be accompanied by oligoarthritis, which develops in other seronegative spondylitis (psoriatic arthritis, AS, oligoarthritis in chronic inflammatory bowel diseases).

Gout

Oligoarthritis (mainly the joints of the lower extremities), as a rule, is not the first manifestation of gout. In such patients, there is usually a history of recurrent acute monoarthritis. The main diagnostic value is the detection of urate crystals in the cerebrospinal fluid.

The disease of deposition of calcium pyrophosphate crystals

Pyrophosphate gout, pseudogout, chondrocalcinosis. It develops mainly in the elderly. It can be provoked by intercurrent infection, trauma, operation. As a rule, knee joints are involved. Chondrocalcinosis is characteristic of both clinically affected and other joints (calcification of menisci and articular cartilage). The diagnosis is confirmed by the discovery of crystals of calcium pyrophosphate dihydrate in the cerebrospinal fluid.

Rheumatoid arthritis

Oligoarthritis, accompanied by fever, is more typical for the seronegative variant of the disease.

Acute rheumatic fever

The chronological connection with acute angina, pharyngitis and / or scarlatina, a very strong pain in joints, a migrating nature of arthritis, signs of heart damage and the detection of serological markers of acute streptococcal infection have a diagnostic significance. Post-streptococcal oligoarthritis without cardiac damage is also possible.

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Oncological diseases

In adults, oligoarthritis is naturally observed in acute leukemia, chronic lymphocytic leukemia and certain types of lymphoma (angioimmunoblastic lymphadenopathy). Alarming symptoms of hematologic and lymphatic tumors should include the following symptoms: generalized enlargement of lymph nodes, liver and spleen, persistent changes in peripheral blood (anemia, hyperleukocytosis with a shift in the leukocyte formula to the left until immature forms, leukopenia, pancytopenia).

Valuable, though not absolute, significance for distinguishing between bacterial infections with oligoarthritis (other than tuberculosis) and non-infectious arthritis accompanied by fever, have the results of calcitonin and blood determination, an increase in the level of procalcitonin greater than 0.5 pg / ml is highly likely to indicate a bacterial infection . The negative result of this test does not exclude the diagnosis of infection.

Persistent oligoarthritis, not accompanied by fever

In the majority of patients and eventually the disease is diagnosed from the group of seronegative spondyloarthritis or rheumatoid arthritis.

For diseases from the group of seronegative spondyloarthritis, the asymmetric lesion of large and middle joints of the legs is characteristic, as well as additional signs, like enthesites (especially heel areas), arthritis of distal interphalangeal joints of brushes, dactylitis (oligoarthritis combined with tenosynovitis). Sarcoiliitis, spondylitis, anterior uveitis, aortic failure, aortic valve failure, atrioventricular conduction disorders, psoriasis of the skin and nails, detection of HLA-B27, signs of Crohn's disease or ulcerative colitis, the presence of diseases of this group in direct relatives. Most often from this group of diseases chronic oligoarthritis is noted in patients with psoriasis. When suspected of spondyloarthritis, regardless of the clinical manifestations, X-ray examination of the sacroiliac joints is indicated.

In rheumatoid arthritis, the lesion of 1-3 joints is usually only a relatively short-term phase of the disease. Over time (as a rule, during the first year of illness) inflammation of other joints, including small joints of hands and feet, is attached.

How is oligoarthritis recognized?

To clarify the nosological diagnosis of oligoarthritis, history and the identification of changes from other organs and systems characteristic of various rheumatic, endocrine, metabolic and other diseases are of primary importance.

Role of synovial membrane biopsy

In general, the diagnostic value of synovial sheath biopsy is small. As a rule, the usual morphological study does not give more information than a full-fledged investigation of the cerebrospinal fluid. Only in rare cases and sometimes only with the use of special stains with the help of synovial sheath biopsy it is possible to establish a previously unclear diagnosis, for example, in granulomatous diseases (sarcoidosis, tuberculosis), hemochromatosis (iron staining by Perls), Whipple's disease (staining with Schiff's iodine reagent) , amyloidosis (color of Congo red). As was shown, the study of cerebrospinal fluid is more informative for microcrystalline arthritis, osteoarthrosis, and synovial biopsy (under arthroscopic conditions) for synovial chondromatosis and synovial hemangioma. Nevertheless, it should be noted that biopsy of the synovial membrane is always desirable in case of suspected joint diseases characterized by specific morphological changes (tuberculosis, sarcoidosis, amyloidosis), when it is not possible to confirm the diagnosis by less invasive methods. In addition, biopsy of the synovial membrane with subsequent microbiological examination is also indicated in cases where infectious involvement of the joint is suspected in both acute purulent and chronic non-arthritic arthritis, for example, in Whipple's disease, fungal oligoarthritis, and others.

X-ray and other imaging methods

To find out the causes of oligoarthritis and clarify the condition of the affected joints, radiography is mandatory. There are no radiographic signs pathognomonic for individual joint diseases, but changes can be made that do not contradict or contradict the inflammatory lesion of the joints or direct the diagnosis in the right direction.

• Purulent oligoarthritis: rapid (in the first weeks) development of periarticular osteoporosis and narrowing of the joint space.
• Oligoarthritis chronic non-parasitic: for RA the following sequence of development of radiographic changes is typical: okolosustavnoj an osteoporosis -> narrowing of a crack -> edge cysts and erosions. Deviations from this sequence (for example, the absence of periarticular osteoporosis in the presence of constriction of the joint space) should be considered as a contradiction to this diagnosis.
• Oligoarthritis of peripheral joints with snundiloarthritis: the absence of periarticular osteoporosis is possible, focal proliferation of the mantle tissue can occur (around erosions, in the places of attachment of the capsule and tendons), periostitis of metaphyses or diaphyses.
• Psoriatic oligoarthritis: typical intraarticular and extraarticular osteolysis, multidirectional subluxation of bones; is characterized by the destruction of the distal interphalangeal joints of the hands.
• Gouty oligoarthritis: in the case of chronic arthritis, intraosteal cysts and marginal erosion are possible in both the jointed bones and around the joint; okolosustavnoy osteoporosis is rare; Change is most often found in the joints of the thumbs of the feet.
• Disease of deposition of calcium pyrophosphate crystals: typical chondrocalcinosis (menisci, articular cartilage), signs of secondary osteoarthritis in combination with periarticular osteoporosis; the most constantly chondrocalcinosis is localized in the knee joints, triangular cartilage in the wrist joints and cartilage of the lone articulation.

The main role of joint ultrasound in the diagnosis and differential diagnosis of oligoarthritis is to clarify the state of articulations that are difficult to access directly (humeral and hip). The method allows to assess the presence of effusion in the joint cavity, to reveal the pathology of tendons attached to the joint area (tears, tenosynovitis) and deep-seated bags (bursitis).

X-ray CT allows us to clarify the state of the mainly bone structures of the joints. This study is especially valuable for the diagnosis of those joint diseases in which primary changes are localized in bone tissue (tuberculosis, septic oligoarthritis due to osteomyelitis), as well as for differential diagnosis of oligoartritis with bone tumors (eg, with osteoid osteoma).

MRI, in contrast to X-ray CT, is the most informative for visualizing the state of soft tissues (cartilage, meniscus, intraarticular ligaments, synovial membrane, tendons, synovial bags). In addition, MRI can detect bone marrow edema. In this regard, it is used for early diagnosis of osteoarthritis, other diseases, the basis of which is the pathology of articular cartilage, ischemic necrosis of the bones, latent leaking bone fractures (stress fractures), sakroileitis, for traumatic pathology of menisci and cruciate ligaments of the knee joint, pathology of the periarticular soft tissues.

Scintigraphy of the skeleton using bisphosphonates labeled with technetium-99m, allows to identify areas of bone tissue in which metabolism is enhanced (increased accumulation of radionuclide). In addition, this radiopharmaceutical is accumulated in those tissues of the joint, where the blood flow is increased (for example, in the synovial membrane with arthritis). This method, due to very high sensitivity and low specificity, is used mainly to obtain preliminary information about the localization of the pathological process. The nature of the revealed changes usually requires further refinement with the help of tomographic methods of investigation.