Tuberculous arthritis in clinical practise

Tuberculous arthritis  accounts for approximately 1% of all cases of tuberculosis and 10% of extrapulmonary cases.

Clinical presentation of tuberculous arthritis

• The most common clinical presentation is chronic granulomatous monarthritis.
• An unusual syndrome, Poncet’s disease, is a reactive symmetric form of polyarthritis that can affects persons with visceral or disseminated tuberculosis. No mycobacteria are identified in the joints, and symptoms resolve with antituberculous treatment.Unlike the tuberculous osteomyelitis which typically affect  the thoracic and lumbar spine in about 50% of cases, tuberculous arthritis primarily involves the large weight-bearing joints, especially  the hips, knees, and ankles, and only occasionally involves smaller non-weight-bearing joints. Progressive monarticular swelling and pain may develop over months or years, and systemic symptoms are seen in only half of all cases.

Tuberculous arthritis usually occurs as part of a disseminated primary infection or through late reactivation particularly  in persons with HIV infection or other immunocompromised hosts. Coexistent with arthritis active pulmonary tuberculosis is unusual.

Diagnosis of  tuberculous arthritis

Aspiration of the involved joint yields synovial fluid with  the following findings

• An average cell count of 20,000/μL, with approximately 50% neutrophils.
• Acid-fast staining of the fluid yields positive results in fewer than one-third of cases,
• Cultures are positive in 80%.
• Culture of synovial tissue taken at biopsy is positive in ~90% of cases and shows granulomatous inflammation
• NAA methods can shorten the time to diagnosis to 1 or 2 days.

Radiographs may reveal the following findings

• Peripheral erosions at points of synovial attachment
• Periarticular osteopenia,
•  Eventually jointspace narrowing

Therapy for tuberculous arthritis

This  is the same as that for tuberculous pulmonary disease, administration of multiple agents for 6–9 months. Therapy is more prolonged in immunosuppressed individuals such as those infected with HIV.

Weight-resistance training in osteoarthritis - What are the patient guidelines?

When weight-resistance exercises are prescribed for patients with osteoarthritis (OA) as a part of treatment they should be advised properly about certain guidelines that should be followed.This is aimed for the following

• Better planning of exercise program.
• Strategies for performing exercises effectively.
• To avoide injury.

What are the General considerations for the patient in planning weight-resistance training as part of treatment of OA?

Not all type of OA respond to exercise treatment, infact it is contraindicated in some form of OA. Before starting any weight-resistance program, always consult with a medical specialist who is well experienced in arthritis care. This will help you to learn what response you might expect from weight-resistance training and to discuss about its limitations.

Some exercise are contraindicated in certain form of arthritis. You should consult with a qualified physical therapist and / or personal trainer to make out which type of exercises are best for your arthritis. 

Better response is seen with supervised exercise program in a gym than an individual home-based program. This is because people are likely to adhere to a program and better motivated if they are being supervised.It is a good experience to practice in a gym that has a greater diversity of equipment and classes.

You should identify a training partner.This is to improve your interest and motivation. A good partner can also provide you constructive criticism.

If you are on medication for arthritis,you should be aware of the possible side effects of that drugs and effects it could have for exercise. Certain drugs give you a false sense of well-being and they may allow you to push beyond your limits, which results in more injury to joints and exacerbate your condition. Avoid over-the-counter medications. If you have little or no relief from the recommended dose of medication, this may be a sign of a more serious condition. Some people use ointments for relief for the symptoms of arthritis. There are no scientific data to suggest how much relief is obtained by ointment use or whether they are effective in the treatment of arthritis.

Plan your exercise at that time of the day when you feel most energetic as well as when you are not in a hurry.

Overweight is a always a problem in patients with osteoarthritis.It increases the physical load on damaged joint as well decreases the exercise tolerance. If you are overweight, don’t hesitate to incorporate a weight-loss program which can be done with diet control and cardiovascular exercise. This will definitely reduce the weight bearing loads placed on the joints.

You should be always aware of latest trends in exercise. Try different exercises. Try free weights as well as machines, because they have different benefits. Do not take anything for granted.

It is better to Incorporate recreational activities of your interest into the fitness program such as golf, hiking, swimming or bicycling.

It is true that You will never continue doing any activity if you do not enjoy it.So have fun to make it more enjoyable.

Screening tests for acute and chronic polyarthritis

Screening tests in arthritis will help you to arrive at a diagnosis.

Screening tests for acute polyarthritis are the following

Blood cultures.

Antistreptolysin O titer.

Parvovirus B-19 immunoglobulin G and immunoglobulin M levels.

Hepatitis B serology.

ANA.

Others
HIV test, a rubella titer, an angiotensin-converting enzyme level . chest radiograph, and ANCA.

Screening tests for chronic polyarthritis are the following

Complete blood cell count.

ESR and CRP level.

ANAs.

Rheumatoid factor and CCP antibody.

Liver function tests, serum creatinine level.

Serum uric acid level.

Urinalysis.

OthersThyroid-stimulating hormone level, a serum ferritin level, and an iron saturation of serum transferrin.

Screening tests for diffuse arthralgias and myalgias

ESR and CRP - elevated in  inflammatory disease, including polymyalgia rheumatica.

Creatine kinase and aldolase level - myositis.

Thyroid test.

Chemistry profile (ie, calcium, phosphorus, electrolyte, glucose, total protein) - metabolic or endocrine disorders.

Others.

25-hydroxy vitamin D level -Osteomalacia.

Sacroiliac joint radiography - Ankylosing spondylitis, especially in woman <45 y with neck, chest wall, and low back pain).

HLA-B27 - In reactive arthritis.

Hepatitis B and C serology testing.

Serum and urine protein electrophoresis -to rule out multiple myeloma.

ANA and rheumatoid factor (if clinical features suggest RA, SLE, or another connective-tissue disease).