Orthopedics - Oleksa A.P. 2006

Joint Diseases
Infectious Arthritides of Known Etiology
Chlamydial Arthritis

Chlamydial Arthritis is caused by chlamydiae—pathogenic obligate intracellular Gram-negative Bacteria that infect birds, animals, and humans.

Humans can contract chlamydiae via airborne droplets, direct contact, or sexual transmission.

The mainstay of diagnosing a chlamydial infection is the laboratory detection of the pathogen and its Antigens, as well as the serological identification of anti-chlamydial Antibodies.

Clinical practice employs the following diagnostic Methods: 1) in vitro cultivation of Ch. trachomatis; 2) Cytological examination; 3) immunological methods—immunofluorescence assay, enzyme-linked immunosorbent assay (ELISA), Complement fixation test, hemagglutination test, and rapid tests.

Currently, a highly efficient test for chlamydial infection (USA) is widely used, combining high Specificity, sensitivity, technological efficiency, and rapid results. The test involves detecting a specific chlamydial enzyme, indicated by a lilac coloration of the swab within 10 minutes of sample collection. Clinical studies show a sensitivity of 97.1%, a specificity of 97.9%, and an accuracy of 97.8%. This is the most reliable test for diagnosing chlamydia and ensuring targeted Treatment.

In men, the Urethra and occasionally the prostate are the primary sites of chlamydial localization.

Clinically, urogenital chlamydia in men manifests as urethritis, causing itching in the urethra and a burning sensation during urination. In essence, there are few other subjective symptoms of chlamydial urethritis, as it most commonly follows a subacute course with very scant mucous discharge from the urethra. Dysuria is typically absent.

In women, cervicitis is generally asymptomatic; examination reveals only mild inflammation around the external os of the cervical canal, occasionally accompanied by follicles. Mucopurulent discharge is minimal.

One to four weeks after the initial signs of urethritis, an asymmetric polyarthritis develops, accompanied by pain, fever, synovitis, and joint Swelling. The knee and ankle joints are most frequently affected, and less commonly the JOINTS OF THE toes, leading to periarticular swelling of the entire toe. The joints of the hand are very rarely affected.

Both acute and chronic courses of chlamydial arthritis are distinguished, exhibiting corresponding clinical manifestations. In addition to joint involvement, chlamydia is frequently characterized by tendinitis—particularly of the Achilles tendon—which tends to have a torpid clinical course.

Radiographs of the affected joint reveal joint space narrowing and epiphyseal Osteoporosis of the articulating bone ends. Only in chronic chlamydial arthritis do radiographs demonstrate asymmetric erosions in the distal epiphyses of the Metatarsal Bones, along with periostitis of these bones and the Phalanges of the toes, presenting a "feathery" or "fluffy" appearance. Osteophytes resembling "Calcaneal Spurs" are occasionally observed.

Treatment. Korzh O.O. et al. (1998) suggest that the management of patients with chlamydia should be a collaborative effort among surgeons, infectious disease specialists, and internists. The therapeutic regimen must include the eradication of infection foci and the suppression of the inflammatory process in the joints.

The cornerstone of treating chlamydial urogenital arthritis is the administration of individually tailored, high-dose antibiotic therapy.

For acute cases, doxycycline 0.1 g twice daily, azithromycin 1.0 g daily (1st day: 1.0 g; 2nd day: 0.5 g), or clarithromycin 0.25–0.5 g twice daily is prescribed for 10–14 days.

Tetracyclines and macrolides are recommended, with the specific choice determined by the physician on an individual basis. These include: tetracycline 1.5–2.0 g daily divided into four doses, methacycline 0.6–1.2 g daily divided into three doses, doxycycline 0.2–0.3 g daily divided into three doses, erythromycin 1.5–2.0 g daily divided into four doses, or clarithromycin 0.25–0.5 g twice daily.

Antibiotic therapy should be administered for 4–6 weeks, whereas treatment with clarithromycin lasts 6–14 days.

Clarithromycin is highly effective for treating Infections caused by Chlamydia trachomatis and Ureaplasma urealyticum. Concurrently with Antibiotics, sulfasalazine may be prescribed (for adults, 2 tablets

4–6 times daily; for children under 7 years old, 0.5–1 tablet 3–6 times daily; and for older children, 1–1.5 tablets 3–6 times daily).

In cases of severe reactive arthritis, diprospan injections are administered once every 2–3 weeks (1–3 injections in total).

Antibiotic therapy must be accompanied by the administration of nystatin or levorin at 500,000 IU four times daily, nizoral at 0.2 g daily, or diflucan at 3–12 mg daily.

Patients undergo detoxification and general strengthening therapy, along with stimulation of the humoral (B-Cell) immune system.

Immobilization of the affected limb using a plaster splint and joint aspiration (arthrocentesis) are mandatory.

Throughout the course of treatment, follow-up Laboratory tests must be performed to monitor therapeutic efficacy.

Only prolonged treatment with high-dose antibiotics can successfully eradicate chlamydial arthritis and the primary focus of infection.

It is crucial to remember that both sexual partners must be treated.