Tertiary Syphilitic Arthritis (Gummatous Arthritis)
Gummatous arthritis may affect a whole joint, or be localized to part of a joint. It is onset is usually insidious, less commonly acute and sudden; usually the joint has been previously normal, though occasionally it is superimoposed on a secondary syphilitic joint lesion such as hydrarthrosis.
The synovial form
The commonest joints to be affected are the knee, ankle, elbow and shoulder, but smaller ones, such as the interphalangeal joints, are occasionally affected. There is considerable but painless effusion, but exceptionally, pain may be severe, and the disease simulates tuberculosis.
The pathological changes are limited to the outer layers of the capsule, and consist of thickening and perivascular infiltration. The lining endothelium and articular cartilage remain shiny.
The osseous form
The whole of one large joint is affected-as a rule, the knee. The condition resembles osteoarthritis both pathologically and on x-ray examination. Distension of the joint is present, and some increase in the density of the periarticular soft parts can be seen.
The spine is sometimes affected and the disease then closely simulates tuberculosis, the diagnosis being made only when other symptoms or signs of syphilis are present, blood serological tests assist, and/or the response to suitable anti-syphilitic treatment is satisfactory.
Even in well-established gummatous arthritis, timely treatment can produce great improvement, though not so much as in the earlier cases.
A weight-bearing caliper should be worn throughout the active stage of the disease, but is should be taken off daily so that the joint may be put through its full range of movements without weight-bearing. The clinical picture of a painless polyarthirits in a child, without local heat, redness, wasting, pyrexia, night-starting or response to salicylate treatment, makes up a characteristic picture.
Charcot’s joints (tabetic arthorpathy)
This is considered to be neuroarthropathic in origin. It usually occurs in acquired syphilis but may very occasionally follow inherited syphilis. The large joints the knee, ankle, hip or shoulder are commonly affected, but rarely multiple large or smaller joints may be involved.
The early stages of rapid exudation into the joint cavity and periarticular structures are rapidly followed by a painless disorganization of the articular and surrounding structures. Radiological examination shows gross disorganization, disappearance of cartilage and articular margins, and bony rarefaction with calcification in the capsule. Fragments of bones are commonly found lying free in the joint.
Diagnosis is arrived at by correlating a history of a rapidly progressive and painless disorganization of a joint, without associated muscular atrophy, with the clinical and serological signs of locomotor ataxia (tabes dorsalis).
Other associated neurotrophic features may be present, such as perforating ulcers affecting the sole of the foot, or one of the toes, and pathological fractures may occur. Treatment is most unsatisfactory and very disappointing, but where splinting is impracticable, arthrodesis, preceded by suitable anti –syphilitic treatment consisting chiefly of penicillin, may prove successful.
General diagnosis
The family history, that of previous diseases and of the present condition should be most carefully considered. The Wassermann and Treponema immobilization tests should be conducted as a routine in every case of chronic arthritis of any degree of severity and, where serological diagnosis presents any doubts or difficulties, it is advisable to examine the CSF and repeat quantitative tests at monthly intervals, over a period of 6 months in order to observe their variations.
The blood serum and, if obtainable, the joint fluid, should be investigated, for in a number of cases a positive results may be obtained from the fluid when the blood serum gives a negative results.
It is important to remember that blood serological tests may also be negative in late cases of acquired syphilis although the CSF Treponema immobilization tests may be positive. Finally, one must not forget the possibility of a non-syphilitic arthritis occurring in a person with concomitant positive blood serology.
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