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TUBERCULOUS RHEUMATISM: A Resume.

BRAV, ERNEST A.; HENCH, PHILIP S.
The Journal of Bone & Joint Surgery: October 1934
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A resume of the literature on the subject of tuberculous rheumatism has been presented. As described by its proponents, this condition is a form of polyarthritis, simulating in some cases acute rheumatic fever or in other cases chronic atrophic arthritis, but bearing some suggestion of tuberculous etiology. Familial tuberculosis, associated visceral tuberculosis, demonstration of Koch's bacilli in the synovial fluid and in the blood stream, positive results of inoculations of guinea-pigs with joint fluid, and in some cases the presence of a typical tuberculous joint before, coincident with, or subsequent to the development of polyarthritis have been considered as evidence for the diagnosis of tuberculous rheumatism. The condition is thought to be due to a tuberculous toxin from some distant focus, a filtrable virus, an attenuated form of bacilli of tuberculosis, or an allergic reaction. Formation of true tubercles, therefore, is not the expected finding and, when such pathological change is present, a superimposed tuberculous arthritis, rather than the condition of tuberculous rheumatism, is thought to exist. Focal collections of round cells, plasma cells, and histiocytes, somewhat resembling tubercles and Aschoff's nodules, isolated instances of necrosis, intimal thickening and vacuolization of the vessels, and the presence of giant cells and endothelial cells have been reported in studies of the synovial membrane in cases of tuberculous rheumatism. These have been interpreted as representing either a transition stage between simple inflammatory tissue and tuberculosis or an allergic manifestation of the latter. If typical tuberculous arthritis develops in a joint which was previously the site of atrophic polyarthritis, the finding of characteristic pathological change may be due to transformation within the joint of the virus form of infecting agent into virulent bacilli of tuberculosis. This virus form is thought to be the explanation of the 'forme ganglionnaire' of tuberculosis of guinea-pigs, in which inoculation of fluid from a patient with atrophic polyarthritis may produce only enlargement of regional lymph nodes. Subsequent injection of this macerated lymphoid tissue into a second or third guinea-pig may lead to the production of typical tuberculosis in the guinea-pigs and the demonstration of Koch's bacilli in the viscera of these animals.

Against acceptance of the syndrome of tuberculous rheumatism have been arrayed a large number of competent investigators who have argued that there is no adequate clinical method of identifying it, no consistently characteristic roentgenographic evidence, no experimental or laboratory evidence in its favor that is not highly controversial, and no consistent demonstration of any characteristic microscopic pathology.

A statistical study of a series of 150 cases of acute rheumatic fever and 250 cases of chronic atrophic polyarthritis has revealed no significantly higher incidence of familial tuberculosis or associated visceral tuberculosis than that found in a group of 250 control cases. Of a series of seventy-five cases in which a diagnosis of chronic atrophic polyarthritis had been made, and in which the pathological characteristics of a single joint were determined by microscopic examination of tissue or inoculation of guinea-pigs, eight patients were found to be definitely tuberculous. The remainder gave no clear-cut evidence of an intermediary stage between simple inflammation and tuberculosis. In each of the eight cases, the tuberculous identity of the joint was suspected prior to examination of tissue or inoculation of guinea-pigs, but the association with multiple arthritis was confusing. Further investigation of cases of acute rheumatic fever and chronic atrophic polyarthritis, with the possibility of a tuberculous etiology in mind, will be required in order to determine the acceptance or rejection of the syndrome of tuberculous rheumatism. At present we would conclude that no incontrovertible proof exists to support the existence of such an entity.

(C) 1934 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.

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