Ahmed Zedan MDa, Imran Umer MDa, Yasir Ahmed MDb, Donald Loveman MDc
Correspondence to Yasir Ahmed MD
Email: Yasir.ahmed@ttuhsc.edu
SWRCCC 2014;2(8):50-53
doi: 10.12746/swrccc2014.0208.106
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Reactive arthritis is a form of seronegative spondyloarthritis temporally triggered by an apparent infection, usually gastroenteritis or urethritis. This arthritis typically starts within a few weeks of the inciting infection. It commonly affects young adults and is strongly associated with the MHC class I antigen HLA-B27. Here we present an interesting case of young man with HLA-B27 positive reactive arthritis in whom the presumptive diagnosis was reached early in the course of his illness.
Keywords: Reactive arthritis, oligoarthritis, chlamydial urinary tract infection, HLA-B27 positive arthritis
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Reactive arthritis is an autoimmune disease which usually develops soon after or during a presumptive gastrointestinal or urogenital infection.1 Typically reactive arthritis presents with asymmetric oligoarthritis that mainly involves lower limbs.2 Here we present an interesting case of young man who presented with reactive arthritis after gastro-urogenital symptoms.
A 20-year-old man with Gilbert’s syndrome
was admitted with left groin pain for one week. He
had an episode of loose watery diarrhea associated
with abdominal pain two weeks previously. His diarrhea resolved in three days. Subsequently he noticed dysuria with blood in the urine but no fever or chills. He was treated with oral ciprofloxacin. Subsequently he was switched to nitrofurantoin and cephalexin without any improvement. Two days thereafter he noted redness in both eyes and the new onset of pain in the left groin. By the time of his arrival to our facility his ocular redness had resolved. His roommate had also experienced a self-limited diarrheal illness.
Physical examination revealed temperature 98°F, heart rate 110 beats/minute, respiratory rate 16
breaths/minute, and blood pressure 110/67 mmHg.
Examination of his left hip joint demonstrated tenderness over the groin and a restricted range of motion.
The remainder of the musculoskeletal and systemic
examination was unremarkable with the exception of
a small amount of purulent discharge from the urethra.
The patient underwent a left hip joint arthrocentesis
on the day of admission. On hospital day
three his left hip pain was slightly improved, but he developed pain and swelling in the left ankle joint. On hospital day four pain and swelling of left wrist joint developed. Laboratory work revealed hemoglobin 14.2 gm/dl, white blood cell count 8,200/mm3, platelet count 325,000/mm3, and C-reactive protein (CRP) 4.7 mg/dl (normal : <1.0mg/dl); electrolytes, liver, and renal
function tests were normal. Left hip joint synovial
fluid showed white blood cell count of 18,500/mm³
with 79% neutrophils. Tests for infection, including
hepatitis A, B and C screening tests, monospot test,
rapid group A streptococcus pharyngeal smear, human
immune deficiency virus (HIV) screening, blood
and synovial fluid Gram stain, bacterial culture, fungal
culture, urine culture, polymerase chain reaction
(PCR) for Chlamydia trachomatis and Neisseria gonorrhoeae,
and Campylobacter jujeni antibody IgG, were
negative. Stool specimens for Salmonella spp, Shigella spp, Campylobacter spp, Clostridium difficile PCR, and
Giardia lamblia antigen were also negative. Immunologic
work up, including rheumatoid factor, anti-cyclic
citrullinated peptide immunoglobulin G (IgG), double
stranded deoxyribonucleic acid (dsDNA), anti-nuclear
antibodies (ANA) IgG by ELISA, and DNase B antibody,
were normal. HLA-B27 antigen was positive.
Magnetic resonance imaging showed arthritis of the
left wrist joint and some evidence of left Achilles tendinitis.
The patient was initially started on empiric
intravenous vancomycin and ceftriaxone until his
blood cultures, left hip synovial fluid Gram stain, and urethral cultures were reported negative. Oral prednisone 20 mg daily was added along with naproxen
500 mg twice a day. His joint symptoms improved.
He was discharged on a tapering dose of prednisone,
naproxen, and a short course of empiric oral doxycycline plus rifampin. At an outpatient visit four weeks after discharge he had again developed pain in the left wrist and ankle. Low dose prednisone along with weekly methotrexate 15 mg and daily folic acid 1 mg was started. His symptoms are well controlled till now at nine weeks post diagnosis.
Reactive arthritis is a form of seronegative spondyloarthritis
triggered by infection, usually gastroenteritis
or urethritis. However, blood and synovial culture
workup often remains negative.1 Nevertheless certain
microorganisms, most commonly Chlamydia trachomatis,
Yersinia spp, Salmonella spp, Shigella spp, Campylobacter spp, and Escherichia coli, have been strongly
associated with reactive arthritis.2 Reactive arthritis
commonly affects persons between 15 to 35 years of
age.3
The clinical presentation of reactive arthritis
typically occurs one to four weeks after an inciting
infection.4 The patient usually presents with asymmetrical
oligoarthritis involving the lower limbs, but
the upper limbs joints can be involved as seen in our
patient. Arthritis can also be associated with enthesitis,
inflammation at the insertion site of ligaments or
tendons. Extra-articular manifestations include conjunctivitis,
erythema nodosum, keratoderma blenorrhagica,
circinate balanitis, and mucosal ulcers.5
Overall 10% of patients with reactive arthritis develop
cardiac manifestations, and these are more common
in patients with chronic disease.6 Pericarditis, aortic
valve insufficiency, conduction block, and rarely cardiogenic
shock have been reported cardiac manifestations
in the literature.7,8,9 The average duration of
acute reactive arthritis is three to five months. Arthritis
for more than six months is considered a sign of chronicity.4,10
The diagnosis of reactive arthritis is made by
the presence of asymmetric oligoarthritis preceded by
symptoms of gastrointestinal or urogenital infection in
the absence of other causes of arthritis. There are no
definite diagnostic laboratory tests or radiographic
findings in reactive arthritis. Erythrocyte sedimentation
rate (ESR) is markedly elevated in most cases,
and values above 60 mm/ 1st hour are commonly
seen. Complement C3 and C4 levels and CRP are elevated,
especially at the onset of the disease.3 There
may be mild leukocytosis and anemia in the early
phase of the disease. HLA-B 27 antigen is positive
in most cases, and rheumatoid factor is consistently
negative.11
In general, antibiotics are not indicated for uncomplicated
enteric infections or for treatment of the
reactive arthritis itself. Antibiotic therapy should be
used for treatment of active urinary tract infection with
Chlamydia trachomatis.12 Non-steroidal anti-inflammatory
drugs (NSAIDs) are the first line and the cornerstone
treatment, especially if used in full dose in the
early phases of reactive arthritis.2,11 Systemic or intraarticular
glucocorticoids are generally used if the patient
is not responding well to NSAIDS. Disease-modifying
anti-rheumatic drugs (DMARDS) are reserved
for patients who are not responding to NSAIDs and
require high doses of corticosteroids. Sulfasalazine
and methotrexate are the most commonly used medications
in this group. TNF inhibitors are used for patients
resistant to corticosteroids and DMARDS.13
The prognosis of reactive arthritis depends on
causative organism, the presence or absence of HLAB27,
gender, and the presence of recurrent arthritis.14
HLA-B27 antigen has been associated with reactive
arthritis in about 70-80% patients and predicts more
severe disease.2,11 Leirisalo-Repo et al reported a retrospective
study of 63 patients with a mean follow-up
of 11 years. HLA-B 27 antigen was positive in 88%
of the patients. He found that 16% of the patients developed
a chronic course and they were all HLA-B 27
positive.15 Our patient presented with classic symptoms
of reactive arthritis with positive HLA-B27 antigen
and elevated CRP. All other laboratory investigations
were normal. He failed to respond to NSAIDs
and steroids, so methotrexate was added. The patent’s
symptoms are now controlled, and he continues
follow with a rheumatologist.
In summary, reactive arthritis is a common autoimmune
disease that should be suspected in young
patients presenting with asymmetric oligoarthritis preceded
by gastrointestinal or urogenital infection. The
diagnosis of reactive arthritis is made by the exclusion
of other known causes of arthritis, especially septic
arthritis and supported by the presence of extra-articular
manifestations, including conjunctivitis, urethritis,
and tendonitis as seen in our case.
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