SARS-CoV2-triggered acute arthritis: Viral arthritis rather than reactive arthritis

Rheuma nach COVID-19-Infektion oder Impfung

Sowohl nach COVID-Infektion als auch nach ein oder mehreren COVID-Impfungen können rheumatische Beschwerden beginnen. In beiden Fällen scheint der Mechanismus ähnlich zu sein und mit dem Coronavirus oder seinen spezifischen Folgen zusammenzuhängen. Zumeist wird von einer reaktiven Arthritis gesprochen, wenngleich die Bezeichnung COVID-19-assoziierte Arthritis für das Beschwerdebild eher zutreffen dürfte. In Relation zur Zahl der COVID-Infizierten und der COVID-geimpften ist die Zahl der Fälle, in denen es zu COVID-assoziierten Beschwerden kommt, außerordentlich gering und die Prognose scheint eher gut zu sein.

COVID-19 and rheumatic diseases: A mini-review

Joint pain and arthralgia can be manifestations of COVID-19, and studies evaluating long COVID symptoms identified the persistence of these disorders. Moreover, some case reports highlighted the development of new inflammatory arthritis in patients with COVID-19, suggesting a possible relation. Viral infections and rheumatic diseases share a documented relationship; they have been associated with genetic and environmental risk factors responsible for some of them. There is crosstalk between viruses and the immune system during the development of several rheumatic diseases. Moreover, infections may participate in the pathogenesis of autoimmune rheumatic diseases and contribute to patient mortality. Therefore, it is crucial to provide a clearer insight into the interaction between viral infections and rheumatic diseases. Here, we provide a mini-review of the current literature with the aim of shedding light on the relationship between COVID-19 and rheumatic or musculoskeletal diseases, which is still unclear. Specifically, we examined several aspects: risk for the rheumatic population of acquiring the virus or developing severe symptoms, similarities of COVID-19 and arthritis, the possible rheumatic consequence of COVID-19, of rheumatic drugs and vaccines, and COVID-19 prevention in rheumatic patients through vaccination.

[History of reactive arthritis. Historical milestones and future]

The introduction of the term reactive arthritis (ReA) for the joint inflammation observed after infection with Yersinia enterocolitica, in which "a causative pathogen cannot be isolated from the synovial fluid", and the association with the HLA-B27 were the historical milestones for a new classification and assignment to the spondylarthritides (SpA). The division into postinfectious and reactive arthritis proposed in 1976 was put into perspective in the 1990s because of investigations with the newly available molecular biological method of the polymerase chain reaction. Microbial products could be identified from joint samples of patients with ReA. Therefore, it was proposed to abandon the distinction between the two groups of diseases and to prefer the term ReA for both. This created a terminological and nosological issue. On the one hand, there are generally accepted classification and diagnostic criteria for the classical HLA-B27-associated ReA that are assigned to SpA. On the other hand, an increasing number of bacterial pathogens, viruses, amoebas, helminths as well as antiviral and antibacterial vaccinations are described as triggers of arthritis, which have been published under the term ReA. Since the beginning of the SARS-CoV‑2 pandemic, cases of acute post-COVID-19 arthritis have been described, which were also classified as ReA because of comparable clinical features.

Quo vadis reactive arthritis?

PURPOSE OF REVIEW

We provide an overview of recent articles which describe new thinking regarding HLA-B27-associated reactive arthritis (ReA), including those additional infection-related arthritides triggered by microbes that often are grouped under the term ReA.

RECENT FINDINGS

With the advent and continuation of the pandemic, an increasing number of cases and case series of post-COVID-19 arthritis have been reported and classified as ReA. Further, arthritis after COVID-19 vaccination is a new entity included within the spectrum of ReA. New causative microorganisms identified in case reports include Clostridium difficile, Mycoplasma pneumoniae, Giardia lamblia, Leptospira , and babesiosis. SARS-CoV-2 is emerging as a significant etiologic agent for apparent ReA.

SUMMARY

It is now clear that comprehensive clinical and laboratory investigations, synovial fluid analyses, and close follow-up of patients all are essential to differentiate ReA from diseases that may present with similar clinical attributes. Further, and importantly, additional research is required to define the wide diversity in causative agents, epidemiology, and rare case presentations of these arthritides. Finally, new classification and diagnostic criteria, and updated treatment recommendations, are essential to the advancement of our understanding of ReA.

Concomitant septic arthritis of the hip joint and femoral head avascular necrosis in patients with recent COVID-19 infection: a cautionary report

Purpose

At present, concomitant avascular necrosis (AVN) of femoral head and septic arthritis (SA) as a sequel of COVID-19 infection has yet not been documented. By large-scale use of life-saving corticosteroids (CS) in COVID-19 cases, our aim is to warn of the occurrence of hip joint infection in these patients.

Methods

We report a series of five cases in which patients developed septic arthritis concomitant with AVN after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 1695.2 mg. The time period of onset of hip symptoms in our cases from the beginning of the COVID-19 infection was 56 days in the first case, 43 days in the second case, 30 days in the third case, 29 days in the fourth case and 50 days in the last case, with an average time of 41.6 days. All patients underwent surgery depending on the extent of articular cartilage damage by direct anterior approach.

Results

Clinical and laboratory symptoms improved significantly in all patients. The mean visual analogue pain score of the patients decreased from 9.4 (9–10) before surgery to 2.8 (1–4) after 1 week of operation.

Conclusion

In any patient with the history of COVID-19 infection specially those who have been treated with corticosteroid as one of the medications prescribed during the disease, any joint symptom specially in the hips should draw our attention to the joint infection, and with timely diagnosis and surgery, their hip joint can be saved.

Reactive arthritis before and after the onset of the COVID-19 pandemic

Most accepted definitions of reactive arthritis (ReA) consider it a type of spondyloarthritis (SpA) precipitated by a gut or urogenital infection. A wider definition considers any arthritis that occurs after a mucosal surface infection as ReA. There is limited consensus regarding a working definition, status of HLA-B27, or even classification criteria for ReA. This may also contribute to a lack of systemic studies or clinical trials for ReA, thereby reducing further treatment recommendations to expert opinions only. The emergence of post-COVID-19 ReA has brought the focus back on this enigmatic entity. Post-COVID-19 ReA can present at extremes of age, appears to affect both sexes equally and can have different presentations. Some present with small joint arthritis, others with SpA phenotype-either with peripheral or axial involvement, while a few have only tenosynovitis or dactylitis. The emergence of post-vaccination inflammatory arthritis hints at similar pathophysiology involved. There needs to be a global consensus on whether or not to include all such conditions under the umbrella of ReA. Doing so will enable studies on uniform groups on how infections precipitate arthritis and what predicts chronicity. These have implications beyond ReA and might be extrapolated to other inflammatory arthritides.

Key Points

• Classical reactive arthritis (ReA) has a spondyloarthritis phenotype and is preceded by symptomatic gut or urogenital infection

• The demonstration of antigen and nucleic acid sequences of pathogens in synovium has blurred the difference between invasive arthritis and reactive arthritis

• Post-COVID-19 ReA has a transient phenotype and can have different presentations. All reported cases are self-limiting

• The large amount of literature reporting post-COVID-19 ReA calls for introspection if the existing definitions of ReA need to be updated.

Reactive, infectious, or postinfectious arthritis?

The issue of reactive arthritis belongs to one of the most complex problems in rheumatology. Although the original concept of reactive arthritis as a „sterile arthritis“ has already been overcome, much remains unclear. Non-uniform terminology, classification and diagnostic criteria as well as treatment guidelines leave room for different interpretations of this issue. Therefore it is difficult for non-rheumatologists (internal medicine physicians and general practitioners) to find their way around this topic. Our comprehensive report discusses the latest findings from etiology to treatment of reactive arthritis. It also addresses the aforementioned controversies from terminology to the latest list of causative pathogens, including viruses, parasites and vaccines.