Reactive arthritis: update 2018

Enteric Infection-Associated Reactive Arthritis: A Systematic Review and Meta-Analysis

Background. The objective of this systematic review and meta-analysis was to estimate the proportions of individuals infected with Campylobacter, Escherichia, Salmonella, Shigella, or Yersinia who develop reactive arthritis. Methods. A systematic review was conducted, encompassing English-language articles published before January 2024, sourced from the Embase, PubMed, Scopus, and Web of Science databases. This review included observational studies that reported the occurrence of reactive arthritis (ReA) among patients with Campylobacter, Escherichia, Salmonella, Shigella, or Yersinia infections. Data extraction was carried out independently by two reviewers. Subsequently, a random-effects meta-analysis was performed, with heterogeneity assessed using the I2 value. Additionally, meta-regression was employed to investigate the potential influence of study-level variables on the observed heterogeneity. Results. A total of 87 studies were identified; 23 reported on ReA development after Campylobacter infection, 7 reported on ReA after Escherichia infection, 30 reported ReA onset after salmonellosis, 14 reported ReA after shigellosis, and 13 reported ReA after Yersinia infection. The proportion of Campylobacter patients who developed ReA was 0.03 (95% CI [0.01, 0.06], I2 = 97.62%); the proportion of Escherichia patients who developed ReA was 0.01 (95% CI [0.00, 0.06], I2 = 92.78%); the proportion of Salmonella patients was 0.04 (95% CI [0.02, 0.08], I2 = 97.67%); the proportion of Shigella patients was 0.01 (95% CI [0.01, 0.03], I2 = 90.64%); and the proportion of Yersinia patients who developed ReA was 0.05 (95% CI [0.02, 0.13], I2 = 96%). Conclusion. A significant proportion of Salmonella, Shigella, and Yersinia cases resulted in ReA. Nonetheless, it is important to interpret the findings cautiously due to the substantial heterogeneity observed between studies.

Immunologic derangement caused by intestinal dysbiosis and stress is the intrinsic basis of reactive arthritis

Reactive arthritis (ReA) is defined as arthritis resulting from infections in other body parts, such as the gastrointestinal and urogenital tracts. The primary clinical manifestations involve acute-onset and self-limiting asymmetric large joint inflammation in the lower limbs. Although bacterial or chlamydia infections have long been recognized as playing a pivotal role in its pathogenesis, recent studies suggest that antibiotic treatment may perpetuate rather than eradicate chlamydia within the host, indicating an involvement of other mechanisms in Reactive arthritis. Reactive arthritis is currently believed to be associated with infection, genetic marker (HLA-B27), and immunologic derangement. As an autoimmune disease, increasing attention has been given to understanding the role of the immune system in Reactive arthritis. This review focuses on elucidating how the immune system mediates reactive arthritis and explores the roles of intestinal dysbiosis-induced immune disorders and stress-related factors in autoimmune diseases, providing novel insights into understanding reactive arthritis.

Hand conditions as sequelae of infection with COVID-19: a literature review

Patients have attended our clinics with various hand pathologies after contracting COVID-19 or receiving vaccination. We postulate the virus stimulates a systemic inflammatory response that triggers these pathologies and conducted a search of the literature for associated conditions. Twenty publications were included for this review. Three studies identified skeletal muscle inflammation, and several identified reactive arthritis post-infection. Rheumatoid arthritis post-infection was also recognized, along with crystalline arthropathy. Carpal tunnel syndrome was seen in two cases. There is a current paucity in published scientific material regarding COVID-19 sequalae in the hand. This review aims to stimulate discussion in how a virus can induce pathological processes causing common hand pathologies.

Infective Endocarditis Presenting as Rhabdomyolysis and Muscle Abscess: A Case Report

Rhabdomyolysis is characterized by the degradation of skeletal muscle tissue, which releases cellular contents into circulation. This condition commonly stems from various factors, including trauma, overexertion, muscular hypoxia, infections, metabolic and electrolyte imbalances, certain medications, toxins, and genetic abnormalities. Despite this, instances of rhabdomyolysis precipitated by bacteremia of infective endocarditis remain exceedingly rare. This report describes an unusual case wherein infective endocarditis manifested as rhabdomyolysis, accompanied by a muscular abscess and acute renal failure. The patient's condition was successfully managed through hydration and targeted antibiotic therapy, leading to a favorable recovery. The case underscores the importance of vigilance for extracardiac symptoms and signs of infective endocarditis, such as rhabdomyolysis and muscular abscesses. Of particular note in this case was the discovery of an atypical causal bacterium, Streptococcus dysgalactiae, in the setting of infective endocarditis. This case highlights the broad range of potential manifestations and causal factors associated with this serious cardiac condition.

A case of reactive arthritis caused by a perianal abscess

Reactive arthritis is an immune-mediated aseptic arthritis resulting from either genitourinary or intestinal tract in a genetically susceptible host. Reactive arthritis is not uncommon, and the most common infectious agents are Chlamydia trachomatis, Salmonella, Yersinia, and Shigella, some new infectious agents include Staphylococcus lugdunensis, Rothia mucilaginosa, and umbilical cord-derived Wharton's jelly, as well as the SARS-CoV-2 virus, which has been more studied in recent years. We found that reactive arthritis caused by infection of perianal abscesses is very rare and few cases have been described in the medical literature. We report a 21-year-old man with polyarticular swelling and pain, and subcutaneous hematoma at his right ankle joint; he was considered reactive arthritis. After treating with non-steroidal anti-inflammatory drugs, sulfasalazine, surgery, and antibiotics, the patient's arthralgia gradually improved and the symptoms largely disappeared at the 1-month follow-up.

Epidemiology of small intestinal bacterial overgrowth

Small intestinal bacterial overgrowth (SIBO) is defined as an increase in the bacterial content of the small intestine above normal values. The presence of SIBO is detected in 33.8% of patients with gastroenterological complaints who underwent a breath test, and is significantly associated with smoking, bloating, abdominal pain, and anemia. Proton pump inhibitor therapy is a significant risk factor for SIBO. The risk of SIBO increases with age and does not depend on gender or race. SIBO complicates the course of a number of diseases and may be of pathogenetic significance in the development of their symptoms. SIBO is significantly associated with functional dyspepsia, irritable bowel syndrome, functional abdominal bloating, functional constipation, functional diarrhea, short bowel syndrome, chronic intestinal pseudo-obstruction, lactase deficiency, diverticular and celiac diseases, ulcerative colitis, Crohn’s disease, cirrhosis, metabolic-associated fatty liver disease (MAFLD), primary biliary cholangitis, gastroparesis, pancreatitis, cystic fibrosis, gallstone disease, diabetes, hypothyroidism, hyperlipidemia, acromegaly, multiple sclerosis, autism, Parkinson’s disease, systemic sclerosis, spondylarthropathy, fibromyalgia, asthma, heart failure, and other diseases. The development of SIBO is often associated with a slowdown in orocecal transit time that decreases the normal clearance of bacteria from the small intestine. The slowdown of this transit may be due to motor dysfunction of the intestine in diseases of the gut, autonomic diabetic polyneuropathy, and portal hypertension, or a decrease in the motor-stimulating influence of thyroid hormones. In a number of diseases, including cirrhosis, MAFLD, diabetes, and pancreatitis, an association was found between disease severity and the presence of SIBO. Further work on the effect of SIBO eradication on the condition and prognosis of patients with various diseases is required.

Reactive arthritis following COVID-19 current evidence, diagnosis, and management strategies

BACKGROUND

Immune-mediated conditions associated to Corona Virus Disease-19 (COVID-19) have been reported, including vasculitis, antiphospholipid antibody syndrome, myositis, and lupus. Emerging studies have reported the potential occurrence of reactive arthritis in patients previously infected with COVID-19. This systematic review summarised the current evidence on the occurrence of reactive arthritis in patients previously infected by COVID-19.

METHODS

This study was conducted according to the 2020 PRISMA guidelines. All the clinical investigations describing the occurrence of reactive arthritis following COVID-19 were accessed. In September 2022, the following databases were accessed: PubMed, Web of Science, Google Scholar, Embase. The generalities of the study were extracted: author, year and journal of publication, country of the main author, study design, sample size, mean age, number of women, main results of the study. The following data on COVID-19 severity and management were retrieved: type of treatment, hospitalization regimes (inpatient or outpatient), admission to the intensive care unit, need of mechanical ventilation, pharmacological management. The following data on reactive arthritis were collected: time elapsed between COVID-19 infection to the onset of reactive arthritis symptoms (days), pharmacological management, type of arthritis (mono- or bilateral, mono- or polyarticular), extra-articular manifestations, presence of tenosynovitis or enthesitis, synovial examination at microscopic polarised light, imaging (radiography, magnetic resonance, sonography), clinical examination, laboratory findings.

RESULTS

Data from 27 case reports (54 patients) were retrieved, with a mean age of 49.8 ± 14.5 years. 54% (29 of 54 patients) were women. The mean time span between COVID-19 infection and the occurrence of reactive arthritis symptoms was 22.3 ± 10.7 days. Between studies diagnosis and management of reactive arthritis were heterogeneous. Symptoms resolved within few days in all studies considered. At last follow-up, all patients were minimally symptomatic or asymptomatic, and no additional therapy or attentions were required by any patient.

CONCLUSION

Poor evidence suggests that COVID-19 could target the musculoskeletal system causing reactive arthritis at its post infectious stage. COVID-19 can act as a causative agent or as a trigger for development of reactive arthritis even without presence of antibodies of rheumatological disorders. Treating physicians should have a high index of suspicion while treating post infectious COVID-19 patient with arthralgia.

LEVEL OF EVIDENCE

Level IV, systematic review.

Reactive arthritis following COVID-19: cause for concern

Low-quality evidence suggests that COVID-19 may trigger reactive arthritis one to four weeks after the infection. Post COVID-19 reactive arthritis resolves within a few days, and no additional treatment is required. Established diagnostic or classification criteria for reactive arthritis are missing, and a deeper understanding of the immune mechanism related to COVID-19 prompt us to further investigate the immunopathogenic mechanisms capable of promoting or contrasting the development of specific rheumatic diseases. Caution should be exerted when managing post-infectious COVID-19 patient with arthralgia.

Reactive arthritis occurring after COVID-19 infection: a narrative review

PURPOSE

Reactive arthritis is acute aseptic arthritis occurring 1 to 4 weeks after a distant infection in a genetically predisposed individual. It may occur after COVID-19 infection. We summarize, in this article, the current findings of reactive arthritis following COVID-19 infection.

METHODS

A literature search has been performed from December 2019 to December 2021. We included case reports of reactive arthritis occurring after COVID-19 infection. We collected demographic, clinical, and paraclinical data.

RESULTS

A total of 22 articles were reviewed. There were 14 men and 11 women with a mean age of 44.96 + 17.47 years. Oligoarticular involvement of the lower limbs was the most frequent clinical presentation. The time between arthritis and COVID infection ranged from 6 to 48 days. The diagnosis was based on clinical and laboratory findings. The pharmacological management was based on non-steroidal anti-inflammatory drugs in 20 cases. Systemic or local steroid therapy was indicated in 13 patients. Sulfasalazine was indicated in two cases. Alleviation of symptoms and recovery were noted in 22 cases. The mean duration of the clinical resolution was 16 + 57 days.

CONCLUSION

The diagnosis of reactive arthritis should be considered in patients with a new onset of arthritis following COVID-19 infection. Its mechanism is still unclear.

Cutaneous and rheumatological manifestations of reactive arthritis: A case report

Reactive arthritis is a rare form of spondyloarthropathies occurring after genital or enteric infection. It is most often self-limited but can progress to chronic spondylarthritis. We report the case of a 30-year-old man who presented with acute arthritis occurring 2 months after an episode of urethral discharge. Physical examination revealed polyarthritis, dactylitis, sacroiliac joint involvement, and plantar papulosquamous plaques. The human leukocyte antigen B27 was positive. Detection of Chlamydia trachomatis and Gonococcus in the first catch urine specimen was negative. Hepatitis B and C, Chlamydia trachomatis, human immunodeficiency virus, and syphilis serologic test results were negative. Pelvic magnetic resonance imaging revealed left sacroiliitis. The patient was treated with antibiotics, diclofenac, and sulfasalazine. After 6 months of follow-up, a significant clinical improvement was obtained without remission, suggesting an evolution to chronic spondylarthritis. Diagnosis of Reactive arthritis is difficult since microbiologic examinations are commonly negative. This disease should be considered in patients with rheumatologic manifestations occurring after a urogenital or enteric infection, mainly when associated with skin manifestations and human leukocyte antigen B27.

Evaluation of clinical and paraclinical findings in patients with reactive arthritis caused by giardiasis: A systematic review

INTRODUCTION

The aim of this study was to systematically review the clinical and paraclinical findings in patients with reactive arthritis (ReA) caused by giardiasis.

METHODS

In this study, papers describing ReA in patients with giardiasis were found after searching in international databases including MEDLINE/PubMed, Web of Science, Scopus, and ScienceDirect up to 2021. Google Scholar was also searched to find more articles.

RESULTS

Finally, 16 studies met the inclusion criteria with reporting 115 patients, ranging in age from 19 months to 49 years. This disease was more reported in children and adolescents than adults. The most frequently involved joints with arthritis were the knee and ankle followed by the hip, wrist, elbow, shoulder, axial skeleton, metatarsophalangeal, and proximal interphalangeal. The most common extra-articular symptoms included diarrhea, allergic symptoms, and abdominal pain.

CONCLUSION

The signs and symptoms of ReA caused by giardiasis can be various, from moderate to severe manifestations. Also, they can be similar to some other diseases, so it is recommended that physicians and specialists have more knowledge about this disease to treat patients with a correct diagnosis.

Patterns of Viral Arthropathy and Myalgia Following COVID-19: A Cross-Sectional National Survey

Introduction

Viral arthropathy is an increasingly recognized sequela of several viral pathogens including alphaviruses, hepatitis, and potentially coronaviruses. Case reports of viral arthropathy and myalgia associated with SARS-CoV-2 infection (COVID-19) both during active disease and following resolution of acute COVID-19 symptoms are becoming more prevalent. We sought to describe the prevalence of viral arthropathy and myalgia associated with COVID-19, as well as to identify factors that may predict these symptoms.

Methods

A national, cross-sectional survey was conducted using a questionnaire administered online. Subjects self-reporting previous confirmed COVID-19 were recruited using the Amazon Mechanical Turk crowdsourcing platform. Questionnaire items included demographics, frequency and severity of common COVID-19 symptoms, requirement for hospitalization or mechanical ventilation, subject recall of arthropathy or myalgia onset, duration, and severity, as well as WOMAC score. Binary logistic regression was used to identify potential predictive co-variates for the development of either arthropathy or myalgia.

Results

A total of 3222 participants completed the arthropathy/myalgia questionnaire with 1065 responses remaining for analysis following application of exclusion criteria, data integrity review, and omission of respondents with confounding conditions. Of the 1065 cases, 282 (26.5%) reported arthralgia and 566 (53.2%) reported myalgia at some point during or after COVID-19 with 9.9% and 6.0% reporting onset of arthralgia or myalgia, respectively, after resolution of acute COVID-19 symptoms. The presence of several commonly reported COVID symptoms or indicators of disease severity was predictive of arthralgia including hospitalization (OR 3.7; 95% CI 2.4 to 5.8), sore throat (OR 2.3; 95% CI 1.5 to 3.5), fatigue (OR 2.9; 95% CI 1.7 to 4.9), and ageusia/anosmia (OR 1.7; 95% CI 1.1 to 2.7).

Discussion

Based on these results, new-onset arthropathy and myalgia following COVID-19 resolution may be an increasingly encountered etiology for pain.

[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.

Successful use of tofacitinib in reactive arthritis refractory to conventional therapies - a case series

Reactive arthritis is an immune-mediated aseptic arthritis resulting from either genitourinary or gastrointestinal tract in a genetically susceptible host. It commonly presents as oligoarthritis of the lower limbs with or without extra-articular features such as urethritis and non-purulent conjunctivitis. Therapies include non steroidal anti inflammatory drugs (NSAIDs), conventional disease modifying anti-rheumatic drugs (DMARDs) and, rarely, biologics in severe cases. We report the successful use of tofacitinib in four cases of reactive arthritis who failed to respond to conventional therapies.

Reactive arthritis following treatment with intravesical Bacillus Calmette-Guerin for papillary carcinoma of bladder

A man in his 60s developed reactive arthritis following treatment with intravesical Bacillus Calmette-Guerin (iBCG) for papillary carcinoma of bladder. Evaluation revealed leucocytosis and raised inflammatory markers. HLA B27 was positive. Based on the temporal relationship, it was attributed to BCG-related reactive arthritis. iBCG was stopped. Treatment with non-steroidal anti-inflammatory drugs (NSAIDS) and glucocorticoids were ineffective. Prolonged course of disease-modifying antirheumatic drugs (DMARDS) was required which aided in alleviation of symptoms and sustained remission. Intravesical BCG therapy is a treatment for bladder cancer. It is rarely associated with reactive arthritis, which responds to discontinuation of iBCG and treatment with NSAIDS and/or short-term glucocorticoids. iBCG-related reactive arthritis commonly has an acute/subacute course. Chronic arthritis as observed in our case requiring prolonged treatment with DMARDS is rare.

Comparison of immune checkpoint inhibitor-induced arthritis and reactive arthritis to inform therapeutic strategy

INTRODUCTION

Immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA) is a relatively new disease entity caused by ICI agents during cancer therapy. Reactive arthritis (ReA) is a well-known disease entity caused by urogenital or gastrointestinal bacterial infection or pneumonia. In this sense, ICI-IA and ReA are both defined by a reaction to a well-specified causal event. As a result, comparing these diseases may help to determine therapeutic strategies.

METHODS

We compared ICI-IA and ReA with special focus on pharmacological management. Specifically regarding treatment, we conducted a literature search of studies published in the PubMed database. Inclusion criteria were studies on treatment with non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GC), or disease modifying antirheumatic drugs (DMARDs) in ICI-IA or ReA. During systematic selection, 21 studies evaluating ICI-IA and 14 studies evaluating ReA were included.

RESULTS

In ICI-IA, prospective and retrospective studies have shown effects of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoid (GC), sulfasalazine (SSZ), methotrexate (MTX), hydroxychloroquine (HCQ) and TNFi. In ReA, retrospective studies evaluated NSAIDs and GC. A randomized controlled trial reported the effect of SSZ, and a retrospective study reported the effect of MTX and SSZ in combination with tumor necrosis factor alpha inhibition (TNFi). For both entities, small case reports show treatment effects of interleukin 6 receptor inhibition (IL-6Ri).

DISCUSSION

This literature review identified both similarities and differences regarding the pathogenesis and clinical features of ReA and ICI-IA. Studies on treatment reported effectiveness of NSAIDs, GC, MTX, SSZ and TNFi in both diseases. Further, small case reports showed effects of IL-6Ri.

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 arthritis (ReA) following the first dose of Covid-19 vaccine; A case report

Introduction: The development of vaccination against COVID-19 infection was a promising step during the battle against this pandemic; however, some vaccines were associated with some complications starting with just flu-like symptoms up to anaphylaxis; of the reported complications is joints pain. Here, we report a case who developed reactive arthritis (ReA) after receiving the first dose of the Pfizer-BioNTech Covid-19 vaccine. Case presentation: A healthy 54 years old male with no previous history of any medical condition was presented with bilateral hand and bilateral knee pain after one week of receiving his first dose of Pfizer-BioNTech Covid-19 vaccine. Clinical examination revealed swelling, tenderness, and erythema over the right index metacarpophalangeal joint and the medial aspect of the right knee. Radiographs of the hand and knee were normal. Laboratory investigations were within normal values except for an elevated ESR (15 mm/hr.) and a positive CRP titer of 48 mg/l. The symptoms entirely resolved after two weeks of non-steroidal anti-inflammatory medications. Conclusions: Although rare, however, ReA could be presented as a complication of Covid-19 vaccination, and physicians should be aware of the possibility of its occurrence.

Reactive arthritis and silent thyroiditis following SARS-CoV-2 infection: Case report and review of the literature

SARS-CoV-2 has been implicated in the development of reactive arthritis (ReA) days to weeks following exposure or infection. We present a case of ReA with enthesitis and subsequent silent thyroiditis in a patient following infection with SARS-CoV-2, along with a review of the published cases of SARS-CoV-2-related ReA.

Clinical profiles of post-infectious arthritis and transient synovitis of the hip in children

BACKGROUND

Acute inflammatory arthritides can present as a result of immune reaction following infections. Post-infectious arthritis and transient synovitis of the hip in children are included in this disease entity. The aim of this study was to describe the clinical profiles of post-infectious arthritis and transient synovitis of the hip in Thai children.

METHODS

A retrospective review was performed at a tertiary care hospital in Bangkok, Thailand from January 2005 to July 2017.

RESULTS

Eighty-six patients (56 boys and 30 girls) were included in this study. Mean age was 8.4 ± 4.8 years. Reactive arthritis was diagnosed in two patients (2.3%) following Salmonella spp. and Chlamydia trachomatis infections. Post-streptococcal reactive arthritis was present in 10 patients (11.6%). Transient synovitis of the hip was found in 30 patients (34.9%). Forty-four patients (51.2%) were clinically diagnosed with post-infectious arthritis. Mono/oligoarthritis was the most common clinical profile (84.9%). The distribution of lower-extremity involvement was as follows: hip, 47.6%; knee, 46.5%; and ankle joints, 30.2%. The documented preceding illness consisted mostly of upper respiratory tract symptoms (30.2%). Non-steroidal anti-inflammatory drugs were prescribed for 70 patients (81.4%).

CONCLUSION

Mono/oligoarthritis of the lower extremity was the main clinical profile. Preceding viral illness was documented in one-third of children. Reactive arthritis was rarely seen.

Corneal ulcer in reactive arthritis

A 20-year-old male presented with acute lower limb oligoarthritis and enthesitis followed by acute onset redness, watering, pain and decreased vision in the right eye. He had recent history of diarrhoea with fever. Erythrocyte sedimentation rate and high-sensitivity C-reactive protein (hsCRP) were raised and human leukocyte antigen-B27 was positive. The best corrected visual acuity (BCVA) in the right eye was 20/120 and it showed a paracentral shallow corneal ulcer of size 3 × 4 mm with underlying dense stromal infiltrates and haze. Microbiological evaluation of corneal scrapings was reported as Staphylococcus hominis. The epithelium healed on topical antibiotics in one week, but there were persistent punctate erosions and pleomorphic anterior stromal infiltrates and haze. The residual keratitis healed completely on topical steroids in ten days, with BCVA improving to 20/20. A diagnosis of reactive arthritis with immune-mediated keratitis was made.

Post-COVID-19 Arthritis and Sacroiliitis: Natural History with Longitudinal Magnetic Resonance Imaging Study in Two Cases and Review of the Literature

Severe acute respiratory coronavirus-2 syndrome (SARS-CoV-2) is a well-known pandemic infectious disease caused by an RNA virus belonging to the coronaviridae family. The most important involvement during the acute phase of infection concerns the respiratory tract and may be fatal. However, COVID-19 may become a systemic disease with a wide spectrum of manifestations. Herein, we report the natural history of sacroiliac inflammatory involvement in two females who developed COVID-19 infection with mild flu-like symptoms. After the infection they reported inflammatory back pain, with magnetic resonance imaging (MRI) studies showing typical aspects of sacroiliitis. Symptoms improved with NSAIDs therapy over the following months while MRI remained positive. A literature review was performed on this emerging topic. To our knowledge, this is the first MRI longitudinal study of post-COVID-19 sacroiliitis with almost one year of follow-up. Predisposing factors for the development of articular involvement are unclear but a long-lasting persistence of the virus, demonstrated by nasopharyngeal swab, may enhance the probability of altering the immune system in a favourable background.

Giardia lamblia Reactive Arthritis Mimicking Acute Periprosthetic Knee Infection: A Case Report

CASE

A healthy 49-year-old man with a well-functioning total knee replacement developed a painful swollen knee. The erythrocyte sedimentation rate was 12 mm/hour, and C-reactive protein was 20.3 mg/L. Aspiration revealed 24,440 white blood cells and 5% neutrophils. His 2018 International Consensus Meeting (ICM) definition score of 5 met criteria for "possibly infected." He was diagnosed with reactive arthritis (ReA) secondary to Giardia lamblia, mimicking acute periprosthetic infection. He was successfully treated with a 10-week course of multiple oral antiparasitic medications.

CONCLUSION

Systemic parasitic infectious ReA can mimic acute infection in the presence of total knee arthroplasty. Careful application of the 2018 ICM criteria can be critical for workup and the treatment of suspected periprosthetic infection.

Reactive Arthritis Update: Spotlight on New and Rare Infectious Agents Implicated as Pathogens

Purpose of Review

This article presents a comprehensive narrative review of reactive arthritis (ReA) with focus on articles published between 2018 and 2020. We discuss the entire spectrum of microbial agents known to be the main causative agents of ReA, those reported to be rare infective agents, and those reported to be new candidates causing the disease. The discussion is set within the context of changing disease terminology, definition, and classification over time. Further, we include reports that present at least a hint of effective antimicrobial therapy for ReA as documented in case reports or in double-blind controlled studies. Additional information is included on microbial products detected in the joint, as well as on the positivity of HLA-B27.

Recent Findings

Recent reports of ReA cover several rare causative microorganism such as Neisseria meningitides, Clostridium difficile, Escherichia coli, Hafnia alvei, Blastocytosis, Giardia lamblia, Cryptosporidium, Cyclospora cayetanensis, Entamoeba histolytica/dispar, Strongyloides stercoralis, β-haemolytic Streptococci, Mycobacterium tuberculosis, Mycoplasma pneumoniae, Mycobacterium bovis bacillus Calmette-Guerin, and Rickettsia rickettsii. The most prominent new infectious agents implicated as causative in ReA are Staphylococcus lugdunensis, placenta- and umbilical cord–derived Wharton’s jelly, Rothia mucilaginosa, and most importantly the SARS-CoV-2 virus.

Summary

In view of the increasingly large spectrum of causative agents, diagnostic consideration for the disease must include the entire panel of post-infectious arthritides termed ReA. Diagnostic procedures cannot be restricted to the well-known HLA-B27-associated group of ReA, but must also cover the large number of rare forms of arthritis following infections and vaccinations, as well as those elicited by the newly identified members of the ReA group summarized herein. Inclusion of these newly identified etiologic agents must necessitate increased research into the pathogenic mechanisms variously involved, which will engender important insights for treatment and management of ReA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11926-021-01018-6.

Neglected reactive arthritis complicated by bilateral hip and temporomandibular joints ankylosis after a suspected tetanus infection: a case report

Background

Reactive arthritis had been reported to occur after various vaccinations, including the tetanus toxoid vaccine; here, we report a case of ankylosing arthropathy suggested to be a complication of missed neglected reactive arthritis after tetanus infection.

Case presentation

A healthy 20-year-old woman presented with subtrochanteric right femoral fracture; imaging studies showed bilateral ankylosed hip, kyphoscoliosis, bilateral fused temporomandibular joints, and normal sacroiliac joints bilaterally. Laboratory investigations for a rheumatic or autoimmune disease were all within normal ranges. Detailed history revealed admission of the patient to an ICU unit (1 year before the trauma) for a month as she was diagnosed as having tetanus infection, after which she was unable to walk or feed herself. At the final follow-up, the patient started walking with a moderate limb after having a series of surgeries including femoral fracture fixation, temporomandibular joint excision arthroplasty, and bilateral total hip arthroplasty.

Conclusion

Unusual complications after tetanus infection can occur in the form of joint ankylosis, which could be presented after prolonged immobilization possibly due to improper management of reactive arthritis.

[Diagnostic approach and differential diagnosis of mon- and oligoarthritis]

Reasons of mon- and oligoarthritis are heterogeneous. The diagnostic approach includes a detailed medical anamnesis, physical examination and imaging (conventional X-ray, sonography, MRI and, CT). Analysis of the synovial fluid is required in suspected septic arthritis and frequently helps in diagnosis and differential diagnosis of crystal arthropathies. Dual-energy-CT (DECT) detects sodium urate crystals and can replace joint puncture in some cases. In addition to crystal arthropathies and septic arthritis, differential diagnosis of mon-/oligoarthritis includes reactive arthritis, arthrosis and monarthritic courses of SpA/PsA. A rheumatologist should be consulted particularly in the case of persistent monarthritides, in order to initiate a specific therapy to prevent secondary damage.

Treatment of reactive arthritis with biological agents: a review

The pathogenesis of reactive arthritis (ReA) has not been fully elucidated. In recent years, many researchers have confirmed that multiple cytokines are involved in the occurrence and development of ReA. Although ReA is self-limiting, it is still incurable for some patients who have no or a weak response to traditional drugs, such as non-steroidal anti-inflammatory agents, glucocorticoids and immunosuppressive agents. This is called refractory reactive arthritis. Currently, there is insufficient evidences for the treatment of refractory ReA with biological agents, though biological agents against cytokines have been developed over the past few years. This review summarizes the current development of clinical treatments of ReA with biological agents, which provides future investigations on refractory ReA with more evidence and references.

Prevalence of Human Leukocyte Antigen B27 Positivity and Microbiological Profiles of Patients with Reactive Arthritis – A Cross Sectional Study

The present study aims to determine the spectrum of etiological agents and to screen HLA-B27 and, related inflammatory markers in patients presenting with symptoms of Spondyloarthritis(SpA) post diarrhea, which can aid in prompt diagnosis of reactive arthritis (ReA). A total of 903 stool samples of patients presenting with diarrhea were collected and screened with microscopic and culture techniques to identify the etiological agents. Blood samples of patients presenting with both diarrhea and arthritis were collected and subjected to C- reactive protein(CRP), Erythrocyte sedimentation rate(ESR) and Human Leukocyte Antigen B27(HLA-B27) detection tests.Among the total of 903 patients, 20 Salmonella species were isolated. Othergut microbes identified included Escherichia coli 572(63%), Klebsiella species 126(14%), Proteus vulgaris 43(5%), Proteus mirabilis 27(3%), Citrobacter species and Enterococcus species 8(1%), while some of these organisms(3.2%) caused inflammation resulting in ReA. Parasitic etiology was found in 99 patients, among which the most common parasites include Entamoeba histolytica and hookworm, identified through microscopy. Among the total, 29 patients were found to have symptoms of joint pain with articular and extra articular manifestations, and some associated with HLA-B27.

Update on Post-Streptococcal Reactive Arthritis: Narrative Review of a Forgotten Disease

PURPOSE OF THE REVIEW

This topical review attempts to build the concepts of PSRA as an independent entity and discuss prevalent diagnostic criteria. It utilizes a search strategy to collate all clinical features of PSRA reported from across the world and also discusses laboratory and treatment options in brief.

RECENT FINDINGS

There are several immune-mediated diseases described after acute streptococcal infections. Post-streptococcal reactive arthritis (PSRA) is a sterile, self-limiting arthritis that occur as an immune sequelae to streptococcal infection. Though PSRA resembles the arthritis of acute rheumatic fever superficially, it is a separate entity in its own right. It is different from classical reactive arthritis too. It was being recognized worldwide and more frequently in the recent past, possibly due to heightened awareness amongst clinicians. However, research on this enigmatic immune phenomenon is limited. Most acceptable hypotheses suggest molecular mimicry sensitizing the immune system towards synovial peptides such as keratin, vimentin and laminin, leading to arthritis in a genetically predisposed individual. There is still much to be learnt from this unique disease about the vagaries of the immune system.

Isolated Facet Joint Arthritis in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a group of childhood inflammatory arthropathies which has variable clinical presentations and can affect multiple joints including the spine. Arthritis in facet joints is rare and very unusual to be the only presentation of JIA. We report a 16-year-old female who presented with back pain and stiffness, in which CT of the lumbar spine showed evidence of facet joint erosion and pelvis MRI showed facet joint arthritis consistent with juvenile idiopathic arthritis. 

Reactive Arthritis After COVID-19 Infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is a novel virus that results in a variety of clinical manifestations. In this report, I describe an uncommon presentation of reactive arthritis (ReA) following COVID-19. I report the case of a 39-year-old woman who presented with arthritis in the small joints of the hands after recovery from COVID-19 infection. To my knowledge, only four cases involving such a presentation have been reported in the literature so far.

An unusual cause of reactive arthritis with urticarial: A case report

Reactive arthritis (ReA) is a syndrome of arthritis and tenosynovitis with defined extra-articular manifestations following certain infections. Despite being recognized a long time ago, debates still surrounds its definition. It is still unclear if the spectrum of the disease should include arthritis induced by other than the classical organisms. Here, we present an unusual cause of ReA. A young healthy female patient presented with acute polyarthritis and acute urticaria after 2 weeks of diarrheal illness. She was found to have blastocystis in the stool microscopy. Extensive evaluation ruled out other causes of her arthritis. She received metronidazole with a short course of NSAIDS and steroids with complete resolution of her skin and joint symptoms. She was followed for six months with no recurrence of arthritis or urticaria. Blastocystis sp. is a parasite that is prevalent in developing countries. It has been linked to isolated ReA or isolated urticaria among a few other case reports. This is the very first case to have blastocystis induced ReA that coexisted with acute urticaria. Upon review of the literature, we found that blastocystis induced ReA affects mainly young and middle-aged females such as in our case. The arthritis is usually settled with the parasite eradication. Finally, urticaria might be a distinguishing feature for blastocystis induced ReA that requires specific antimicrobial therapy.

Reactive Arthritis: Update

Purpose of Review

The aim of this paper is to provide an overview about reactive arthritis, with an update regarding pathophysiology and therapeutic approach of the disease, outlining the clinical features and diagnostic approach, based on recent literature review.

Recent Findings

Reactive arthritis is considered to be part of the spectrum of the spondyloarthritis. Its epidemiology is changing worldwide due to several reasons, among them are as follows: different diagnosis approach and clinical presentations, different grades of infection, microbiome changes, etc. The understanding of pathophysiological models is challenging, but recent studies contribute to elucidate the major factors involved in the development of the disease. The management of ReA depends on the triggering agent and the phase of disease, whether it is acute or chronic.

Summary

The association between the microbiome changes and spondyloarthropathies (ReA) is becoming increasingly evident. The results regarding the biologic treatment on refectory ReA are promising.

Tackling the autoimmune side in Spondyloarthritis: A systematic review

Spondyloarthritis (SpA) are a heterogeneous group of inflammatory chronic diseases characterized by sharing common pathogenic, clinical and radiologic features. The aim of this review is to support clinicians in understanding and managing this complex disease, from pathogenesis to therapeutic targets, through a systematic review of the current literature in accordance with PRISMA guidelines and checklist. HLA-B27 has been found to be associated with axial involvement either in SA and in PsA patients: it might be involved through presentation of an "arthritogenic peptide" to autoreactive CD8+ T cells or might accumulate in misfolded form and induce production pro-inflammatory cytokines by binding to several innate immune receptors. This genetic background in combination with mechanical stress leads to the activation of both innate and acquired immune responses as well as a possible role of autoimmunity in SpA pathogenesis. The release of IL-23 and IL-17 is relevant for their systemic and local effect on bone, inducing the activation of osteoclasts. Thus, the regulatory role of IL-17 on fibroblasts, osteoblasts and chondrocytes has an impact in both synovial inflammation and joint destruction. Innovative therapies targeting IL-12/23 and IL-17 and the use of small targeted synthetic molecules, as JAK-inhibitors, proved to be effective in SpA patients representing an alternative strategy to TNF-inhibitors.

An overview of reactive arthritis

Reactive arthritis, also known as Reiter syndrome, is a spondyloarthropathy that typically follows a urogenital or gastrointestinal infection, and is characterized by conjunctivitis, urethritis, and arthritis. The frequency of reactive arthritis in the United States is estimated at 3.5 to 5 patients per 100,000. Physician assistants (PAs) can manage the condition; therefore, they should be familiar with the disease's signs and symptoms, diagnostic criteria, and treatment regimens. Without proper management, reactive arthritis can progress to a chronic destructive arthritis. Prompt recognition of the condition is key to early intervention and a better patient outcome with fewer complications.

Reactive Arthritis - A Rare Complication of Intravesical BCG Instillation

Reactive arthritis (ReA) with the classic triad of arthritis, conjunctivitis and urethritis, previously termed Reiter’s syndrome, is a systemic illness, usually induced by genitourinary or gastrointestinal infections. However, it can be a rare complication of intravesical Bacillus Calmette-Guérin instillation (iBCG), a therapy prepared from attenuated strains of Mycobacterium bovis, a common and effective treatment for carcinoma in situ of the bladder (CisB). We report a case of a patient with CisB who developed ReA after iBCG. The symptoms resolved completely with corticosteroids. iBCG was stopped with no recurrence of carcinoma within 2 years.