Evolving patterns of reactive arthritis

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.

Approach to Musculoskeletal Pain in Children

Musculoskeletal (MSK) pain is a common pediatric problem and can occur due to many etiologies. A pediatrician should be clinically equipped to identify the cause of musculoskeletal pain by a meticulous history, a detailed physical examination and judicious use of appropriate investigations. In this review, the authors attempt to delineate the approach and discuss a few common causes of musculoskeletal pain.

Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era

BACKGROUND

Chronic pain is a highly prevalent and disabling condition which is often undertreated and poorly managed in the community. The emergence of COVID-19 has further complicated pain care, with an increased prevalence of chronic pain and mental health comorbidities, and burnout among physicians. While the pandemic has led to a dramatic increase in virtual health care visits, the uptake of a broader range of eHealth technologies remains unclear. The present study sought to better understand physicians' current needs and barriers in providing effective pain care within the context of COVID-19, as well as gauge current use, interest, and ongoing barriers to eHealth implementation.

METHODS

A total of 100 practicing physicians in British Columbia, Canada, completed a brief online survey.

RESULTS

The sample was comprised of physicians practicing in rural and urban areas (rural = 48%, urban = 42%; both = 10%), with the majority (72%) working in family practice. The most prominent perceived barriers to providing chronic pain care were a lack of interdisciplinary treatment and allied health care for patients, challenges related to opioid prescribing and management, and a lack of time to manage the complexities of chronic pain. Moreover, despite expressing considerable interest in eHealth for chronic pain management (82%), low adoption rates were observed for several technologies. Specifically, only a small percentage of the sample reported using eHealth for the collection of intake data (21%), patient-reported outcomes (14%), and remote patient monitoring (26%). The most common perceived barriers to implementation were cost, complexity, and unfamiliarity with available options.

CONCLUSIONS

Findings provide insight into physicians' ongoing needs and barriers in providing effective pain management during the COVID-19 pandemic. Despite the potential for eHealth technologies to help address barriers in pain care, and strong interest from physicians, enhanced useability, education and training, and funding are likely required to achieve successful implementation of a broader range of eHealth technologies in the future.

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 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.

[Postinfectious reactive arthritis after chlamydia infection in competitive sports : Clinical management and current literature review]

BACKGROUND

Reactive arthritis following infection with chlamydia is a rare but important differential diagnosis in atraumatic joint swelling. A delayed diagnosis often leads to prolonged periods of absence from physical activity. This can have serious consequences, especially for the career of competitive athletes.

OBJECTIVES

Recommendation for the clinical management of postinfectious reactive arthritis for rapid diagnosis and targeted treatment in the symptomatic clinical course.

MATERIALS AND METHODS

Review of the literature on the topics "chlamydia", "reactive arthritis", "postinfectious arthritis" and "sexually acquired reactive arthritis", including presentation of two clinical cases of postinfectious reactive arthritis after chlamydia infection from competitive sports.

RESULTS AND CONCLUSION

Reactive arthritis following chlamydia infection in competitive athletes is a rare entity. However, it can be accompanied by far-reaching individual consequences, especially with regard to possible downtime in sports. Long-term consequences such as chronic joint damage in maintained synovitis must also be considered. In order to make a diagnosis, a specific anamnesis and the direct detection of the pathogen in the specimen of synovial fluid by polymerase chain reaction is essential. This allows a reliable diagnosis to be made with immediate initiation of therapy. However, a prolonged course of the disease cannot be excluded even if therapy is started in due time.

Approaching Reactive Arthritis Associated With Poor Prognostic Factors: A Case Report and Literature Review

The aim of this paper is to review and discuss the background, common manifestations, differential diagnosis, and current treatment practices of reactive arthritis. The focus will be on the choice of therapy in patients with poor prognostic factors. A PubMed search was performed in March 2020 on reactive arthritis and revealed 137 articles. Fourteen case reports and four large-scale studies that are pertinent for discussion in terms of treatment of reactive arthritis over the past five years are reported along with poor prognostic markers. The first choice of therapy regardless of the number of poor prognostic markers is non-steroidal anti-inflammatory drugs (NSAIDs). The second choice of therapy appeared to be glucocorticoids in the oral as well as intra-articular forms. No correlation was detected between the need for systemic steroids and the number of poor prognostic factors present. The third choice of therapy appears to be disease-modifying anti-rheumatic drugs (DMARDs) (such as sulfasalazine) and their increasing use can be demonstrated over time. Novel therapies such as adalimumab have also been shown to be used and this shows a strong correlation with an increased number of poor prognostic factors. Reporting of these case reports and review of literature contribute to knowing more about reactive arthritis and help keep us up to date with newer therapies available when patients do not respond to conventional therapy. It was notable that the increased number of poor prognostic factors and non-responders have shown increased use of tumor necrosis factor inhibitors (TNFI) such as adalimumab.

Reaktive Arthritis – eine vergessene Erkrankung?

Epidemiologie und Pathogenese Campylobacter jejuni/enteritidis ist in Westeuropa zu einem der häufigsten Erreger der ReA geworden. Auch nach mit Reisediarrhö assoziierten Escherischia-coli-Infektionen (DEC-Infektionen) können Arthralgien und milde ReA auftreten. HLA-B27 spielt eine Rolle bei der Erregerinvasion und -persistenz in Zellen der Mukosa und als antigenpräsentierendes Molekül. Neu sind Erkenntnisse, dass durch Auslösung einer Unfolded Protein Response (UPR) als Folge einer Fehlfaltung des HLA-B27-Moleküls eine proinflammatorische Stressantwort ausgelöst werden kann und dass enterobakterielle Infektionen diese Reaktion des angeborenen Immunsystems auslösen oder verstärken.

Diagnostik Die Diagnostik beruht nicht auf einzelnen Parametern, sondern auf einer Kombination von klinischen, anamnestischen und serologischen bzw. PCR-basierten Faktoren.

Therapie Antibiotika werden nur zur Therapie einer noch bestehenden Chlamydophilia-trachomatis-Infektion an der Eintrittspforte (urogenital) eingesetzt, nicht aber zur Therapie der posturethritischen oder postenteritischen ReA. Bei therapierefraktären chronischen Verläufen können Biologika (TNF-Inhibitoren) entsprechend ihrer Zulassung bei Spondyloarthritiden eingesetzt werden.

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.