Multisystem disease in post-streptococcal arthritis

Post-Streptococcal Reactive Arthritis

INTRODUCTION

Post-Streptococcal Reactive Arthritis (PSRA) is defined as inflammatory arthritis of ≥1 joint associated with a recent group A streptococcal infection in a patient who does not fulfill the Jones criteria for the diagnosis of Acute Rheumatic Fever (ARF).

METHODS

In this narrative review, we conducted a systematic search on MEDLINE, EMBASE, Cochrane Library and Google Scholar using the words poststreptococcal reactive arthritis. The search covered the time period between 1982 and 2016. The purpose of this review is to summarize the current state of knowledge of PSRA with respect to the definition, epidemiology, clinical presentation and treatment. We also summarize the key differences between PSRA, reactive arthritis (ReA) and ARF.

RESULTS

PSRA has a bimodal age distribution at ages 8-14 and 21-37 years with an almost equal male to female ratio. Clinically, it causes acute asymmetrical non-migratory polyarthritis, however, tenosynovitis and small joint arthritis may occur. This disease entity can be associated with extraarticular manifestations, including erythema nodosum, uveitis and glomerulonephritis. The frequency of HLA-B27 in PSRA does not differ from that of the normal population, which suggests that it is a separate entity from ReA. Involvement of the axial skeleton, including sacroiliitis, is uncommon in PSRA. PSRA tends to occur within 10 days of a group A streptococcal infection, as opposed to the 2 to 3 weeks delay for ARF. PSRA can be associated with prolonged or recurrent arthritis, in contrast to ARF, in which arthritis usually lasts a few days to 3 weeks. Treatment usually involves NSAIDs or corticosteroids.

CONCLUSION

We summarize clinical features that help differentiate PSRA from ARF and ReA. First-line treatment options include NSAIDs and corticosteroids. Most cases resolve spontaneously within a few weeks, but some cases are recurrent or prolonged. There are no published randomized controlled trials of PSRA.

Poststreptococcal reactive arthritis in adults: long-term follow-up

BACKGROUND

Poststreptococcal reactive arthritis (PSReA) is a recognized inflammatory articular syndrome that follows group A streptococcal infection in persons not fulfilling the Jones criteria for the diagnosis of acute rheumatic fever. Characteristic features include nonmigratory arthritis, lack of response to aspirin or nonsteroidal anti-inflammatory agents, and the presence of extra-articular manifestations, including vasculitis and glomerulonephritis. Whether or not patients with PSReA develop carditis is a point of contention.

METHODS

We analyzed the clinical features, laboratory findings, response to therapy, and outcome in patients diagnosed with PSReA between 1983 and 1998 and observed through April 2000. All patients were contacted, reexamined, and repeat antistreptolysin, rheumatoid factor, C3 and C4 complement components, and echocardiograms were performed.

RESULTS

Seventeen patients (4 men and 13 women) were included. All were of low socioeconomic status. All patients had acute severe arthritis that began shortly after a sore throat episode. Extra-articular involvement including tenosynovitis, vasculitis, and glomerulonephritis was relatively common. More importantly, none exhibited clinical and/or echocardiographic evidence of cardiac involvement. Longterm antibiotic therapy was not given.

CONCLUSION

Cardiac involvement did not occur in this group of patients with PSReA. Prolonged prophylactic antibiotic therapy may not be required for adult patients presenting with PSReA.

Analysis of human T cell responses to group A streptococci using fractionated Streptococcus pyogenes proteins

Cell extract and spent culture supernatant proteins from Streptococcus pyogenes Manfredo strain (type M5) were each separated to give 22 narrow range molecular weight fractions by blot-elution from SDS-polyacrylamide gels. Eluted samples and unfractionated proteins were screened for T cell stimulatory activity using human peripheral blood mononuclear cells (PBMC) from healthy adults in proliferation assays. Responses were measured in 4- and 7d cultures. Responses to a wide range of cell extract proteins were revealed by fractionation, the degree of response to each fraction varying between donors. Unfractionated culture supernatant proteins elicited proliferative responses by PBMC from all individuals examined. Responses to culture supernatant fractions containing 25-33 kDa proteins could be attributed to known superantigens. Furthermore, samples from culture supernatants containing higher molecular weight fractions (> 45 kDa) elicited responses in 50% of donors in 7d cultures, suggesting that these fractions contained common recall antigens. The efficacy of using electroeluted samples to identify T lymphocyte stimulatory proteins was confirmed by demonstrating that a known superantigen of S. pyogenes Manfredo strain, streptococcal pyrogenic exotoxin C (SPEC), could be fractionated successfully using this method and its activity recovered. Our results show that human T cell responses to group A streptococci involve a remarkably wide range of both cell-associated and released streptococcal proteins.

Group A streptococcal antigens and superantigens in the pathogenesis of autoimmune arthritis

Evidence from repeated clinical observations and from a variety of experimental approaches implicates group A streptococci in the pathogenesis of the autoimmune arthritides. Several streptococcal antigens and superantigens have now been characterized and their properties suggest that they may be involved in the mechanisms which underlie these diseases, although other antigens and superantigens yet to be discovered may also be involved. The association between group A streptococcal infection and autoimmune arthritis offers a useful model for providing a long-elusive understanding of the role of bacterial infection in the pathogenesis of autoimmune disease.

Beta haemolytic streptococci and reactive arthritis in adults

There is an increasing occurrence of reactive group A beta haemolytic streptococci (BHS) phenomena. This review makes a case for considering BHS in the differential diagnosis of adult reactive arthritis. This is based on (a) published reports over the past 45 years describing first attacks of rheumatic fever in adults; (b) the longstanding observation that polyarthritis is the most commonly expressed Jones major criterion in adults; (c) the broad spectrum of clinical expression of disease following streptococcal infection, with the re-emergence of the term 'poststreptococcal reactive arthritis'. The arthritis in adult rheumatic fever is characterised by sequential involvement of large weightbearing joints. Recurrent, severe, prolonged arthritis has been a prominent feature of adult poststreptococcal reactive arthritis. Carditis has been reported in 33% of adult patients with rheumatic fever. Consequently long term antibiotic prophylaxis for adults with reactive BHS phenomena should be strongly considered, and guidelines are suggested for this in individual patients. Further areas for research are discussed, particularly the interrelations between bacteria and host in disease expression, and the possibility that BHS might play a part in chronic arthritides and vasculitides.