Acute arthritis associated with Clostridium difficile colitis

A Case Report and Review of the Literature: Reactive Arthritis Caused by Clostridioides difficile ribotype 027

With an annual incidence of 250-300 per 100,000 inhabitants, reactive arthritis is not uncommon. However, the fact that Clostridioides difficile infection (CDI) can also lead to this complication is largely unknown. We report on a 69-years-old man who developed reactive arthritis of his right knee joint one week after antibiotic-associated diarrhea with evidence of C. difficile of the hypervirulent ribotype 027. His female partner also became infected with C. difficile ribotype 027, but did not develop reactive arthritis. The further investigation showed that the patient - in contrast to his partner - was HLA-B27 positive and had strong antibody levels against C. difficile. The case history together with the review of 45 other cases described so far shows that C. difficile can also lead to reactive arthritis. C. difficile-associated reactive arthritis (CDARA) is characterized by the fact that patients suffer from diarrhea or colitis after taking antibiotics, toxigenic C. difficile or only the toxins are detectable in the stool and there are no other explanations for the arthritis and diarrhea.

Reactive arthritis: newer developments

Reactive arthritis (ReA) is characterized by an aseptic inflammatory articular involvement occurring in a genetically predisposed individual secondary to an infectious process localized outside the joint. ReA usually refers to an acute or insidious oligoarthritis process after enteric (enteroarthritis) or urogenital (uroarthritis) infection. Conventional antirheumatic therapeutic modalities based on nonsteroid anti-inflammatory drugs, sulfasalazine, and steroids are effective in the majority of patients. In more refractory cases, the use of second-line agents including methotrexate and more recently biological agents such as etanercept and infliximab has been found highly effective. The role of antibiotics remains not well established, although they appear to be effective in acute ReA of urogenital origin.

Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature

Clostridium difficile is most commonly associated with colonic infection. It may, however, also cause disease in a variety of other organ systems. Small bowel involvement is often associated with previous surgical procedures on the small intestine and is associated with a significant mortality rate (4 of 7 patients). When associated with bacteremia, the infection is, as expected, frequently polymicrobial in association with usual colonic flora. The mortality rate among patients with C. difficile bacteremia is 2 of 10 reported patients. Visceral abscess formation involves mainly the spleen, with 1 reported case of pancreatic abscess formation. Frequently these abscesses are only recognized weeks to months after the onset of diarrhea or other colonic symptoms. C. difficile-related reactive arthritis is frequently polyarticular in nature and is not related to the patient's underlying HLA-B27 status. Fever is not universally present. The most commonly involved joints are the knee and wrist (involved in 18 of 36 cases). Reactive arthritis begins an average of 11.3 days after the onset of diarrhea and is a prolonged illness, taking an average of 68 days to resolve. Other entities, such as cellulitis, necrotizing fasciitis, osteomyelitis, and prosthetic device infections, can also occur. Localized skin and bone infections frequently follow traumatic injury, implying the implantation of either environmental or the patient's own C. difficile spores with the subsequent development of clinical infection. It is noteworthy that except for cases involving the small intestine and reactive arthritis, most of the cases of extracolonic C. difficile disease do not appear to be strongly related to previous antibiotic exposure. The reason for this is unclear. We hope that clinicians will become more aware of these extracolonic manifestations of infection, so that they may be recognized and treated promptly and appropriately. Such early diagnosis may also serve to prevent extensive and perhaps unnecessary patient evaluations, thus improving resource utilization and shortening length of hospital stay.

Rheumatologic manifestations of gastrointestinal diseases

One of the most significant extraintestinal manifestations of gastrointestinal diseases is rheumatologic disorders. The gastrointestinal diseases with rheumatologic manifestations can be divided into two major categories: intestinal disorders and disorders of the liver, biliary tree, and pancreas. The cause of diseases in each of these categories is different. Although intestinal permeability and immune responsiveness are frequently implicated in disorders of the intestine, diseases of the liver, biliary tree, and pancreas usually involve the production of autoantibodies, cytokines, or enzymes. Treatment of rheumatologic complications frequently involves therapy directed at the underlying gastrointestinal disease.

Reactive arthritis associated with Clostridium difficile pseudomembranous colitis

Reactive arthritis is associated with several gastrointestinal pathogens, particularly Shigella, Salmonella, Campylobacter, and Yersinia. Another, less well recognized bowel infection leading to reactive arthritis is pseudomembranous colitis, caused by Clostridium difficile. An illustrative case is presented, and the clinical features and characteristics of all reported patients with this association are reviewed. The pathogenesis of the reactive arthritis seems to be related to an immunological response in joints and other tissues against bacterial antigens, which gain access to the systemic circulation through increased intestinal permeability. Therapy with nonspecific antiinflammatory drugs, anticlostridial agents, or a combination of the above is effective. Despite the possibility of persistent articular involvement after gastrointestinal symptoms have subsided, the long-term prognosis seems to be excellent.

Reactive arthritis: the role of bacterial antigens in inflammatory arthritis

For more than 100 years it has been suspected that bacteria or products derived from them are deposited in joints and cause arthritis without suppuration. Over this time a vast amount of evidence, much of which is still unchallenged, has accumulated to demonstrate that whole bacteria and subcellular bacterial elements do pass, under certain circumstances, from sites of mucosal colonization or infection into the circulation and thence into joints. Similarly, experimental studies have demonstrated that the deposition of both inert material and bacterial components within synovium is sometimes, but not always, associated with the development and persistence of synovitis. In human reactive arthritis aseptic synovitis follows localized bacterial infection in the gut or genitourinary tract. A genetic predisposition, associated with the HLA B27 antigen, is recognized, and interaction between class I HLA determinants and bacteria-derived antigens may underlie the development of arthritis. Although much remains to be learned about the dissemination of antigens from the primary site of infection in reactive arthritis, strong evidence implicates the deposition of antigenic elements of Chlamydia, Yersinia, Salmonella and perhaps other micro-organisms within the synovium. Immunological findings support the notion that such antigens are being presented within the joint and participating in the induction and/or maintenance of synovitis. It is not yet clear whether such bacteria are complete or viable or whether persistence at an extra-articular site is important to the persistence of arthritis. The possibility that reactive arthritis, and perhaps other forms of seronegative arthritis also, is caused and perpetuated by bacterial antigens within the joint poses new questions about the role of HLA B27 in pathogenesis. It also raises important and exciting issues regarding treatment. Already, studies of antimicrobial therapy have yielded encouraging initial findings, and it is now possible to design and evaluate therapies aimed at blocking specific antigen recognition within the joint.

Clostridium difficile toxin-induced reactive arthritis in a patient with chronic Reiter's syndrome

The first case of Clostridium difficile toxin-induced reactive arthritis in a patient with chronic Reiter's syndrome is described and compared with previous cases of reactive arthritis associated with this organism. This case demonstrates how distinct clinical manifestations may develop at different times in Reiter's syndrome, according to the infecting organism. Diagnostic terminology is discussed in this context. Clostridium difficile should now be considered a firmly established cause of reactive arthritis.

Seronegative arthritis and the bowel

In this chapter we have outlined the seronegative spondarthritides associated with bowel disease, excluding those discussed in separate chapters. Although, traditionally, Crohn's disease and ulcerative colitis have been dealt with separately in any discussion of seronegative arthritides, they have been discussed together here for the following reasons. Despite being pathologically distinct they show remarkable similarity in extraintestinal manifestations including any associated arthritis. Any observed differences in prevalence rates of arthritis may be secondary to the relative difficulty in diagnosing Crohn's disease, and most of the important prevalence studies were done before the more sophisticated techniques to investigate the bowel became available. This may in part explain the dramatic increase in the world-wide incidence of Crohn's disease seen in the last 30 years, particularly through the 1970s, but which has fallen off recently (Miller et al, 1974). It would seem that the body has a limited means of expressing disease processes. The final common pathway of a number of quite distinct disease entities is the concept of the seronegative spondarthritides. Exactly how the microbiological, immunogenetic and molecular factors interact to produce a particular disease end-point is currently not clearly defined, but with the increasingly sophisticated means to investigate the body at a cellular level the explanations may soon be at hand. Further controlled family studies are also needed to define the genetic relationships more precisely. We may then be able to piece the jigsaw puzzle together.

Osteomyelitis presenting as a swollen elbow in a patient with the acquired immune deficiency syndrome

A patient suffering from the acquired immune deficiency syndrome (AIDS), who developed swelling of the left elbow four weeks after Staphylococcus aureus septicaemia is reported. The cause was osteomyelitis of the olecranon process.

Follow-up study of Reiter's disease and reactive arthritis. Factors influencing the natural course and the prognosis

The acute clinical picture and long-term prognosis of 160 patients with Reiter's disease (RD), and 144 patients with reactive arthritis triggered by yersinia infection (YA), was analysed. Most of the patients with RD were men, while YA was as common among male and female patients. YA manifested in a third of patients as incomplete or complete RD. The long-term prognosis in RD was less favourable than in YA. Recurrent arthritis, development of chronic destructive arthritis and radiologic sacroiliitis were more frequent in RD than in YA. The presence of HLA-B27 was the major factor determining extra-articular inflammatory symptoms and the development of chronic problems.

Reactive arthritis associated with Clostridium difficile

A case of reactive arthritis in a patient with a previously documented history of Reiter's syndrome is described. The precipitating agent appears to have been Clostridium difficile. High levels of toxin were demonstrable in the faeces and neutralising antitoxin was detected in the patient's serum but not synovial fluid. Resolution of the polyarthropathy was slow despite successful eradication of the C. difficile with a course of vancomycin.