Salmonella-triggered reactive arthritis

Unusual Salmonella typhi periprosthetic joint infection involving bilateral knees: management options and literature review

A 70-year-old Indian woman, who had undergone primary bilateral total knee arthroplasty (TKA) for rheumatoid arthritis 10 months prior, presented with 10 days history of pain, swelling and erythema over both knees with pus discharging from the right knee. She had type 2 diabetes mellitus and was on long-term steroid, leflunomide and antitumour necrosis factor therapy for rheumatoid arthritis. Her clinical and laboratory features were suggestive of a haematogenous periprosthetic joint infection (PJI). The final diagnosis of bilateral Salmonella typhi PJI was made based on culture reports. Considering her underlying immunosuppression, a bilateral two-stage revision TKA was done with complete remission of symptoms and good functional recovery at last follow-up after 18 months. S. typhi infection of prosthetic joint has not been reported in the literature. Patients presenting with gastrointestinal complaints and PJI should alert the clinician to the possibility of infection with such atypical organisms endemic to the region.

Non-typhoid salmonella septic arthritis in dual living liver transplant recipient: a case report

Non-typhoid salmonellosis is an infectious disease caused by Salmonella species other than Salmonella typhi. Although the usual clinical course of non-typhoid salmonellosis is a benign self-limiting gastroenteritis, these bacteria are especially problematic in immunocompromised individuals, including patients with malignancies, human immunodeficiency virus, or diabetes, and those receiving corticosteroids or other immunotherapy agents. In addition to enteric symptoms, Salmonella species give rise to extra-intestinal complications, including self-limiting arthritis, which appears 1 to 3 weeks after the onset of infection and lasts from a few weeks to several months. In some patients, however, this arthritis spears to be chronic in nature. We describe herein a living-donor liver transplant recipient who experienced non-typhoid Salmonella-triggered arthritis in the left hip. The patient recovered uneventfully after 6-month-long antibiotics treatment. Clinicians involved in transplantation should be aware of the possibility that transplant recipients, like other immunocompromised individuals, are at risk of salmonellosis and therefore require careful clinical and microbiological evaluation, with the goals of prevention and early recognition of infection.

A retrospective study of secondary bacteraemia in hospitalised adults with community acquired non-typhoidal Salmonella gastroenteritis

Background

The clinical significance of bacteraemia secondary to non-typhoidal Salmonella (NTS) gastroenteritis in hospitalised adults is uncertain.

Methods

Adults admitted to a hospital in Liverpool, UK, with NTS gastroenteritis were identified using hospital discharge data and laboratory records. Patients with known HIV infection were excluded. Risk factors for a complicated or fatal course were determined.

Results

Between 1982 and 2006 inclusive, 633 adults were identified. Serovars causing infection included Enteritidis (46.6%), Typhimurium (27.6%) and Virchow (4.9%). A blood culture was taken in 364 (57.5%) patients who were generally sicker than those who were not cultured. Bacteraemia was detected in 63 (17.3%) patients who had blood cultures taken (63/633 (10.0%) of all patients). Bacteraemia was more common in those aged ≥ 65 years (p < 0.001) and in those aged < 65 years who had an underlying chronic disease. A complicated course occurred in 91 (25.0%) patients who had had a blood culture taken (148/633 (23.4%) of all patients). Independent factors associated with a complicated or fatal course among the patients investigated with a blood culture were bacteraemia (Adjusted Odds Ratio 5.34, 95% CI 2.86–9.95); new onset confusion or coma (AOR 4.80, 95% CI 1.91–12.07); prolonged symptoms prior to admission (AOR 2.48, 95% CI 1.44–4.27); dehydration (AOR1.90, 95% CI 1.07–3.38); and absence of fever (AOR 0.56, 95% CI 0.32–0.95). The 30 day attributable case fatality for all patients was 1.5%.

Conclusions

In this study secondary bacteraemia, as well as other clinical factors, was independently associated with a complicated or fatal course in non-HIV infected adults admitted to hospital with NTS gastroenteritis.

Reactive arthritis or post-infectious arthritis?

The term 'reactive arthritis' was first used in 1969 to describe the development of sterile inflammatory arthritis as a sequel to remote infection, often in the gastrointestinal or urogenital tract. The demonstration of antigenic material (e.g. Salmonella and Yersinia lipopolysaccharide), DNA and RNA, and, in occasional cases, evidence of metabolically active Chlamydia spp. in the joints has blurred the boundary between reactive and post-infectious forms of arthritis. No validated and generally agreed diagnostic criteria exist, but the diagnosis of reactive arthritis is mainly clinical based on acute oligoarticular arthritis of larger joints that develops within 2-4 weeks of the preceding infection. In about 25% of patients, the infection can be asymptomatic. Diagnosis of the triggering infection is very helpful for the diagnosis of reactive arthritis. This is mainly achieved by isolating the triggering infection (stools, urogenital tract) by cultures (stool cultures for enteric microbes) or ligase reaction (Chlamydia trachomatis). However, after the onset of arthritis, this is less likely to be possible. Therefore, the diagnosis must rely on various serological tests to demonstrate evidence of previous infection, but, these serological tests are unfortunately not standardized. Treatment with antibiotics to cure Chlamydia infection is important, but the use of either short or prolonged courses of antibiotics in established arthritis has not been found to be effective for the cure of arthritis. The long-term outcome of reactive arthritis is usually good; however, about 25-50% of patients, depending on the triggering infections and possible new infections, subsequently develop acute arthritis. About 25% of patients proceed to chronic spondyloarthritis of varying activity.

Etiology of reactive arthritis inPan paniscus, P. troglodytes troglodytes, andP. troglodytes schweinfurthii

The character of arthritis has not received the same attention in Pan paniscus as it has in P. troglodytes. Reactive arthritis (a form of spondyloarthropathy) in the latter has been considered to be either a sexually transmitted or an infectious-agent diarrhea-related disorder. The unique sexual promiscuity of P. paniscus enables us to distinguish between those hypotheses. The macerated skeletons of 139 adult P. paniscus, P. troglodytes troglodytes, and P. troglodytes schweinfurthii were macroscopically analyzed for osseous and articular pathologies. The sex of the animal was recorded at the time of acquisition. Twenty-one percent of the P. paniscus, 28% of the P. t. troglodytes, and 27% of the P. t. schweinfurthii specimens had peripheral and central joint erosive disease characteristic of spondyloarthropathy. Subchondral pauciarticular distribution and reactive new bone clearly distinguish this disease from rheumatoid arthritis, osteoarthritis, and direct bone/joint infection. The fact that P. paniscus and P. t. troglodytes were similar in terms of disease frequency makes the notion of sexual transmission unlikely. While the frequencies of spondyloarthropathy were indistinguishable among all species/subspecies studied, the patterns of joint involvement were disparate. The Pan paniscus and P. t. troglodytes home ranges are geographically separate. We assessed possible habitat factors (e.g., exposure to specific infectious agents of diarrhea) by comparing P. paniscus and P. t. troglodytes with P. t. schweinfurthii. The latter shared similar patterns and habitats (separated by the Congo River) with P. paniscus. The explanation offered for habitat-specific patterns is differential bacterial exposure-most likely Shigella or Yersinia in P. paniscus and P. t. schweinfurthii.

Comparison of arthritis characteristics in lowlandGorilla gorilla and mountainGorilla beringei

Gorilla gorilla and the less-studied G. beringei occupy very different, geographically separate habitats. We studied the occurrence of various forms of arthritis to examine possible nature/nurture causality. The macerated skeletons of 38 G. beringei and 99 G. gorilla individuals were examined macroscopically for the presence of articular and osseous pathologies. Contrasting with only isolated osteoarthritis and infectious arthritis was the frequent occurrence of a form of erosive arthritis associated with joint fusion. Twenty-one percent of the G. beringei and 20% of G. gorilla specimens were afflicted, which are statistically indistinguishable frequencies. While both had prominent axial disease, they differed in patterns of peripheral arthritis. Whereas G. beringei showed a pauciarticular pattern, the pattern in G. gorilla was more often polyarticular. Susceptibility to spondyloarthropathy was apparently genetically imprinted before Gorilla separated into G. gorilla and G. beringei. However, the different patterns of peripheral joint involvement suggest a causality resulting from lifestyle (e.g., the presence/absence or extent of knuckle walking) or a habitat-related infectious agent.

HLA-B27 modulates nuclear factor kappaB activation in human monocytic cells exposed to lipopolysaccharide

OBJECTIVE

To study whether HLA-B27 modifies some key factors controlling inflammatory responses on lipopolysaccharide (LPS) stimulation in human monocytic cells.

METHODS

U937 human monocytic cells were stably transfected with either HLA-B27 genomic DNA, HLA-B27 complementary DNA, HLA-A2 genomic DNA, or with the resistant vector pSV2neo (mock) alone. The cells were stimulated with LPS. Electrophoretic mobility shift assay was performed to determine nuclear factor kappaB (NF-kappaB) and heat-shock factor 1 activities, Western blotting was performed to detect the expressions of inhibitory kappaBalpha (IkappaBalpha) and heat-shock proteins (HSPs), and enzyme-linked immunosorbent assay was performed to measure tumor necrosis factor alpha (TNFalpha) secretion.

RESULTS

The expression of HLA-B27 modulated the response to LPS in U937 human monocytic cells. Stimulation with LPS led to faster degradation of IkappaBalpha regulatory proteins, accompanied by faster and prolonged activation of NF-kappaB in HLA-B27-expressing cells compared with HLA-A2 and mock transfectants. The secretion of TNFalpha upon LPS stimulation correlated well with the activation of NF-kappaB. No activation of the heat-shock response was observed.

CONCLUSION

Our data indicate that HLA-B27 has effects on host responses to LPS that are unrelated to antigen presentation. Two crucial events in the development of arthritis, the activation of NF-kappaB and the secretion of TNFalpha, were found to be enhanced in HLA-B27-expressing cells upon LPS stimulation. Because LPS is known to be present in the inflamed joints of patients with reactive arthritis (ReA), the enhanced inflammatory response of HLA-B27-positive cells upon LPS stimulation offers an attractive explanation for the role of HLA-B27 in the development of ReA.

Characterization of Salmonella enterica derivatives harboring defined aroC and Salmonella pathogenicity island 2 type III secretion system (ssaV) mutations by immunization of healthy volunteers

The attenuation and immunogenicity of two novel Salmonella vaccine strains, Salmonella enterica serovar Typhi (Ty2 Delta aroC Delta ssaV, designated ZH9) and S. enterica serovar Typhimurium (TML Delta aroC Delta ssaV, designated WT05), were evaluated after their oral administration to volunteers as single escalating doses of 10(7), 10(8), or 10(9) CFU. ZH9 was well tolerated, not detected in blood, nor persistently excreted in stool. Six of nine volunteers elicited anti-serovar Typhi lipopolysaccharide (LPS) immunoglobulin A (IgA) antibody-secreting cell (ASC) responses, with three of three vaccinees receiving 10(8) and two of three receiving 10(9) CFU which elicited high-titer LPS-specific serum IgG. WT05 was also well tolerated with no diarrhea, although the administration of 10(8) and 10(9) CFU resulted in shedding in stools for up to 23 days. Only volunteers immunized with 10(9) CFU of WT05 mounted detectable serovar Typhimurium LPS-specific ASC responses and serum antibody responses were variable. These data indicate that mutations in type III secretion systems may provide a route to the development of live vaccines in humans and highlight significant differences in the potential use of serovars Typhimurium and Typhi.

The involvement of class Ib molecules in the host response to infection with Salmonella and its relevance to autoimmunity

Class I molecules with limited polymorphism have been implicated in the host response to infectious agents. Following infection with Salmonella typhimurium, mice develop a CD8+ CTL response that specifically recognizes bacteria infected cells. An immunodominant component of the CTL response recognizes a peptide epitope derived from the Salmonella GroEL molecule that is presented by the non-polymorphic MHC class Ib molecule Qa-1. T cells recognizing the bacterial peptide also cross-recognize a homologous peptide from the mammalian hsp60 molecule. Since Qa-1 has a functional equivalent in humans, this observation may be relevant not only to the host response involved in clearing infection but also in understanding the link between infection with Gram-negative pathogens and autoimmune disease.

Two forms of reactive arthritis?

Inflammatory arthritides developing after a distant infection have so far been called reactive or postinfectious, quite often depending on the microbial trigger and/or HLA-B27 status of the patient. For clarity, it is proposed that they all should be called reactive arthritis, which, according to the trigger, occurs as an HLA-B27 associated or non-associated form. In addition to the causative agents and HLA-B27, these two categories are also distinguished by other characteristics. Most important, HLA-B27 associated arthritis may occur identical to the Reiter's syndrome with accompanying ureteritis and/or conjunctivitis, whereas in the B27 non-associated form this has not been clearly described. Likewise, only the B27 associated form belongs to the group of spondyloarthropathies.

The spectrum of skin, mucosa and other extra-articular manifestations

The seronegative spondyloarthropathies appear to be the genetically predisposed host's clinical expression to acute, subacute or chronic reaction to the invasion by environmental microorganisms. In the ensuing days or weeks, depending on the infectious load, clinical manifestations may occur ranging from constitutional complaints such as fever, to a variety of symptoms and/or signs related to the portal of entry-intestinal, genitourinary or respiratory. Within weeks or months, the initial or other target organs, such as the mucocutaneous, ocular and cardiovascular systems, may develop an acute reaction of greater or lesser specificity regarding the triggering agent (oral ulcers, circinate balanitis, erythema nodosum, acute anterior uveitis, pericarditis, heart blocks). Lastly, many years later, a minority of patients, probably those with a large genetic component, exhibit a spectrum of clinical manifestations related to those organs, with a chronic or recurrent course. Acute clinical manifestations--reactive arthritis--are prominent in the initial phase of the clinical spectrum, while chronic manifestations--ankylosing spondylitis--are seen at the other end of the spectrum.

Reactive arthritis following an outbreak of Salmonella Bovismorbificans infection

A large, single-source Salmonella outbreak caused by a rare serovar Bovismorbificans (6,8:r:1,5) occurred in southern Finland in 1994. The origin of the outbreak was sprouted alfalfa seeds. A questionnaire was mailed to all 210 subjects with positive stool culture. Ninety-one percent (191/210) returned the questionnaire. One hundred and fifty-three (80%) were adults. One hundred and fifty-nine out of one hundred and ninety-one (83%) reported diarrhoea, 109 (57%) fever, 104 (54%) abdominal pains, 83 (43%) fatigue, 66 (35%) articular symptoms and 20 (10%) had no symptoms. The median duration of diarrhoea was 5 days (range 1-35), that of other symptoms 4 days (range 1-30). Those reporting articular symptoms were examined (51 patients) or contacted by telephone (13 patients). Twelve percent (22/191) fulfilled the criteria for reactive arthritis (ReA). The difference in the incidence of ReA between children and adults was not significant (8%, vs. 12%). The median onset of joint symptoms was 8.5 days; symptoms were oligoarticular in 14 (67%) and polyarticular in four (19%) patients. Mostly ReA was mild, but in four patients (18%) the joint symptoms lasted for more than 4 months. Ten (45%) ReA patients had HLA-B27 tissue type. The duration and severity of ReA did not differ between HLA-B27 positive and negative patients. Fourteen (64%) ReA patients had received fluoroquinolone treatment before reactive joint or tendon symptoms manifested, but this treatment did not prevent ReA symptoms.

Long-term prognosis of reactive salmonella arthritis

OBJECTIVES

Reactive joint complications triggered by salmonella gastroenteritis are increasingly reported, but the outcome and long term prognosis of the patients is incompletely known. This study looked at the prognosis of salmonella arthritis in patients hospitalised in 1970-1986.

METHODS

Hospital records from two hospitals in southern Finland were screened for patients with the discharge diagnosis of salmonellosis or reactive, postinfectious arthritis or Reiter's disease. For the patients with confirmed diagnosis of reactive salmonella arthritis, data about the acute disease were collected from the hospital records. A follow up study was performed.

RESULTS

There were 63 patients (28 women, 35 men, mean age 36.5 years) with salmonella arthritis. Urethritis occurred in 27%, eye inflammation in 13%, and low back pain in 44% of the patients. HLA-B27 was present in 88%. More men than women were HLA-B27 positive. HLA-B27 positive patients had higher erythrocyte sedimentation rate (mean 80.9 v 46.5 mm 1st h, p = 0.0180). Also, extra-articular features and radiological sacroiliitis were seen only in HLA-B27 positive patients. A follow up study was performed on 50 patients mean 11.0 (range 5-22 years) later. Twenty patients had recovered completely. Ten patients had mild joint symptoms, 11 patients had had a new acute transient arthritis, and five acute iritis. Eight patients had developed chronic spondyloarthropathy. Radiological sacroiliitis was seen in six of 44 patients, more frequently in male than in female patients (32% v 0%; p = 0.0289). Recurrent or chronic arthritis, iritis or radiological sacroiliitis developed only in HLA-B27 positive patients.

CONCLUSION

Joint symptoms are common after reactive salmonella arthritis. HLA-B27 contributes to the severity of acute disease and to the late prognosis.

Rheumatic manifestations of Campylobacter jejuni and C. fetus infections in adults

Reports of the rheumatic manifestations of Campylobacter jejuni and C. fetus infections in adults are reviewed in order to determine the most common presentations and which individuals are at risk for rheumatic disease. Relevant English-language articles were identified through a Medline search and from bibliographies of identified articles. 105 articles were reviewed in detail. 29 cases of reactive arthritis or Reiter's syndrome following Campylobacter jejuni enteritis were identified. The knee is the most commonly involved joint and an average of 3.2 joints were involved in affected persons. HL-A B27 positive patients are more frequently affected and have higher erythrocyte sedimentation rates than HL-A B27 negative patients. Eight cases of septic arthritis and 4 cases of osteomyelitis caused by C. fetus or C. jejuni were identified, and these cases generally occurred in compromised hosts or in diseased joints.