Reactive Arthritis in a 37-Year-Old Female With SARS-CoV2 Infection

COVID-19 with Suspected Secondary Pyogenic Arthritis of the Hip: A Case Report and Literature Review

Introduction

COVID-19 may be associated with orthopedic symptoms, including myalgia and joint pain. There are reports of reactive arthritis and acute arthritis diagnosed after COVID-19; however, COVID-19-associated pyogenic arthritis has not been reported.

Case Report

We treated a young woman with secondary pyogenic hip arthritis that started after COVID-19. The patient was a 23-year-old woman who developed acute pain in the right hip 9 days after being diagnosed with COVID-19. Blood cultures revealed methicillin-sensitive Staphylococcus aureus and contrast-enhanced computed tomography revealed joint effusion in the right hip. Although the joint fluid culture results were negative, we suspected pyogenic arthritis of the hip joint and performed curettage and continuous irrigation of the right hip joint. Intraoperative histopathological examination of the synovial membrane revealed numerous neutrophils with segmental nuclei, consistent with a diagnosis of pyogenic arthritis.

Conclusion

To the best of our knowledge, this is the first report of probable secondary pyogenic hip arthritis in a patient with COVID-19.

Reactive arthritis following COVID-19: clinical case presentation and literature review

Reactive arthritis (ReA) is a clinical condition typically triggered by extra-articular bacterial infections and often associated with the presence of HLA-B27. While ReA has traditionally been associated with gastrointestinal and genitourinary infections, its pathogenesis involves immune and inflammatory responses that lead to joint affections. The emergence of COVID-19, caused by SARS-CoV-2, has prompted studies of plausible associations of the virus with ReA. We present a case of ReA in a patient who survived COVID-19 and presented with joint affections. The patient, a 31-year-old man, presented with lower limb joints pain. SARS-CoV-2 was confirmed by PCR testing during COVID-19-associated pneumonia. Following a thorough examination and exclusion of all ReA-associated infections, a diagnosis of ReA after COVID-19 was confirmed. In addition, this article encompasses a study of similar clinical cases of ReA following COVID-19 reported worldwide.

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.

Does post-COVID reactive arthritis exist? Experience of a tertiary care centre with a review of the literature

Background

Rheumatological manifestations following COVID-19 are various, including Reactive Arthritis (ReA), which is a form of asymmetric oligoarthritis mainly involving the lower limbs, with or without extra-articular features. The current case series describes the clinical profile and treatment outcome of 23 patients with post-COVID-19 ReA.

Methods

A retrospective, observational study of patients with post-COVID-19 arthritis over one year was conducted at a tertiary care centre in India. Patients (n = 23) with either a positive polymerase chain reaction test for SARS-CoV2 or an anti-COVID-19 antibody test were included. Available demographic details, musculoskeletal symptoms, inflammatory markers, and treatment given were documented.

Results

Sixteen out of 23 patients were female. The mean age of the patients was 42.8 years. Nineteen patients had had symptomatic COVID-19 infection in the past. The duration between onset of COVID-19 symptoms and arthritis ranged from 5 to 52 days with a mean of 25.9 days. The knee was the most involved joint (16 out of 23 cases). Seven patients had inflammatory lower back pain and nine had enthesitis. Most patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids - either depot injection or a short oral course. Three patients required treatment with hydroxychloroquine and methotrexate which were eventually stopped. No relapse was reported in any of the patients.

Conclusion

On combining our data with 21 other case reports of ReA, a lower limb predominant, oligoarticular, asymmetric pattern of arthritis was seen with a female preponderance. The mean number of joints involved was 2.8. Axial symptoms and enthesitis were often coexistent. Treatment with NSAIDs and intra-articular steroids was effective. However, whether COVID-19 was the definitive aetiology of the arthritis is yet to be proven.

Does post-COVID reactive arthritis exist? Experience of a tertiary care centre with a review of the literature

BACKGROUND

Rheumatological manifestations following COVID-19 are various, including Reactive Arthritis (ReA), which is a form of asymmetric oligoarthritis mainly involving the lower limbs, with or without extra-articular features. The current case series describes the clinical profile and treatment outcome of 23 patients with post-COVID-19 ReA.

METHODS

A retrospective, observational study of patients with post-COVID-19 arthritis over one year was conducted at a tertiary care centre in India. Patients (n=23) with either a positive polymerase chain reaction test for SARS-CoV2 or an anti-COVID-19 antibody test were included. Available demographic details, musculoskeletal symptoms, inflammatory markers, and treatment given were documented.

RESULTS

Sixteen out of 23 patients were female. The mean age of the patients was 42.8 years. Nineteen patients had had symptomatic COVID-19 infection in the past. The duration between onset of COVID-19 symptoms and arthritis ranged from 5 to 52 days with a mean of 25.9 days. The knee was the most involved joint (16 out of 23 cases). Seven patients had inflammatory lower back pain and nine had enthesitis. Most patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids - either depot injection or a short oral course. Three patients required treatment with hydroxychloroquine and methotrexate which were eventually stopped. No relapse was reported in any of the patients.

CONCLUSION

On combining our data with 21 other case reports of ReA, a lower limb predominant, oligoarticular, asymmetric pattern of arthritis was seen with a female preponderance. The mean number of joints involved was 2.8. Axial symptoms and enthesitis were often coexistent. Treatment with NSAIDs and intra-articular steroids was effective. However, whether COVID-19 was the definitive aetiology of the arthritis is yet to be proven.

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.

The Musculoskeletal Manifestations of COVID-19: A Narrative Review Article

The coronavirus pandemic has caused a devastating impact across the planet. Millions of lives lost and economic structures are struggling to remain afloat. Clinical effects of SARS CoV-2 virus include tiredness, fatigue, headache, cough, loss of appetite, fever, loss of sensations of taste, and smell as well as other respiratory difficulties. Pulmonary complications of coronavirus infections result in severe pneumonia with the final sequelae being sepsis, and end-stage respiratory failure. Further cardiovascular, neurological, hematological, and gastrointestinal complications build up to cause the demise of the immune system ultimately leading to death of the affected individual. The attack of the virus and the resultant reaction of the epithelial cells lining the respiratory tract have been in the limelight of most studies pertaining to the pandemic. However, a lesser number of studies have detailed the muscular and osseous pathologies that appear post-coronavirus infection. Inflammation post-infection, across the organ systems, may appear as a link to bone and joint pathology. Myalgia is a typical COVID-19 infection symptom. On the contrary, other musculoskeletal signs have very seldom been reported. Multimodality imaging techniques stand a chance at showing the diagnosis and the degree of follow-up after evaluation. Apart from myalgia, there are cases of arthralgia, myopathies, and neuropathies. According to numerous reports, there is the possibility of a link between the current drug regimen used to treat the SARS-CoV-2 infection and the musculoskeletal manifestations observed. In this study, we aim to shed light on the coronavirus pandemic and its association to various musculoskeletal manifestations, provide a different perspective of the infected patients, and address the major points that a clinician must take care while administering care to the patient. We will also address the present treatment in line with the various musculoskeletal symptoms observed.

COVID-19-associated arthritis: an emerging new entity?

The current COVID-19 pandemic raises several clinical challenges. Cases of COVID-19-associated arthritis have been reported, and inconsistently described as either COVID-19 viral arthritis or COVID-19 reactive arthritis. We aimed to review all the reported cases of 'COVID-19-associated arthritis', which we propose, is a better term to define the entire spectrum of new-onset arthritis believed to be associated with SARS-CoV-2 infection. We performed a systematic literature review using MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews to search for articles published up to 13 December 2021. We included cohort studies, case series and case reports describing patients diagnosed with COVID-19 reactive or viral arthritis by a physician, irrespective of fulfilment of classification criteria. To identify relevant studies, medical subject headings and keywords related to 'COVID-19/SARS-CoV-2 infection' and 'reactive arthritis' were used. Our search retrieved 419 articles, of which 31 were included in the review. A total of 33 cases were reported in these 31 articles, the majority being adults (28/33=85%) with peripheral joint involvement (26/33=79%). Most of the patients responded well to treatment and the disease was self-limiting. These 33 case reports describe a possible causal relationship between exposure to SARS-CoV-2 and the onset of arthritis. However, since these cases were reported during a pandemic, other aetiologies cannot be fully excluded. The exact mechanism through which SARS-CoV-2 might trigger arthritis is not fully understood and robust epidemiological data to support a causal relationship are still lacking.

Rheumatoid arthritis and post-COVID-19 syndrome

In the third year of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2, COVID-19) pandemic doctors are encountering a new pathology – post-COVID-19 syndrome (PCS, long covid). Musculoskeletal manifestations are among the most common and may present as myalgia, arthralgia, or arthritis. Currently, there is no generally accepted definition of the disease, its duration, classification, or diagnostic criteria, and no single view on the “content” of musculoskeletal manifestations of PCS. We have enough descriptions of the debut of rheumatoid arthritis (RA) after SARS-CoV-2. That is a question: it is a coincidence, or COVID-19 may be a trigger factor of RA? We thought that SARS-CoV-2 infection may be a trigger factor for new rheumatic musculoskeletal diseases, including rheumatoid arthritis or COVID-19 can unmask previously undetected RA. The occurrence of arthritis may be a sign of PCS with transient character. So arthritis in the post covid period may induce problems in differential diagnosis of rheumatic diseases. 

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.

A Case of Axial Spondyloarthritis Triggered by SARS-CoV-2 Infection

Ever since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there has been a noticeable change in atypical presentations of several rheumatological diseases following COVID-19 infections. In this case report, we present a case of SARS-CoV-2-induced axial and peripheral spondyloarthritis. This case highlights the possibility of SARS-CoV-2 infection accelerating the onset of autoimmune diseases such as axial spondyloarthritis. Although uncommon, these cases warrant a referral to the rheumatologist for appropriate diagnosis and management. This case also highlights the need for further research on the mechanisms behind the viral interaction of SARS-CoV-2 infections with the host immune system, especially about accelerating the onset of autoimmune diseases.

New-onset Polymyalgia Rheumatica Following the Administration of the Pfizer-BioNTech COVID-19 Vaccine

We herein report the case of an 80-year-old Japanese woman who presented to our hospital with bilateral pain in the shoulders and hips lasting for a month since 2 days after the second dose of the BNT162b2 COVID-19 vaccine. Her physical findings, laboratory data, and ultrasonographic findings of bilateral biceps tenosynovitis and lateral subacromial bursitis were consistent with a diagnosis of polymyalgia rheumatica (PMR). She was successfully treated with oral prednisolone 15 mg/day. Although a causal relationship could not be definitively confirmed, PMR should be considered as a differential diagnosis in cases of persistent myalgia after administration of the BNT162b2 vaccine.

New Onset of Autoimmune Diseases Following COVID-19 Diagnosis

There is growing evidence that coronavirus disease 2019 (COVID-19) can lead to a dysregulation of the immune system with the development of autoimmune phenomena. The consequence of this immune dysregulation ranges from the production of autoantibodies to the onset of rheumatic autoimmune disease. In this context, we conducted a systematic review to analyze the current data regarding the new-onset systemic and rheumatic autoimmune diseases in COVID-19 patients. A literature search in PubMed and Scopus databases from December 2019 to September 2021 identified 99 patients that fulfilled the specific diagnostic/classification criteria and/or nomenclature for each rheumatic autoimmune disease. The main diseases reported were vasculitis and arthritis. Idiopathic inflammatory myopathies, systemic lupus erythematosus, and sarcoidosis were also reported in a limited number of patients, as well as isolated cases of systemic sclerosis and adult-onset Still's disease. These findings highlight the potential spectrum of systemic and rheumatic autoimmune diseases that could be precipitated by SARS-CoV-2 infection. Complementary studies are needed to discern the link between the SARS-CoV-2 and new onset-rheumatic diseases so that this knowledge can be used in early diagnosis and the most suitable management.

Reactive Arthritis Post-SARS-CoV-2

Reactive arthritis (ReA) following bacterial infection from the urogenital and gastrointestinal tract is widely described but is not typical post-viral infections. This report presents the second case of ReA after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the United States. A 45-year-old black male with chronic low back pain was hospitalized for 45 days with coronavirus disease 2019 (COVID-19), complicated due to the development of multiorgan failure managed with intubation, extracorporeal membrane oxygenation, and hemodialysis. He was subsequently discharged to an acute rehabilitation facility where he complained of new-onset pain in his shoulders, left elbow, and left knee three weeks after a negative SARS-CoV-2 test. He was readmitted from his acute rehabilitation facility due to recurrent fever and the development of a swollen, warm left knee. Laboratory studies at readmission showed elevated inflammatory markers, negative extensive infectious disease workup, and aseptic inflammatory left knee synovial fluid without crystals. Testing returned negative for most common antibodies seen in immune-mediated arthritides (e.g., rheumatoid arthritis, systemic lupus erythematosus), as well as for common respiratory and gastrointestinal tract pathogens responsible for viral arthritis. The multidisciplinary inpatient medical team deemed the clinical presentation and laboratory findings most consistent with ReA. The patient received a course of oral corticosteroids, followed by a second course due to the recurrence of symptoms weeks after initial treatment and recovery. The current body of medical literature on SARS-CoV-2 pathophysiology supports plausible mechanisms on how this infection may induce ReA. Such a scenario should be considered in the differential of COVID-19-recovered patients presenting with polyarthritis as prompt steroid treatment may help patient recovery.

Reactive arthritis after COVID-19: a case-based review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the coronavirus disease 19 (COVID-19) pandemic, which is deeply affecting the whole world. In this new case for the scientific world, scientists are investigating the etiopathogenesis of viral infection-induced damage and have started to focus on the short and long-term immune system effects and alterations after SARS-CoV-2 infection. The case is here reported of a 53-year-old female patient with acute monoarthritis after SARS-CoV-2 infection, who responded adequately to 150 mg/day diclofenac treatment, and the available case reports are comprehensively reviewed. With the focus on arthritis after SARS-CoV2 infection, which emerges as a new pathological condition associated with COVID-19, it was aimed to examine the possible immunological mechanisms of post-COVID-19 arthritis based on the current data on SARS-CoV-2 and the known pathogenetic background of viral arthritis.

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.

[Post-Corona-Virus-Disease‑19 arthritis. Manifestation under the clinical picture of a reactive arthritis]

A total of 13 case reports of reactive arthritis reported in the literature in connection with coronavirus disease 2019 (COVID‑19) are reviewed. Men were affected more frequently than women. The arthritis was manifested 4-44 days after the infection or the occurrence of the COVID‑19 symptoms. Acute arthritis was monoarticular or oligoarticular. Only 1 out of 7 patients examined was human-leucocyte-antigen(HLA)-B27 positive. A direct viral infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could not be detected in the synovial fluid and was not investigated in the synovial membrane. The arthritis was successfully treated with nonsteroidal anti-inflammatory drugs and/or intra-articular or systemic corticosteroids. The pathogenesis of post-COVID‑19 reactive arthritis is unknown.

Axial and peripheral spondyloarthritis triggered by sars-cov-2 infection: a report of two cases

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can show musculoskeletal symptoms such as peripheral arthritis. In rare cases, peripheral arthritis can develop after the resolution of SARS-CoV-2. We present two cases of spondyloarthritis induced by SARS-CoV-2; one case with axial and peripheral spondyloarthritis and the other with peripheral spondyloarthritis. Both cases refer to Lebanese patients who were HLA-B27 positive. These two cases highlight the possible predisposition of HLA-B27 positive patients to the development of spondyloarthritis symptoms triggered by SARS-CoV-2.

Post-COVID-19 arthritis: a case report and literature review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is the novel pathogen responsible for the coronavirus disease 19 (COVID-19) outbreak. Researchers and clinicians are exploring the pathogenetic mechanisms of the viral-induced damage and growing interest is focusing on the short-term and long-term immune-mediated consequences triggered by the infection. We will focus on post-SARS-CoV2 infection arthritis which may arise as a new pathological condition associated with COVID-19. In this article, we describe a case of acute oligoarthritis occurring 13 days after a SARS-CoV2 severe pneumonia in a middle-aged Caucasian man and we go over a brief review of the current available literature. We hypothesize that molecular mimicry might be the basic immunological mechanism responsible for the onset of COVID-19-related arthritis based on the current knowledge of SARS-CoV2 and on the known pathogenetic mechanism of viral-induced arthritis.

Musculoskeletal involvement of COVID-19: review of imaging

The global pandemic of coronavirus disease 2019 (COVID-19) has revealed a surprising number of extra-pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While myalgia is a common clinical feature of COVID-19, other musculoskeletal manifestations of COVID-19 were infrequently described early during the pandemic. There have been emerging reports, however, of an array of neuromuscular and rheumatologic complications related to COVID-19 infection and disease course including myositis, neuropathy, arthropathy, and soft tissue abnormalities. Multimodality imaging supports diagnosis and evaluation of musculoskeletal disorders in COVID-19 patients. This article aims to provide a first comprehensive summary of musculoskeletal manifestations of COVID-19 with review of imaging.

The JANUS of chronic inflammatory and autoimmune diseases onset during COVID-19 - A systematic review of the literature

The diverse clinical manifestations of COVID-19 is emerging as a hallmark of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. While the initial target of SARS-CoV-2 is the respiratory tract, it is becoming increasingly clear that there is a complex interaction between the virus and the immune system ranging from mild to controlling responses to exuberant and dysfunctional multi-tissue directed autoimmune responses. The immune system plays a dual role in COVID-19, being implicated in both the anti-viral response and in the acute progression of the disease, with a dysregulated response represented by the marked cytokine release syndrome, macrophage activation, and systemic hyperinflammation. It has been speculated that these immunological changes may induce the loss of tolerance and/or trigger chronic inflammation. In particular, molecular mimicry, bystander activation and epitope spreading are well-established proposed mechanisms to explain this correlation with the likely contribution of HLA alleles. We performed a systematic literature review to evaluate the COVID-19-related autoimmune/rheumatic disorders reported between January and September 2020. In particular, we investigated the cases of incident hematological autoimmune manifestations, connective tissue diseases, antiphospholipid syndrome/antibodies, vasculitis, Kawasaki-like syndromes, acute arthritis, autoimmune-like skin lesions, and neurologic autoimmune conditions such as Guillain–Barré syndrome. We screened 6263 articles and report herein the findings of 382 select reports which allow us to conclude that there are 2 faces of the immune response against SARS-CoV-2, that include a benign virus controlling immune response and a many faceted range of dysregulated multi-tissue and organ directed autoimmune responses that provides a major challenge in the management of this viral disease. The number of cases for each disease varied significantly while there were no reported cases of adult onset Still disease, systemic sclerosis, or inflammatory myositis.

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The immune system plays a major role in the acute progression of COVID-19.

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SARS-CoV-2 infection shares features with autoimmune diseases.

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SARS-CoV-2 can induce Guillain-Barré syndrome, arthritis, chilblain-like lesions.

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.