Chronic sexually acquired reactive arthritis secondary to Chlamydiatrachomatis

Reactive arthritis is included in the spectrum of seronegative spondyloarthritides, occurring secondary to triggers of genitourinary and gastrointestinal tract infections. We describe two cases of sexually acquired reactive arthritis secondary to genital infection by Chlamydia trachomatis, diagnosed by in-house polymerase chain reaction performed on the first void urine. Both patients were managed with a combined approach of short course antibiotics, immunosuppressive agents, biologicals and surgical intervention.

[Faecal microbiota study reveals specific dysbiosis in spondyloarthritis according to subtype, disease activity and treatment]

OBJECTIVE

To compare the diversity and composition of the gastrointestinal microbiome of patients with SpA.

METHODS

MiSeq sequencing of the V3-V4 region of the 16S ribosomal RNA gene was performed on DNA isolated from stool. Patients with concurrent SpA and IBD were excluded. Differences were assessed for richness and diversity indices by QIIME 2™. Differences between means >0,2% with a p-value<0,05 were assumed significant. Institutional Ethics Committee endorsement.

RESULTS

69 individuals included, 49 with SpA (ankylosing spondylitis-AS 72,9%, psoriatic arthritis-PsA 18,8%, reactive arthritis-ReA 8,3%) 5 positive controls-dysbiosis and 15 controls-eubiosis. Conventional treatment in 42,9%, anti-IL-17 16,3% and anti-TNF 40,8%. By subtype, statistically significant differences in favour of AS were found for the diversity indices. AS vs PsA there was a difference in favour of AS for Clostridium clostridioforme (p=0,002), Gemmiger formicilis (p=0,009), Roseburia inulivorans (p=0,008) and Lachnospira pectinoschiza. AS vs ReA there was a difference in favour of AS for L. pectinoschiza (p=0,009), Ruminococcus callidus (p=0.006), Clostridium ruminantium (p=0.031); G. formicilis (p=0,034). Diversity and richness showed differences in patients with high activity for Simpson's and Pielou's indices. In high activity, lower enrichment of Bacteroides eggerthii (p= 0,0003), C. ruminantium (p= 0,026) and Alistipes putredinis (p=0,035) was found. The number of ASV was higher in the anti-IL-17 vs conventional group (p=0.025) and a trend between anti-IL-17 vs anti-TNF (p=0.09). In anti-TNF there was a lower proportion for C. clostridioforme (p=0.023), G. formicilis (p=0.030) and R. callidus (p= 0.003). In anti IL-17, Alistipes indistinctus (p= 0.012) was decreased.

CONCLUSIONS

There are differences in microbial diversity for SpA subtypes. The level of disease activity is plausible to influence the composition of the faecal microbiota. Anti-TNFα treatment may influence the microbiome environment favouring restoration of the gut microbiota, while anti-IL-17 may maintain an inflammatory environment.

Elucidating potential molecular signatures through host-microbe interactions for reactive arthritis and inflammatory bowel disease using combinatorial approach

Reactive Arthritis (ReA), a rare seronegative inflammatory arthritis, lacks exquisite classification under rheumatic autoimmunity. ReA is solely established using differential clinical diagnosis of the patient cohorts, where pathogenic triggers linked to enteric and urogenital microorganisms e.g. Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia have been reported. Inflammatory Bowel Disease (IBD), an idiopathic enteric disorder co-evolved and attuned to present gut microbiome dysbiosis, can be correlated to the genesis of enteropathic arthropathies like ReA. Gut microbes symbolically modulate immune system homeostasis and are elementary for varied disease patterns in autoimmune disorders. The gut-microbiota axis structured on the core host-microbe interactions execute an imperative role in discerning the etiopathogenesis of ReA and IBD. This study predicts the molecular signatures for ReA with co-evolved IBD through the enveloped host-microbe interactions and microbe-microbe 'interspecies communication', using synonymous gene expression data for selective microbes. We have utilized a combinatorial approach that have concomitant in-silico work-pipeline and experimental validation to corroborate the findings. In-silico analysis involving text mining, metabolic network reconstruction, simulation, filtering, host-microbe interaction, docking and molecular mimicry studies results in robust drug target/s and biomarker/s for co-evolved IBD and ReA. Cross validation of the target/s or biomarker/s was done by targeted gene expression analysis following a non-probabilistic convenience sampling. Studies were performed to substantiate the host-microbe disease network consisting of protein-marker-symptom/disease-pathway-drug associations resulting in possible identification of vital drug targets, biomarkers, pathways and inhibitors for IBD and ReA.Our study identified Na(+)/H(+) anti-porter (NHAA) and Kynureninase (KYNU) to be robust early and essential host-microbe interacting targets for IBD co-evolved ReA. Other vital host-microbe interacting genes, proteins, pathways and drugs include Adenosine Deaminase (ADA), Superoxide Dismutase 2 (SOD2), Catalase (CAT), Angiotensin I Converting Enzyme (ACE), carbon metabolism (folate biosynthesis) and methotrexate. These can serve as potential prognostic/theranostic biomarkers and signatures that can be extrapolated to stratify ReA and related autoimmunity patient cohorts for further pilot studies.

Reactive Arthritis Provoked by Campylobacter jejuni Enterocolitis Mimicking Prosthetic Joint Infection: A Case Report

CASE

A 59-year-old man with previously well-functioning partial knee replacement was admitted with a warm, swollen, and painful knee. The clinical presentation was consistent with prosthetic joint infection (PJI), but the synovial fluid analysis was negative for microbial growth. Further discussion revealed earlier Campylobacter jejuni enterocolitis that subsequently provoked reactive arthritis (ReA) mimicking PJI. The patient was treated with oral naproxen and intra-articular injection of triamcinolone and recovered completely without antibiotics or surgery. After 29 months, the knee is functioning normally.

CONCLUSION

ReA is rare but should be included in the differential diagnosis of PJI.

[PCR-based detection of pathogens in clinical rheumatology]

In the differential diagnostics of autoimmune-mediated rheumatic diseases, rheumatologists often have to consider infections (e. g. Lyme arthritis) or reactive diseases (e. g. reactive arthritis after urogenital bacterial infections). Furthermore, infections with an atypical presentation or caused by atypical pathogens (opportunistic infections) can complicate the immunosuppressive therapy of autoimmune diseases. For this purpose not only conventional microbiological culture methods but also PCR-based methods are increasingly being applied for the direct detection of pathogens in clinical specimens. The aim of this overview is to present commonly used PCR methods in the clinical practice of rheumatology and to describe their benefits and limitations compared to culture-based detection methods.

Causality of Chlamydiae in Arthritis and Spondyloarthritis: a Plea for Increased Translational Research

Current molecular genetic understanding of the metabolically active persistent infection state of Chlamydia trachomatis and Chlamydia pneumoniae in the synovium in patients with arthritis and spondyloarthritis favors a causal relationship. Here, we examine how adequately the accepted criteria for that etiologic relationship are fulfilled, emphasizing the situation in which these microorganisms cannot be cultivated by standard or other means. We suggest that this unusual situation of causality by chlamydiae in rheumatic disease requires establishment of a consensus regarding microorganism-specific terminology as well as the development of new diagnostic and classification criteria. Recent studies demonstrate the value of molecular testing for diagnosis of reactive arthritis, undifferentiated spondyloarthritis, and undifferentiated arthritis caused by C. trachomatis and C. pneumoniae in clinical practice. Data regarding combination antibiotic therapy is consistent with the causative role of chlamydiae for these diseases. Observations of multiple intra-articular coinfections require more research to understand the implications and to respond to them.

[SPECIES COMPOSITION OF INFECTIOUS FACTORS THAT CAUSE THE REACTIVE ARTHRITIS DEVELOPMENT AND THEIR EFFECT ON ARGINASE-NO-SYNTHASE REGULATORY SYSTEM OF PERIPHERAL BLOOD LYMPHOCYTES]

The own observations results of urogenital, gastrointestinal and nasopharyngeal infectious factors that cause the development of reactive arthritis (PeA) are being presented. The greatest contribution to the development of this disease make Chlamidia trachomatis (36%), Streptococcus haemolyticus (pyogenes) (19%) and hepatitis viruses B and C (10%). As a result of the research a number of kinetic parameters of arginase and NO-synthase reactions in peripheral blood lymphocytes of patients with reactive arthritis was identified. The authentic increase of arginase activity in 3.3 times and eNO-synthase activity decrease by 1,9 times in peripheral blood lymphocytes of patients with PeA, compared to practically healthy donors were determined. Increased activity of arginase and iNO-synthase of lymphocytes indicates changes in immune cells functional activity, which may be due to impaired metabolic and regulatory processes in these cells caused by a bacterial or viral infection.

Concurrent peritonsillar abscess and poststreptococcal reactive arthritis complicating acute streptococcal tonsillitis in a young healthy adult: a case report

BACKGROUND

Streptococcus pyogenes is responsible for 5-15% and 20-30% of acute pharyngitis/tonsillitis in adults and children, respectively. It not only causes acute illness but also can give rise to local suppurative complications such as peritonsillar abscess as well as trigger the postinfectious syndromes of glomerulonephritis, acute rheumatic fever and poststreptococcal reactive arthritis. Here, we report a case of a young healthy adult in whom both peritonsillar abscess and poststreptococcal reactive arthritis developed as a complication of acute streptococcal tonsillitis. To the best of our knowledge, such a coincidence of poststreptococcal sequelae has not been reported previously.

CASE PRESENTATION

A 32-year-old previously healthy woman was diagnosed with acute tonsillitis by her family doctor and treated empirically with amoxicillin/clavulanic acid (875/125 mg) twice daily for 5 days. Four days after completing antibiotic therapy, peritonsillar abscess of left tonsil developed. Needle aspiration followed by incision and drainage were performed by otolaryngologist at the Emergency Department. Next, the patient was discharged home on a 10-day course of cefuroxime and metronidazole. The symptoms of peritonsillar abscess were subsiding during treatment, however on the last day of antibiotic therapy, swelling and pain of the left ankle appeared. Five days later the patient was consulted by rheumatologist. Cultures of throat swabs and abscess aspirate collected 2 weeks before revealed the presence of Streptococcus pyogenes. Antistreptolysin O (ASO) titer was evaluated and proved to be 412 IU/ml (normal 0-200 IU/ml). The level of C-reactive protein was 13,0 mg/L (normal <5,0 mg/L). There was no known cardiac involvement. Poststreptococcal reactive arthritis was diagnosed. Left ankle arthralgia persisted for about 5-6 weeks. Six months after the presentation at the Emergency Department, the patient was well, with ASO titer reaching 262 IU/ml.

CONCLUSIONS

Clinicians should be aware that appropriate choice of antibiotic, proper dose as well as duration of therapy of acute GAS pharyngitis/tonsillitis are crucial to prevent poststreptococcal sequelae.

[Haemophilus influenzae type b meningitis in a vaccinated, immunocompetent infant with reactive arthritis]

Due to the excellent immunogenicity of the Haemophilus influenzae type b (Hib) conjugate vaccines, vaccine failures are rarely seen in patients following the recommended national immunization programmes. We present an infant with Hib meningitis despite relevant prophylaxis, without known risk factors such as medical co-morbidity, immunosuppression, immunoglobulin deficiency or prematurity. Later, a reactive arthritis developed. In conclusion, Hib-meningitis can occur in vaccinated, immunocompetent patients, and antibiotics covering Hib should be chosen in patients presenting with meningitis.

Essential role for CD103+ cells in the pathogenesis of spondyloarthritides

The clinical features of spondyloarthritides include extraarticular manifestations involving the skin, eyes, and gastrointestinal tract. At these sites, a membrane integrin can be acquired by virtue of the presence of CD4+ T cells and specific dendritic cells and correlates with a regulatory behavior of these cells. This membrane integrin conjugates the beta7 subunit and the alphaE subunit, also known as CD103. CD103 expression requires high levels of TGF-beta and retinoic acid; in addition, expression of CD103 by T cells requires antigen recognition. Whether CD103 is found in the entheses has not yet been investigated. CD103 is expressed at high levels in the skin, eyes, and bowel but it is found in only very low levels in the bloodstream. CD8+ CD103+ T cells differ markedly from other CD103+ cells in that they are resident cells with no tendency to migrate and usually exert predominantly cytotoxic functions as opposed to regulatory functions. Several bacteria, such as Salmonella, can become dormant within the mucous membranes and/or their lymph nodes, where they use CD103+ dendritic cells and CD4+ CD103+ regulatory T cells (Tregs) to evade the immune response. This phenomenon could be studied in other tissues targeted by spondyloarthritides, where dormant microorganisms can migrate by using M2 macrophages as Trojan horses, since M2 macrophages express the CD103 ligand E-cadherin. Microorganism peptide recognition by CD8+ CD103+ T cells (which are overrepresented in psoriasis and joint fluid in some forms of spondyloarthritis) induces an inflammatory response that may be sufficient to transiently reverse the regulatory function of the CD103+ dendritic cells and CD4+ CD103+ T cells during disease flares. The sensitivity of these diseases to retinoids further supports a pathogenic role for transient CD103+ cell failure.

[Fc-receptor proteins of Streptococcus pyogenes and pathogenesis of post-infection complications]

Phenomenon and mechanism of non-immune binding of immunoglobulins G and A by various emm-genotypes of group A streptococcus and in particular M-family proteins--main factors of pathogenicity of this causative agent of widespread human diseases are examined. The role of these receptor proteins in pathogenesis of post-streptococcal damage of kidneys (glomerules) and heart (myocarditis) are proved. Results of long-term studies that confirm hypothesis of initiating function of Fc-receptor M proteins in genesis of immune inflammation in organ tissues that precede development of glomerulonephritis and myocarditis are provided. According to the basic position, Fc-binding of an immunoglobulin by M proteins initiates production of anti-IgG, immune complexes of various composition and complement activation, deposition of those in tissues results in lymphocyte infiltration and production of pro-inflammatory cytokines. Literature data on the role of Fc-binding proteins in genesis of IgA-nephropathies and rheumatoid factor is also examined. An important role of other factors of the microbe is discussed such as cross-reacting antigens, erythrogenic toxin B, system of streptokinase-plasmin receptor or endostreptosin in post-streptococcal processes in kidneys. Their participation in the process must be mediated by an inflammation reaction in the tissue that is initiated by interaction of immunoglobulins with Fc-binding proteins of the microbe. A novel approach to understanding the nature of this pathology allowed to establish the ability of Fc-fragments of immunoglobulin G to suppress the development of the process.

Reactive arthritis mimicking inflammatory bowel disease arthritis: a challenging diagnosis

Reactive arthritis comprises a subgroup of infection-associated arthritis which occurs after genitourinary or gastrointestinal tract infection in genetically susceptible hosts. Studies have proposed Salmonella, Shigella or Yersinia infection as the microorganisms responsible for the post-dysenteric form. The human leukocyte antigen (HLA)-B27 is a well recognised best-known predisposing factor. We report a case of HLA-B27-associated reactive arthritis after Salmonella goldcoast enteritis, mimicking inflammatory bowel disease arthritis.

Poncet's disease: a symmetric seronegative polyarthritis with enthesopathy refractory to the therapy

Poncet's disease is a reactive polyarthritis associated to active tuberculosis (TB), with excluded presence of mycobacterium in the joints and bones affected, and no other cause for the clinical arthritis. It is a frequently forgotten entity, especially in countries with low tuberculosis prevalence. It is described a case report of a man of Guinea-Bissau that presented symmetrical generalized polyarthralgias and hands swelling, clinical sacroiliítis and multiple enthesopathies. Serum and urinary biochemical testing were normal. Immunologic studies were negative and serum levels of angiotensin-converting enzyme and calcium were normal. Sexual transmitted diseases were excluded. The initial diagnose was undifferentiated polyarthritis or reactive arthritis. A persistent and refractory monoarthritis of the right wrist demanded a direct and cultural exam of the synovial fluid, synovial biopsy and protein chain reaction for TB that were negative. After he developed right wrist arthritis with purulent synovial fluid positive to TB in the direct exam and the detection of M. tuberculosis in the cultural exam. Granula was found in his chest radiograph. He was diagnosed a Poncet's disease reactive to a pulmonary TB infection.

Reactive arthritis: developments and challenges in diagnosis and treatment

Reactive arthritis (ReA) has traditionally been described as a nonseptic arthritis occurring in the joint following an extra-articular bacterial infection. This concept became clinically associated with antecedent infections of either the gastrointestinal or genitourinary tract. Yet this operational definition of ReA has led to diagnostic uncertainty in different clinical settings. There are several scenarios in which the ReA has been complex. One is in the SAPHO syndrome, which shares many features with ReA. Another is the development of arthritis after infection with atypical organisms such as Clostridium difficile and Giardia lamblia. Treatment of ReA remains an area of ongoing investigation. There has been a randomized controlled trial of combination antibiotics in Chlamydia-induced ReA, which reported a positive result. There are several uncontrolled reports of anti-TNF agents being used successfully in refractory ReA. These studies in treatment modalities require validation on larger samples but do provide some encouraging preliminary findings from which to develop new therapeutic approaches.

The role of Chlamydia and Chlamydophila infections in reactive arthritis

Chlamydia trachomatis and Chlamydophila pneumoniae are human pathogens; the former being the etiologic agent for trachoma as well as a prevalent sexually transmitted bacterium, while C. pneumoniae is a respiratory pathogen responsible for community-acquired pneumonia. Patients with reactive arthritis show evidence of present or past Chlamydial infection. Chlamydia spp., has been strongly implicated as a triggering factor for reactive arthritis. We describe the simultaneous occurrence of C. pneumoniae and C. trachomatis infections in a subject with reactive arthritis. We suggest treatment for a patient with Chlamydia-associated arthritis to define a means by which persistent organisms can be induced to return to the active developmental cycle, thereby making them more accessible to antibiotic activity.

Reactive arthritis

Reactive arthritis (ReA) can be defined as the development of sterile inflammatory arthritis as a sequel to remote infection, often in the gastrointestinal or urogenital tract. Although no generally agreed-upon diagnostic criteria exist, the diagnosis is mainly clinical, and based on acute oligoarticular arthritis of larger joints developing within 2-4 weeks of the preceding infection. According to population-based studies, the annual incidence of ReA is 0.6-27/100,000. In addition to the typical clinical picture, the diagnosis of ReA relies on the diagnosis of the triggering infection. Human leucocyte antigen (HLA)-B27 should not be used as a diagnostic tool for a diagnosis of acute ReA. In the case of established ReA, prolonged treatment of Chlamydia-induced ReA may be of benefit, not only in the case of acute ReA but also in those with chronic ReA or spondylarthropathy with evidence of persisting chlamydia antigens in the body. In other forms of ReA, there is no confirmed evidence in favour of antibiotic therapy to shorten the duration of acute arthritis. The outcome and prognosis of ReA are best known for enteric ReA, whereas studies dealing with the long-term outcome of ReA attributable to Chlamydia trachomatis are lacking.

Sialylation of Campylobacter jejuni lipo-oligosaccharides is associated with severe gastro-enteritis and reactive arthritis

We used various genotyping methods to identify bacterial genetic markers for development of arthritic symptoms following Campylobacter enteritis. We genotyped a collection of population derived Campylobacter strains, with detailed information on clinical characteristics, including arthritic symptoms. Besides using whole genome screening methods, we focused on the lipo-oligosaccharide (LOS) gene locus in which marker genes for developing post-Campylobacter neurological disease are present. Patients with arthritic symptoms were more frequently infected with Campylobacter jejuni strains with a class A LOS locus. We also found that patients who were infected with a C. jejuni strain containing sialic acid-positive LOS (class A, B or C) more frequently had bloody diarrhoea and a longer duration of symptoms. Furthermore, the IgM antibody response against Campylobacter was stronger in patients with a sialic acid containing LOS. Ganglioside auto-antibodies were observed in a small number of patients following infection with a class C strain. We conclude that sialylation of C. jejuni LOS is not only a risk factor for development of post-infectious symptoms, but is also associated with increased severity of enteric disease.

Potential triggering infections of reactive arthritis

OBJECTIVES

The aim of the study was to investigate possible triggering infections causing reactive arthritis (ReA) of urogenital origin.

METHODS

One hundred and twenty ReA patients, 85 control group patients with other arthritides (61 with rheumatoid arthritis, 13 with osteoarthritis, and 11 with microcrystal arthritis), and 52 healthy persons were tested for urogenital tract inflammation and several infectious agents. Ligase chain reaction was used for detection of Chlamydia trachomatis (CT). Genital mycoplasmas Ureaplasma urealyticum (Uu) and Mycoplasma hominis (Mh) were tested using the Mycoplasma Duo Test (MDT). Only titres greater than 10(4) CCU/mL were accepted as pathogenecity threshold levels for Uu.

RESULTS

Inflammation of the urogenital tract (most frequently urethritis in men and cervicitis in women) was found in 95% of patients with acute ReA. Possible causative pathogens were identified in 58% of ReA patients. CT was found in 29%, Uu in 21%, and Mh in 8% of patients with ReA. While CT and Uu were found more often in HLA-B27-positive than in HLA-B27-negative patients, this was statistically proved only for CT. In ReA males Uu was found four times more frequently than in men with other arthritides.

CONCLUSIONS

In active ReA of urogenital origin, inflammation of the urogenital tract is found in the majority of patients. Although CT is the main microorganism associated with urethritis in men and cervicitis in women, mycoplasmas, especially Uu, may be possible aetiological factors for ReA.

Yersinia EnterocoliticaO:3 Isolated from Patients with or without Reactive Arthritis Induces Polyclonal Activation of B Cells and Autoantibody ProductionIn Vivo

The mechanisms by which arthritis-provoking pathogens such as Yersinia enterocolitica interact with the human immune system to produce inflammatory synovitis are not well known. One of the immunomodulating mechanisms used against these pathogens is the polyclonal activation of lymphocytes. In this study, we investigated the extent of the B-lymphocyte activation induced in mice by a strain of Y. enterocolitica O:3 (FCF 526) isolated from a patient with arthritis, and compared it with two other strains, a virulent one (FCF 397[+]) isolated from a patient without arthritis and its plasmidless isogenic pair (FCF397[-]). Also we investigated the production of autoantibodies in mice infected with these different strains. SPF Swiss mice were infected intravenously with a suspension of Y. enterocolitica. Spleen cells were taken on days 7, 14, 21 and 28 after infection and the number of cells secreting nonspecific and specific antibodies of IgG1, IgG2a, IgG2b, IgG3, IgM and IgA isotypes were determined by the ELISPOT technique. The presence of autoantibodies in mouse serum was investigated by the dot-blot assay. The pattern of infection of the three bacterial strains were almost the same. We observed a general increase in the number of nonspecific Ig-secreting cells with all three strains, and the greatest increases observed were in the IgG2a and IgG3 isotypes. Only a small fraction of the immunoglobulins detected were antibacterial, suggesting that the rest resulted from polyclonal B cell activation. The strain isolated from the patient with arthritis (FCF526) induced the greatest production of autoantibodies, coinciding with the period in which the greatest activation of nonspecific B lymphocytes was seen. There were no signs of arthritis or inflammation in the joints of the infected animals. Based on our results, we were unable to determine whether there is an association between the arthritogenic capability of Y. enterocolitica and polyclonal activation of B cells.

Reactive arthritis

Reactive arthritis (ReA) is a non-purulent joint inflammation that usually follows bacterial gastrointenstinal or urogenital infections. The classic presentation of ReA is characterized by an asymmetric arthritis usually in the lower limbs associated with urethritis, conjunctivitis and occurrence of other articular or extra-articular manifestations. ReA is classified as a type of seronegative spondyloarthopathy. Approximately 65-85% of patients with ReA are HLA-B27 positive. Regardless of the preceding infection, the clinical picture is similar, but management can differ according to the triggering infection. Treatment of Chlamydia-induced ReA should be started with antibiotics because of several mechanisms by which Chlamydia can cause persistent infection. The disease may have an acute or self-limited course, however some patients develop chronic arthritis.

Symptomatic acute reactive arthritis after an outbreak of salmonella

OBJECTIVE

In 2005, 592 individuals in Ontario developed acute gastroenteritis, predominantly after consuming bean sprouts contaminated with Salmonella enteritidis. Salmonella is a known trigger of reactive arthritis (ReA). We describe the population affected by the Salmonella outbreak in terms of clinical presentation of self-reported arthritic symptoms and HLA-B27 genotyping.

METHODS

Subjects were mailed a questionnaire, which assessed symptoms consistent with ReA. Subsequently, subjects were asked to submit saliva samples, which were analyzed for HLA-B27. Simple descriptive statistics were performed for analysis of survey responses, and the genetic component was analyzed by chi-square or Fisher's exact tests.

RESULTS

Most respondents were female (71.3%), with a mean age of 46.0 years. The mean duration of diarrhea symptoms was 16.5 days. 62.5% of respondents reported extraintestinal symptoms that were consistent with ReA. The most commonly reported features were joint pain, swelling or stiffness (46.2%), stiffness > 30 min (35.6%), ocular symptoms (24.0%), and visibly swollen joints (19.2%). Subjects with Salmonella infection had a similar incidence of HLA-B27, regardless of whether they developed symptoms consistent with ReA or not. Notably, HLA-B27 was present more frequently in those who developed Salmonella infection than in healthy controls (OR 3.0).

CONCLUSION

The study, one of the largest for a dysenteric outbreak, revealed a high event rate of self-reported symptoms consistent with ReA in those infected with Salmonella. Our results showed that HLA-B27 may have rendered individuals more susceptible to Salmonella infection, but did not contribute to the development of symptoms consistent with ReA after infection. We note that the methods used in this study, including self-report, are not ideal for diagnosis of inflammatory arthritis. However, given the rarity of large outbreaks of Salmonella, the study adds valuable knowledge about the course of ReA.

Clostridium difficile: an under-recognized cause of reactive arthritis?

Reactive arthritis usually presents as a sterile, inflammatory, asymmetric oligoarthritis, affecting large lower extremity joints. Extra-articular features (conjunctivitis, uveitis, enthesopathy, urethritis, balanitis, keratoderma blenorrhagicum) may occur. Common causes of enteric reactive arthritis are preceding infections attributable to Salmonella, Shigella, Campylobacter, and Yersinia. In contrast, Clostridium difficile is an uncommon cause of reactive arthritis, with only approximately 40 reported cases. We describe a patient with an intense additive, asymmetric oligoarthritis after an antecedent C. difficile infection. The potential contribution of C. difficile to more insidious cases of undifferentiated oligoarthritis is discussed, with emphasis on corresponding therapeutic interventions.

Study of predominant bacterial antigens triggering antibody response in Salmonella reactive arthritis: apropos of a case

Reactive arthritis (ReA) is a sterile arthritis triggered by distal mucosal infection, which suggests a contribution from bacterial products. The pathogenesis of ReA is unclear. There are no international standards for the serological methods used to confirm ReA. In the present work, we analyzed the predominant bacterial component that triggered an immune response in a 24-year-old woman with acute ReA. The candidate bacterial trigger was investigated by measuring the antibacterial antibodies (all immunoglobulin classes and IgA) to Salmonella enteritidis, Shigella flexneri and Yersinia enterocolitica. ELISA for Salmonella gave a positive result. To identify the bacterial component triggering ReA, antibodies to crude lysate, outer membrane proteins (OMP), cytosolic fraction, supernatant proteins and lipopolysaccharide of S. enteritidis were analyzed in sera and synovial fluid (SF) by ELISA, dot blot, and Western blot. Among the antigen preparations, the antibody response to OMP was dominant in both serum and SF; a strong reaction to seven OMP bands (50-21 kDa) was observed. We concluded that OMP were the main bacterial antigens that trigged ReA in the reported case. Determining the triggering bacterial components in each case can help elucidate the precise causes of ReA and will contribute to the designing of a specific serological diagnostic method for this arthritis.

New insights into bacterial persistence in reactive arthritis

Persistence of arthritis-triggering bacteria can cause chronization of reactive arthritis (ReA). In the evaluation of bacterial persistence in ReA, the persistence of both the triggering bacteria and also of the other bacteria residing in the foci of chronic infection, are important. Two forms of bacterial persistence, cell wall-deficient bacteria (L-forms) and bacterial biofilms, are characterized, and the possible links between these forms and ReA are revealed. Data showing the possibility of bacterial ReA triggers to enter the cell wall-deficient state and to persist in bacterial biofilms, and evidence, suggesting that cell wall-deficient bacteria and bacterial biofilms are involved in the foci of chronic infection, are discussed. The understanding of the properties of microbes when they exist in cell wall-deficient state and bacterial biofilms may expand our knowledge on the clinical value of persisting microorganisms in ReA. In conclusion, both modes of persistence, cell wall-deficient state of bacteria and bacterial biofilms, deserve rheumatologists' attention, as their investigation, applying modern standardized methods, may contribute to the elaboration of new beneficial schemes of antibacterial ReA therapy.

Campylobacter reactive arthritis: a systematic review

OBJECTIVE

To review the literature on the epidemiology of Campylobacter-associated reactive arthritis (ReA).

METHODS

A Medline (PubMed) search identified studies from 1966 to 2006 that investigated the epidemiology of Campylobacter-associated ReA. Search terms included: "reactive arthritis," "spondyloarthropathy," "Reiter's syndrome," "gastroenteritis," "diarrhea," "epidemiology," "incidence," "prevalence," and "Campylobacter."

RESULTS

The literature available to date suggests that the incidence of Campylobacter ReA may occur in 1 to 5% of those infected. The annual incidence of ReA after Campylobacter or Shigella may be 4.3 and 1.3, respectively, per 100,000. The duration of acute ReA varies considerably among reports, and the incidence and impact of chronic ReA from Campylobacter infection is virtually unknown.

CONCLUSIONS

Campylobacter-associated ReA incidence and prevalence varies widely among reviews due to case ascertainment differences, exposure differences, lack of diagnostic criteria for ReA, and perhaps genetics and ages of exposed individuals. At the population level it may not be associated with HLA-B27, and inflammatory back involvement is uncommon. Follow-up for long-term sequelae is largely unknown. Five percent of Campylobacter ReA may be chronic or relapsing (with respect to musculoskeletal symptoms).

Presence of D8/17 B-cell marker in patients with poststreptococcal reactive arthritis

An elevated expression of the alloantigen D8/17 on B lymphocytes has been previously proposed as a susceptibility marker in rheumatic fever. The aim of the study was to investigate the presence of the D8/17 marker on B lymphocytes in poststreptococcal reactive arthritis (PSRA). The study sample included 19 patients (15 boys, 4 girls; mean age 11.7 +/- 5.4 years) who were diagnosed with PSRA (mean age at diagnosis, 9.4 +/- 5.6 years) and 18 healthy controls (10 boys and 8 girls) matched for ethnic background. B-cell D8/17 expression was tested by flow cytometry assay using monoclonal antibodies. Laboratory results showed a higher expression of D8/17 in the patient group (23.1 +/- 10.4%, range 11.6-51.9%) than in the control group (17.1 +/- 8.2%, range 7.1-35.7) in controls; this difference was statistically significant after log transformation of the data (P = 0.035). The high rate of expression of the D8/17 marker in patients with PSRA suggests that RF and PSRA share the same genetic susceptibility.

Rheumatoid arthritis is linked to Proteus--the evidence

Rheumatoid arthritis (RA) is a chronic inflammatory arthritic and potentially disabling condition, mainly affecting women of middle age and having characteristic clinical features. Various microbial agents were implicated in the causation of RA. Extensive literature based on the results of various genetic, microbiological, molecular, and immunological studies carried out by independent research groups supports the role of Proteus mirabilis bacteria in the etiopathogenesis of RA. New diagnostic markers and criteria and the use of a novel therapeutic protocol in the form of antibiotic and dietary measures are suggested to be used together with current treatments in the management of RA. Prospective longitudinal studies with the use of antimicrobial measures in patients with RA are required to establish the therapeutic benefit of this microbe-disease association.

[Endogenic intoxication and metabolism of the connective tissue in Reiter's disease]

The purpose of the research was to study the medium-weight molecules, level of lipoperoxydation products and parameters of the connecting tissue metabolism in plasma at different stages of infectious process at urogenital clamydiosis. It is determinated that at chronic chlamydiosis infections (Reiter's disease) more significant infringements of the connecting tissue metabolism are arised than in patients with an acute infection. Among the leading factors in the development of this pathological process could be the metabolic intoxication which level of expressiveness at Reiter's disease is proved and accumulation of medium-weight molecules in plasma.

Correlation between Yersinia enterocolitica and type I collagen reactivity in patients with arthropathies

We investigated the association with Yersinia infection in patients with arthropathies in our region. To assess the reactivity to articular antigens, the correlation of anti-Yersinia with anti-type I and type II collagen antibodies was studied. Sera from 124 patients with musculoskeletal symptoms, and 47 synovial fluids (SF) from patients with rheumatoid arthritis (RA), spondyloarthopathies (SpA) or osteoarthritis (OA) were examined. Immunoglobulins against Yersinia enterocolitica, type I and type II collagens were determined by enzyme-linked immunosorbent assay. Immunoglobulin (Ig) A to Yersinia lipopolysaccharide (LPS) was present in 13/124 sera (10%) and 3/47 SF (6%). By Western blot, IgA to Yersinia outer proteins (Yops) was found in 14/124 sera (11%) and 2/47 SF (4%). Yersinia DNA from SF was not amplified by polymerase chain reaction. We found a significant correlation with anti-collagen type I but not type II antibodies. These results suggest different reactivity to articular collagen in patients with Yersinia antibodies.

Reactive arthritis

Reactive arthritis (ReA) has been recognized as a clinical disease entity for nearly 100 years. The prevalence is estimated to be 30-40/100,000 adults. The HLA-B27-associated form is part of the spondyloarthritis concept. According to the current hypothesis the arthritis follows a primary extra-articular infection and is characterized by the presence of bacterial antigen and/or of viable but non-culturable bacteria persisting within the joint. Pathogenesis involves the modification of host cells by pathogen-associated molecular patterns (PAMPs, e.g. lipopolysaccharide), bacterial effector proteins, the adaptive immune system, and the genetic background. Up to 30% of patients develop chronic symptoms, and therapeutic options for these patients are still limited. Data for recommendations to apply conventional disease-modifying anti-rheumatic drugs (DMARDs) are rare; however, sulfasalazine seems to be effective, and first reports on agents that block tumour necrosis factor (TNF) are promising. Combination therapy of several antibiotics might open the window to curing the disease; however, controlled clinical studies are needed.

Role of TNFRp55 in Yersinia enterocolitica O:3-induced arthritis: triggering bacterial antigens and articular immune response

OBJECTIVES

The pathogenesis of reactive arthritis (ReA), an aseptic synovitis that follows an extra-articular infection, is incompletely known. We studied the impact of tumour necrosis factor receptor (TNFR) p55 deficiency on the progression to ReA after oral Yersinia enterocolitica O:3 infection, the Yersinia antigens triggering articular inflammation and a possible articular TNFRp55-mediated mechanism that protects against ReA.

METHODS

Wild-type C57BL/6 and TNFRp55-/- mice were orogastrically infected with Y. enterocolitica O:3 and monitored for survival and arthritis development. The bacterial load was determined in mesenteric lymph nodes (MLNs), the spleen and joints. Interferon (IFN)-gamma, TNF-alpha and IL-10 mRNA expression in MLN and joints were analysed by reverse transcription-polymerase chain reaction (RT-PCR). Articular antibodies to Yersinia antigens, TNF-alpha protein and nitric oxide (NO) levels were assessed. Acute arthritis was evaluated after joint injection of Yersinia antigens.

RESULTS

The survival rate was 60% in TNFRp55-/- mice. They showed impaired bacterial clearance in MLN, the spleen and joints, and excessive mRNA expression of pro-inflammatory cytokines in MLN. Clinical and histological examinations revealed that TNFRp55-/- mice developed severe arthritis. Moreover, augmented articular outer membrane protein (OMP)-specific antibodies and TNF-alpha but impaired NO levels were detected in TNFRp55-/- mice. Synovial inflammatory response was detected by joint OMP injection.

CONCLUSIONS

TNFRp55-mediated immune mechanisms prevent ReA development after oral infection with Y. enterocolitica O:3. Yersinia OMPs are the relevant antigens triggering ReA. NO induction through TNFRp55 signalling could have a local antibacterial function to prevent ReA. This study could contribute to ReA-specific therapeutic studies.

Syphilis mimicking Reiter's syndrome in an HIV-positive patient

A 38-year-old man with HIV infection presented with panuveitis, urethritis, and a papulosquamous eruption on his palms and soles. Careful physical and laboratory examination led to the diagnosis of syphilitic keratoderma, uveitis, and balanitis. The patient was successfully treated with penicillin and prednisone therapy. Because the initial presentation was difficult to distinguish from the symptoms of Reiter's syndrome, a high degree of clinical suspicion was required to accurately diagnose syphilis, a curable and potentially fatal disease.

Mechanisms of disease: infection and spondyloarthritis

There is compelling evidence that some infections can initiate a chronic nonseptic arthritis. This has proved to be an important area of investigation into gene-environment interactions, particularly since HLA-B27 confers increased susceptibility to reactive arthritis. This research has investigated the microbiology of these events, and the strategies used by pathogens to induce chronic joint inflammation. Insights into the HLA-orchestrated immune response in this context have also shed light on the impact of HLA-B27 on immunity, which might provide insights into the mechanism of other HLA-B27-associated diseases. Despite the genetic link to reactive arthritis, there is no proven relationship between ankylosing spondylitis and an inciting infection. In general, most trials have found antibiotics to be ineffective in modifying the course of spondyloarthritis.

An outbreak of gastrointestinal illness and erythema nodosum from grated carrots contaminated with Yersinia pseudotuberculosis

BACKGROUND

Outbreaks of Yersinia pseudotuberculosis infection have been epidemiologically linked to fresh produce, but the bacterium has not been recovered from the food items implicated. In May 2003, a cluster of gastrointestinal illness and erythema nodosum was detected among schoolchildren who had eaten lunches prepared by the same institutional kitchen.

METHODS

We conducted a case-control study and trace-back, environmental, and laboratory investigations. Case patients had culture-confirmed Y. pseudotuberculosis O:1 infection, erythema nodosum, or reactive arthritis. Bacterial isolates from clinical and environmental samples were compared using pulsed-field gel electrophoresis (PFGE).

RESULTS

Of 7392 persons at risk, 111 (1.5%) met the case definition; 76 case patients and 172 healthy control subjects were enrolled in the case-control study. Only raw grated carrots were significantly associated with illness in a logistic-regression model (multivariable odds ratio, 5.7 [95% confidence interval, 1.7-19.5]); a dose response was found for increasing amount of consumption. Y. pseudotuberculosis O:1 isolates from 39 stool specimens and from 5 (42%) of 12 soil samples that contained carrot residue and were obtained from peeling and washing equipment at the production farm were indistinguishable by PFGE.

CONCLUSIONS

Carrots contaminated early in the production process caused a large point-source outbreak. Our findings enable the development of evidence-based strategies to prevent outbreaks of this emerging foodborne pathogen.

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.

Diagnosis and treatment of Chlamydia trachomatis infection

Chlamydia trachomatis infection most commonly affects the urogenital tract. In men, the infection usually is symptomatic, with dysuria and a discharge from the penis. Untreated chlamydial infection in men can spread to the epididymis. Most women with chlamydial infection have minimal or no symptoms, but some develop pelvic inflammatory disease. Chlamydial infection in newborns can cause ophthalmia neonatorum. Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever. Treatment options for uncomplicated urogenital infections include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days. The recommended treatment during pregnancy is erythromycin base or amoxicillin. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend screening for chlamydial infection in women at increased risk of infection and in all women younger than 25 years.

[Reactive arthritis]

Reactive arthritis is a disease closely related to the presence of the HLA-B27 antigen and characterized by sterile joint inflammation secondary to infection. Arthritis is only one of the clinical manifestations of this systemic disease. Its diagnosis rests on history, clinical examination and various serologies. The prognosis is generally good, but recurrences are frequent, in particular in HLA-B27 positive patients. Treatment is mainly symptomatic, and antibiotics should be prescribed only in the event of an active infection. A 3 months course of antibiotics could be beneficial on the long-term evolution in HLA-B27 positive patients, but this practice deserves to be confirmed by additional randomized controlled studies.

Is the enthesitis-related arthritis subtype of juvenile idiopathic arthritis a form of chronic reactive arthritis?

OBJECTIVE

Enteric organisms are known to trigger reactive arthritis. The enthesitis-related arthritis (ERA) form of juvenile idiopathic arthritis (JIA) clinically resembles reactive arthritis. Therefore, we looked for a role of enteric bacteria in ERA.

METHODS

Synovial fluid (SF) was obtained from 26 patients with ERA and 10 patients with rheumatoid arthritis (RA). Blood specimens were also obtained from patients with ERA and from 10 normal individuals. Lymphocyte proliferation assays were done on whole blood and SF mononuclear cells using as antigens crude lysates of the enteric bacteria Salmonella typhimurium, Yersinia enterocolitica, Shigella flexneri and Campylobacter jejuni. Crude lysate of Escherichia coli was used as a control antigen. HLA-B27 typing was done using the polymerase chain reaction. Homing of gut-specific T cells (CD103+) to the synovial compartment was studied using tri-colour flow cytometry. The antigen-specific cytokine profile was determined by flow cytometry.

RESULTS

Antigen-specific lymphoproliferative responses were observed in 14 of 26 patients. Among these patients, 12 showed a response in SF (four each to S. typhimurium and C. jejuni, and in two each to S. flexneri and Y. enterocolitica), and two patients in blood (S. typhimurium in both). None of the healthy controls showed a response in the blood. Lymphoproliferative responses in SF were more frequent in patients with JIA (12/26) than in controls with RA (1/10, P < 0.05). Patients with an antigen-specific response had a higher ratio of SF/blood CD103+ T cells compared with those with no antigen-specific response (P < 0.01). Antigen-specific as well as mitogen-stimulated cytokine production showed a Th1 bias.

CONCLUSION

Enteric bacteria may have a role in exacerbation of disease in patients with ERA. The immune response in patients with ERA is Th1-dominant.

Emergence ofSalmonellaBlockley, possible association with long-term reactive arthritis, and antimicrobial resistance

We previously reported the case of a patient who became ill with Salmonella serotype Blockley after eating a chicken meal and who was still suffering symptoms of salmonella-reactive arthritis 10 years after the initial infection. The immunological consequences of infection were of concern and prompted a literature review because of the possibility that Salmonella Blockley may be more likely to cause long-term illness in certain patients than more common serovars. The review revealed the additional cause for concern of plasmid-borne extended spectrum beta-lactamases and the high frequency of integron-associated multidrug resistance in some isolates. The serovar was described in 1955 in the USA and Europe. It has become common in South East Asia and recently has been reported more often in Europe. A review of reactive arthritis outbreaks shows that information on the incidence and duration of the condition caused by serovars other than Salmonella serotype Enteritidis and Salmonella serotype Typhimurium is very limited. Rheumatologists can assist microbiologists and epidemiologists by reporting relevant cases of long-term reactive arthritis.

Clinical presentations of chlamydial and non-chlamydial reactive arthritis

The aim of this study was to investigate the triggering micro-organisms and the clinical as well as laboratory differences between Chlamydial and non-chlamydial reactive arthritis (ReA) in a prospective study on 98 patients with acute/subacute arthritis. An inciting organism was found in 42 patients. Eighteen of these were chlamydial. Fifty-seven percent of all ReA patients were carriers for HLA-B27, which increased to 67% in the chlamydial group. Chlamydial ReA patients had more urethritis (P<0.05) with a longer period between arthritis and inciting infection, significantly lower CRP levels, and involved joint counts (P<0.05). Additionally, sacroiliitis was more frequent besides extra-articular manifestations in chlamydial ReA group. This study shows that chlamydial ReA differs in some points from non-chlamydial ReA, which in turn may affect the evaluation of an arthritic patient. ReA due to chlamydia more frequently encompasses a monoarticular or oligoarticular clinical picture with predominant distal extremity involvement. Non-chlamydial ReA presents higher joint counts and may involve upper extremity joints.