Reactive arthritis after an outbreak of Yersinia pseudotuberculosis serotype O:3 infection

OBJECTIVE: To determine the occurrence and clinical characteristics of reactive arthritis (ReA) after an outbreak of Yersinia pseudotuberculosis serotype O:3 infection. METHODS: From 15 October to 6 November 1998, a widespread outbreak of Y pseudotuberculosis serotype O:3 occurred in Finland. A questionnaire on musculoskeletal symptoms was mailed to 38 patients with infection confirmed by culture. All patients who reported joint symptoms were interviewed by phone and their medical records of outpatient visits or hospital admission because of recent joint symptoms were reviewed. RESULTS: Thirty three of 38 (87%) patients returned the questionnaire. Reactive musculoskeletal symptoms were reported by 5/33 (15%): four patients (12%) fulfilled the criteria for ReA and one additional patient had reactive enthesopathy. The patients with ReA were adults (age range 40-47 years), whereas the patient with reactive enthesopathy was a 14 year old boy. In all patients with ReA, the arthritis was polyarticular. In addition to peripheral arthritis, other musculoskeletal symptoms included sacroiliitis (one patient), pain in Achilles tendon (one patient), and heel pain (two patients). HLA-B27 was positive in all the three patients tested. In three of four patients with ReA, the duration of acute arthritis was over six months. CONCLUSION: Y pseudotuberculosis serotype O:3 infection is frequently associated with ReA and the clinical picture is severe.     

Reactive joint symptoms following an outbreak of Salmonella typhimurium phage type 135a

OBJECTIVE: To quantify the incidence and clinical features of reactive arthritis (ReA) developing in a cohort exposed to an outbreak of Salmonella typhimurium phage type 135a, and factors affecting host susceptibility to ReA. METHODS: A screening questionnaire was mailed to 493 patients with confirmed Salmonella infection. Musculoskeletal symptoms and extraarticular manifestations of ReA were quantified. Positive responders with joint pain were invited to participate further, with a detailed history, examination, and investigations including HLA-B27 status. RESULTS: A total of 261/461 (57%) subjects responded to the questionnaire, with 23/54 adults (43%) and 41/207 children (20%) reporting joint symptoms. Although joint pains were less common in children compared with adults, those children affected usually had eye (34%) or mucocutaneous (37%) symptoms. The incidence of ReA was 14.6%, with adults more frequently affected (24%) than children (12%). This may be an underestimate given the large proportion of children involved. Associated clinical features were similar to previous studies, with the distribution of arthritis affecting the lower limbs predominantly in an oligoarticular pattern, as were the extraarticular manifestations and enthesopathy. We found 17% of subjects were HLA-B27 positive, and 55% were still symptomatic after 6 months. CONCLUSION: In an Australian cohort study of a S. typhimurium phage type 135a outbreak, joint symptoms were common, affecting 25% of subjects. The incidence of ReA of 14.6% and the clinical features were comparable to previous studies. There was a small effect of HLA-B27 status on the development of ReA.     

Reactive arthritis following an outbreak of Campylobacter jejuni infection

OBJECTIVE: To study the occurrence and the clinical picture of musculoskeletal (MSK) complications including reactive arthritis (ReA) following an outbreak of Campylobacter jejuni. METHODS: An outbreak of C. jejuni infection occurred in 2000 in Asikkala, Finland, during which 350 exposed subjects contacted the Municipal Health Centre (MHC). All primary care physicians in the MHC were advised to refer patients with acute MSK complications to the Rheumatism Foundation Hospital (RFH) for a specialist clinical examination, which was performed 相似文献   

Reactive arthritis attributable to Shigella infection: a clinical and epidemiological nationwide study

OBJECTIVES: To study the incidence and clinical picture of Shigella associated reactive arthritis (ReA) and the arthritogenicity of various Shigella species in the population. METHODS: A questionnaire on enteric and extraintestinal, especially musculoskeletal, symptoms was sent to 278 consecutive patients with Shigella positive stool culture and to 597 controls. Analysis of self reported musculoskeletal symptoms was supplemented with clinical examination of those subjects with recent symptoms. RESULTS: Of the patients, 14/211 (7%) had ReA, and a further 4/211 (2%) other reactive musculoskeletal symptoms (tendonitis, enthesopathy, or bursitis). Of the 14 patients with ReA, all adults, 10 had S sonnei, three S flexneri, and one S dysenteriae infection. HLA-B27 was positive in 36% of the patients with ReA. One control subject had ReA. In the patients with Shigella infection, the odds ratio for developing ReA was 16.2 (95% confidence interval 2.1 to 123.9), p = 0.001. CONCLUSIONS: ReA occurred in 7% of patients after Shigella infection, with an annual incidence of 1.3/1 000 000 in Finland. Besides S flexneri, S sonnei and S dysenteriae can also trigger ReA.     

Campylobacter-triggered reactive arthritis: a population-based study

OBJECTIVE: To study the incidence and clinical picture of Campylobacter-associated reactive arthritis (ReA) and other reactive musculoskeletal symptoms in the population. METHODS: A questionnaire on enteric and extraintestinal, including specifically musculoskeletal, symptoms was sent to 870 consecutive patients with Campylobacter-positive stool culture and 1440 matched controls. Analysis of self-reported musculoskeletal symptoms with clinical examination was performed. RESULTS: Forty-five of the patients (7%) had ReA and eight (1%) had reactive tendinitis, enthesopathy or bursitis. No child had ReA. The arthritis was oligo- or polyarticular, and, in most cases, mild. HLA-B27 was positive in 14% of ReA patients. Of the 45 ReA patients, 37 had C. jejuni and 8 had C. coli infection. No controls had ReA. CONCLUSION: ReA is common following Campylobacter infection, with an annual incidence of 4.3 per 100000. At the population level, acute ReA is mild, more frequent in adults, and not associated with HLA-B27. Besides C. jejuni, C. coli can trigger ReA.     

High frequency of reactive joint symptoms after an outbreak of Salmonella enteritidis

OBJECTIVE: To study reactive symptoms following an outbreak of Salmonella enteritidis that occurred after a dinner party held January 15, 1999, in Copenhagen, Denmark. An epidemiological study pointed toward a dish of minced raw salmon, in which one of the constituents was unboiled eggs as the likely cause of the outbreak. Remnants of this dish were not available for bacteriological exam. METHOD: All 94 guests and kitchen staff members were mailed a questionnaire about gastrointestinal, joint, and eye symptoms. Nonrespondents were contacted by telephone. Thirty-five individuals delivered blood samples for serological analysis mean 90 days (range 60-186) after the exposure. RESULTS: Answers were obtained from all participants and 91 were regarded as Salmonella exposed. Male/female ratio was 40/51, mean age 49 years. Fifty-two reported diarrhea (57%), 49 abdominal pain (54%), 33 fever (36%), and 12 vomiting (13%). Eight (9%) delivered stool samples, and all were positive for S. enteritidis. Seventeen fulfilled predefined criteria of reactive arthritis/arthralgia (ReA), and of these 13 had had enterocolitis. Joint pain from knees and ankles was most frequently reported. The mean duration of diarrhea among the patients reporting joint symptoms was 7.5 days, while in the group of patients with enterocolitis without joint symptoms it was 4.1 days (p = 0.00047). Three participants, all from the ReA group, reported ocular redness and irritation compatible with conjunctivitis. Although there was a trend to higher IgG anti-Salmonella antibody levels among the patients with ReA the difference was not significant. CONCLUSION: Reactive joint symptoms after food-borne Salmonella infection may be more frequent than previously thought. The duration of diarrhea is strongly correlated with the occurrence of joint symptoms.     

Low incidence of reactive arthritis in children following a salmonella outbreak

OBJECTIVES: To assess the incidence of reactive arthritis (ReA) in an outbreak of salmonella infection in a large cohort of children in Germany. METHODS: A few days after the salmonella outbreak all parents of affected children and all paediatricians and general practitioners in the region were provided with detailed information about the possibility of ReA. Six weeks after the outbreak a telephone call was made to all general practitioners and paediatricians to identify patients with ReA. Ten weeks after the outbreak a questionnaire assessing symptoms of ReA was mailed to all parents, and after a period of 4 months paediatricians and general practitioners were contacted again to search for additional unreported cases of ReA. RESULTS: Of the 286 children (age range 11 months to 9 years) with diarrhoea and stool cultures positive for Salmonella enteritidis lysotype 8/7, not a single case of arthritis was reported over the 4 month period. However, six children (2%) had arthralgia of various duration (1 day to 6 weeks) with a single recurrence in one child. The joint pattern was oligoarticular and lower limb joints (knee/ankle) were affected exclusively. CONCLUSION: The incidence of ReA after salmonella infection in children appears to be very low which may be related to differences in the immune response between children and adults.     

Reactive arthritis and other sequelae following sporadic Salmonella typhimurium infection in British Columbia,Canada: a case control study

OBJECTIVE: To describe sequelae occurring in the 3 months after sporadic Salmonella typhimurium (ST) infection in British Columbia (BC), Canada. METHODS: We compared the incidence of sequelae to similar symptoms in controls; identified risk factors for developing sequelae; identified the incidence of reactive arthritis (ReA) as diagnosed by a rheumatologist, and assessed primary care physician diagnosis of ReA. A questionnaire was administered by telephone to cases of ST occurring in BC between December 1, 1999, and November 30, 2000; and to controls obtained from the BC provincial client registry. Cases reporting symptoms were followed up by a rheumatologist. RESULTS: Thirty-five of 66 (53%) cases reported any symptom, 17 (26%) reported joint symptoms. The Mantel-Haenszel odds ratio (weighted by sex and pediatric/adult) of a salmonella case reporting "any symptom" compared to controls was 5.42; 95% confidence interval (CI) 2.18-16.27; and reporting joint symptoms was 4.40; 95% CI: 1.25-19.53. The sex distribution of cases reporting joint symptoms was not significantly different. No medication taken during the salmonella infection was significantly different between the cases who had joint symptoms and those who did not. Four cases (2 adults, 2 children) were considered by the rheumatologist to have symptoms consistent with ReA, 2 of these had been told by a physician that their symptoms were related to their ST infection. CONCLUSION: Cases were more than 4 times more likely to report joint symptoms than controls; and despite the loss of many cases to followup, 6% of all cases were considered to have ReA.     

HLA-B27 expression and reactive arthritis susceptibility in two patient cohorts infected with Salmonella Typhimurium

Background: Reactive arthritis (ReA) is an inflammatory arthritis triggered by certain gastrointestinal and genitourinary infections. Single source outbreaks of triggering infections provide an opportunity to elucidate host susceptibility factors in this disease. Aim: To determine the role of Major Histocompatibility Complex (MHC) Class I alleles in ReA susceptibility after two large single source outbreaks of Salmonella Typhimurium gastroenteritis. Methods: A questionnaire screening for features of ReA and a request for HLA class I typing were sent to all patients affected by two single source outbreaks of S. Typhimurium gastroenteritis. Individuals with arthritis of recent onset were interviewed, examined and diagnostic criteria for ReA applied. Results: Nineteen cases of reactive arthritis, 11 female, were diagnosed in the 424 respondents with S. Typhimurium gastroenteritis from both outbreaks. Clinical features of the arthritis were similar to those described after other large single source outbreaks of Salmonella infection. HLA‐B27 was expressed by only two of the 19 ReA patients and therefore did not predict susceptibility to this form of arthritis. Caucasians were, however, more likely to develop reactive arthritis than Asians. Conclusions: In this study, susceptibility to ReA was not increased in HLA‐B27 positive individuals or males but was greater in those of Caucasian descent.     

Frequency of recent parvovirus infection in patients examined for acute reactive arthritis. A study with combinatorial parvovirus serodiagnostics

OBJECTIVE: To determine the causative role of human parvovirus B19 as a preceding infection in patients examined for acute reactive arthritis (ReA). METHODS: Sixty adult patients with acute arthritis were screened for evidence of triggering infections. In all patients, cultures of stool specimens and of Chlamydia trachomatis in urethra/cervix, and/or bacterial serology were studied. The timing of primary infection of human parvovirus B19 was determined by measurement in serum of VP2-IgM, VP2-IgG, epitope-type specifity of VP2-IgG, and avidity of VP1-IgG. RESULTS: Median time from onset of joint symptoms to the rheumatological consultation was five weeks (range 1-62). Of the 60 patients, 35 fulfilled the diagnostic criteria for ReA; in the remaining, the diagnosis was unspecified arthritis (UA). Thirty-six patients had antibodies for the B19 virus. Occurrence of these antibodies did not differ significantly between ReA and UA groups (P = 0.61). Of these 36 patients, 34 had a pre-existing immunity to the B19 virus. Of the two other patients, one had rash and self-limiting polyarthritis with serological evidence of B19 primary infection, and the other had arthritis of the lower extremities with serological evidence of a convalescence period after the B19 primary infection. The latter patient also had antibodies to Yersinia, with a clinical picture typical for ReA. CONCLUSION: In patients examined for acute ReA, the frequency of recent B19 virus infection was 3.3% (2 out of 60). The diagnostic utility of the presented methodology, by using a single serum sample, was evident.     

Treatment of reactive arthritis with infliximab

We describe two patients with acute reactive arthritis (ReA) caused by Yersinia enterocolitica who were treated with infliximab with a good response in the acute phase. In a patient with prior ankylosing spondylitis (AS) and subsequent ReA the peripheral joint disease responded well to three infliximab infusions, but later he needed retreatment with infliximab to control the spinal symptoms of AS. The other previously healthy patient with acute ReA also responded well to one infliximab infusion although he did not fully recover and needed further treatment with disease modifying antirheumatic drugs. The influence of new drugs on the short and long term prognosis of the patients with ReA remains to be evaluated.     

Circulating soluble interleukin-2 receptor level predicts remission in very early reactive arthritis

OBJECTIVES: To assess the predictive value of serum soluble interleukin-2 receptor (sIL-2R) levels in patients with acute reactive arthritis (ReA). METHODS: The study includes 26 patients with acute ReA who had participated in a prospective population-based cohort study of very early arthritis. The patients had had arthritis of at least one joint with a maximum duration of 3 months. They were assessed by a rheumatologist on presentation and 6 months later. Serum sIL-2R levels on presentation were measured by the Immulite automated immunoassay analyser. Remission at 6 months, defined by the absence of swollen and tender joints, was related to the baseline sIL-2R level using a permutation test with general scores. Bootstrap estimation was used to derive the 95% confidence interval (CI). RESULTS: A total of 17 patients (65%) were in remission at 6 months and nine patients (35%) still had joint symptoms. In patients reaching remission within 6 months, the mean baseline sIL-2R level, 891 U/mL (95% CI: 658 to 1123), was higher than in patients not reaching remission, 501 U/mL (95% CI: 436 to 566), p = 0.022. CONCLUSIONS: A high serum sIL-2R level at baseline is a predictor of remission in patients with acute ReA.     

Reactive arthritis in patients attending an urban sexually transmitted diseases clinic

Objective. To assess the prevalence, clinical manifestations, associated genital infections, and HLA associations of reactive arthritis (ReA) among patients attending an urban sexually transmitted diseases (STD) clinic. Methods. Using a standardized questionnaire, 271 consecutive adults, primarily black, with possible or proven Chlamydia trachomatis genital infection were screened for symptoms of ReA. A followup questionnaire was administered 6 weeks later by mail. Patients who reported at least 1 symptom were evaluated by a rheumatologist. HLA–B typing was performed on patients with objective ReA features. Results. Nine of 217 patients (4.1%) with genital infection/inflammation had objective ReA features. Chlamydial or nongonococcal STD syndromes were diagnosed in 8 of these 9 patients (88%). Genital infection/inflammation was asymptomatic in 78% of patients with ReA features. HLA–B27 or other B7–cross-reactive group antigens were not associated with the occurrence of ReA. Conclusion. Nongonococcal genital infections, often asymptomatic, can trigger a relatively mild ReA in a larger number of exposed patients than previously thought, irrespective of the individual's HLA status.     

Detection of Salmonella infantis in synovial fluid cells of a patient with reactive arthritis.

We investigated a patient with Salmonella infantis triggered reactive arthritis (ReA) for a possible occurrence of S. infantis-specific antigens and DNA in the synovial fluid (SF) cells. S. infantis-specific antigens were abundantly observed by immunofluorescence in SF cells of the patient during acute joint inflammation. Salmonella-specific DNA was detected by Southern blotting of the amplified polymerase chain reaction product once, but the result could not be repeated. It seems that if bacterial DNA exists in inflamed joints in Salmonella triggered ReA, its amount is extremely low. This is the first report of intraarticular S. infantis antigens and potentially of Salmonella DNA in Salmonella triggered ReA.     

Outcome of reactive arthritis after an extensive Finnish waterborne gastroenteritis outbreak: a 1-year prospective follow-up study

The purpose of the study was to assess the 1-year outcome of definitive reactive arthritis (ReA) after a waterborne outbreak. A cohort of 21 patients (15 females and 6 males, median age 54 years) with ReA related to an extensive waterborne outbreak in Finland was clinically followed-up by rheumatologists with visits at baseline, at 1 month and 3, 6 and 12 months. Although the outcome was in general favourable, 1/3 of the patients had chronic course; 7 (33 %) of the 21 patients needed disease-modifying anti-rheumatic drugs (DMARDs) and even 8 (38 %) of them used glucocorticoids at 12 months. Four (19 %) were using non-steroidal anti-inflammatory drugs and nine (43 %) other analgesics. Many patients had articular pain and impaired physical function still at 12 months, even though inflammatory parameters and the number of swollen joints were low. Only one patient (5 %) was human leucocyte antigen-B27-positive. She had the most severe ReA and also additional infectious arthritis caused by Salmonella serotype enteritidis leading to osteonecrosis of her hip joint with subsequent need for arthroplasty. ReA as observed in our study was overall fairly mild, but in many individuals, postinfectious arthralgia and DMARD use continued at least up to 1 year.     

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).     

Antibiotic treatment and long term prognosis of reactive arthritis

OBJECTIVE: To evaluate whether a three month course of lymecycline has an effect on the long term prognosis of reactive arthritis (ReA). METHODS: In 1987-88 a double-blind controlled study with three month course of lymecycline/placebo was conducted. 17 of 23 patients treated at the outpatient department of Helsinki University Central Hospital volunteered to take part in a follow up study, where a physical examination were performed, and erythrocyte sedimentation rate, C reactive protein, rheumatoid factor, and radiographs of the lumbosacral spine and sacroiliac joints and of symptomatic peripheral joints were examined. RESULTS: 16/17 (94%) patients reported some kind of back pain and 10/17 (59%) peripheral joint symptoms during the follow up. Two patients had unilateral grade 1 sacroiliitis, one patient grade 4 sacroiliitis, and one patient bilateral grade 2 sacroiliitis. In one patient the disease had progressed to ankylosing spondylitis (AS), and in another to chronic spondyloarthropathy. In addition, two patients had small erosions in radiocarpal joints. No statistically significant differences were found between placebo and lymecycline groups in the development of chronic arthritis, sacroiliitis, or AS. CONCLUSION: The results of the initial study showed that long term treatment with lymecycline in patients with acute ReA decreased the duration of arthritis in those with Chlamydia trachomatis triggered ReA, but not in other patients with ReA. Ten years after the acute arthritis one patient had developed AS, and three had radiological sacroiliitis, three patients had radiological changes at peripheral joints. Long term lymecycline treatment did not change the natural history of the disease.     

Modification of disease outcome in Salmonella-infected patients by HLA-B27

OBJECTIVE: To study whether HLA-B27 modifies the outcome of Salmonella infection in vivo. METHODS: The frequency of HLA-B27 was determined in 198 Salmonella-infected patients and 100 healthy controls by immunofluorescence and polymerase chain reaction. The excretion of Salmonella was monitored at monthly intervals. The symptoms of acute infection and possible joint involvement were evaluated using questionnaires. RESULTS: Thirty-eight of 198 Salmonella-infected patients (19.2%) and 13 of 100 healthy controls (13.0%) were HLA-B27 positive. The excretion of Salmonella did not differ significantly between HLA-B27-positive and -negative patients, or for patients with versus those without joint symptoms. As many as 35 patients (17.7%) reported Salmonella-triggered joint symptoms. Three of 14 patients (21.4%) with arthralgia, 5 of 13 patients (38.5%) with probable reactive arthritis (ReA), and 6 of 8 patients (75%) with confirmed ReA were HLA-B27 positive. The duration and severity of joint symptoms directly correlated with HLA-B27 positivity. Women reported Salmonella-induced pain and swelling of joints more frequently than men (P = 0.07 and P = 0.03, respectively). Patients with Salmonella-triggered joint symptoms reported abdominal pain and headache more frequently than patients without joint symptoms (P = 0.05 and P = 0.004, respectively). CONCLUSION: HLA-B27 did not (at least, not strongly) confer susceptibility to Salmonella infection. Salmonella excretion correlated neither with HLA-B27 positivity nor with the occurrence of joint symptoms. Joint symptoms were surprisingly common during or after Salmonella infection. HLA-B27-positive patients had a significantly increased risk of developing joint and tendon symptoms. Moreover, HLA-B27 positivity correlated with the development of more severe and prolonged joint symptoms.