The comparative effectiveness of serological and microbiological studies in the etiological diagnosis of reactive arthritis

The information content of serological and microbiological studies was studied and compared in 72 patients suffering from enterogenous reactive arthritis. A high level of antibodies to intestinal Yersinia was detected in 11.1% of the patients, positive coproculture in 8.3%. Only one patient demonstrated at a time a high level of antibodies and isolation of intestinal Yersinia coproculture. The causative agent could usually be isolated in patients with the symptoms of enterocolitis. It is assumed that among patients suffering from reactive arthritis there are at least two different groups: with positive coproculture and a low level of antibodies and with a high level of antibodies and negative coproculture. The indicated conditions can be regarded as different phases of the disease in the same patients and reflect the pathogenetic heterogeneity of the patients' group with reactive arthritis. Serological and microbiological tests are viewed as equivalent in etiological diagnosis of reactive arthritis. Emphasis is laid on the fact that microbiological tests are more successful in patients with the symptoms of concomitant enterocolitis.     

Poststreptococcal reactive arthritis in adults: a case series

OBJECTIVE: To guide primary care physicians regarding the diagnosis and treatment of poststreptococcal reactive arthritis (PSReA) in adults. PATIENTS AND METHODS: We retrospectively reviewed an indexed database of all patients evaluated or hospitalized between 1976 and 1998 at Mayo Clinic Rochester and identified 35 patients with the diagnosis of reactive streptococcal arthritis, arthralgia, or arthritides. Twenty-nine patients with the diagnosis of acute rheumatic fever (ARF), septic streptococcal arthritis, or nonspecific reactive arthritis were excluded. RESULTS: PSReA was confirmed in 6 adults (3 women, 3 men; age range, 25-66 years). All patients were symptomatic with polyarthritis and oligoarthritis disproportionate to the objective findings on physical examination. Although all patients had negative throat cultures at the onset of arthritis, increased titers of anti-DNase B and antistreptolysin O confirmed recent streptococcal infection. Antecedent events included pharyngitis in 3 patients (who had received a minimum of a 10-day course of penicillin) and toxic shock syndrome in 1 patient. The latency of onset of arthritis ranged from 4 days to 6 weeks. The arthritic symptoms had a protracted course beyond the typical maximum of 3 weeks described for ARF. Treatment with aspirin did not provide symptomatic relief in any of the patients, whereas the response to therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) was at least partial in all cases. Symptomatic relief occurred in 1 patient who received indomethacin and in 1 patient treated with prednisone. Penicillin prophylaxis was recommended in 1 patient. CONCLUSION: PSReA should be included in the differential diagnosis of all adult patients presenting with arthritis. Treatment strategies include aspirin, other NSAIDs, and corticosteroids. In adult patients with PSReA, there is no evidence to support the use of penicillin prophylaxis at this time.     

Common urgent musculoskeletal injuries in primary care

The patient who presents with an acute painful synovitis of a single joint provides a significant diagnostic and therapeutic challenge to the primary care physician. An aggressive approach is required to differentiate a potential infectious arthritis, with its attendant morbidity and potential mortality, from other causes of monarthritis that are not immediately life-threatening. This article reviews the common causes of acute monarthritis in the adult, including the presentation, as well as guidelines for rapid and efficient diagnosis and management. Common causes include infections (bacterial/Lyme/mycobacterial/viral), microcrystalline disease (gout/pseudogout), and traumatic and reactive arthropathy. In addition, guidelines are suggested for the management approach to acute monarthritis when initial diagnostic testing is unrevealing of a specific diagnosis.     

Role of arthroscopy in the diagnosis of chronic monoarthritis of the knee joint

The author analyzes the arthroscopy findings of 70 knee joints in 68 patients (35 men and 33 women) suffering from chronic monoarthritis of the knee joints with a disease standing from 3 months to 12 years. According to the x-ray data the overwhelming majority of the joints (54) showed stage 0-1, 15 stage II and 1 stage III of the pathological process. In accordance with the preliminary diagnoses 32 patients had synovitis of unclear genesis, 4 rheumatoid arthritis, 3 gonarthrosis deformans, 2 psoriatic arthritis, 5 patients were afflicted with Bechterew's disease, 1 with chondromatosis, and in 21 patients the diagnosis was doubtful. Arthroscopy promoted considerable improvement of the diagnosis, since rheumatoid arthritis including juvenile one was recognized in 12 patients, psoriatic arthritis in 8, reactive synovitis due to gonarthrosis in 16, Bechterew's disease in 12, Reiter's disease in 2, chondromatosis in 4, and pigmented villous-nodular synovitis in 3. The arthroscopic appearance of the disease remained unclear in 7 patients. Therefore, arthroscopy proved a highly effectual method that permits one to differentiate between reactive synovitis and genuine inflammatory diseases and to differentiate with a great probability between rheumatoid synovitis, psoriatic arthropathy and Bechterew's disease.     

Nichtradiographische axiale Spondyloarthritis

The heterogenic rheumatic disease group of ankylosing spondylitis (Bechterew‘s disease), psoriatic arthritis, reactive arthritis, enteropathic arthritis, juvenile spondyloarthritis and undifferentiated spondyloarthritis have common features in clinical symptoms and signs, radiographic changes and increased incidence of HLA-B27 and are, therefore, collectively known under the term spondyloarthritides. These diseases are manifested in the spine with different frequencies. Early diagnosis of spondyloarthritides has been strongly hampered by late development of radiographic changes. The definition of a new disease entity, non-radiographic axial spondyloarthritis (nr-axSpA) as an early spondyloarthritis characterized by deep-seated back pain, typical magnetic resonance imaging (MRI) changes but without radiographic lesions on the axial skeleton, is intended to improve the early diagnosis. The nr-axSpA seems to be more than just an early manifestation of ankylosing spondylitis and is now thought to be a distinct disease entity.     

Bilateral retinal detachment in reactive arthritis: coincidence or association?

Retinal lesions are not typically found in reactive arthritis. However, a previous case report documented co-existing retinal detachment and reactive arthritis. We report here a similar case of a 32-year-old male patient with concurrent non-traumatic bilateral retinal detachment and HLA-B27 associated reactive arthritis after urogenital and gastrointestinal infections. Our report substantiates a potential rare association of retinal detachment and reactive arthritis.     

Causes and management of shoulder arthritis

We recommend that physicians distinguish shoulder arthritis from periarticular disorders. A specific diagnosis should be made in the former, if possible. A number of arthritides have frequent shoulder involvement, and they should be kept in mind. Septic arthritis should always be suspected when there is acute pain and swelling. Joint fluid aspiration should almost always be performed when fluid is present. The diagnosis of gout or CPPD deposition disease usually requires crystal identification from joint fluid for diagnosis. Treatment of shoulder arthritis with oral anti-inflammatory medication is usually indicated; appropriate treatment of the underlying disorder, e.g., rheumatoid arthritis, is necessary. Physical therapy started early, often combined with IA corticosteroids, helps to maintain or improve shoulder motion.     

Reactive arthritis. Immune-mediated synovitis or joint infection

Reactive arthritis is one form of the seronegative Spondyloarthropathies. Susceptibility to reactive arthritis is closely linked to individuals who have the genetic predisposition to the HLA-B27 allele (gene form). Although there is a reactive-inflammatory joint reaction present, the synovium is not damaged by infectious agents (bacteria, fungi, or virus). This article discusses the pathogenesis of reactive arthritis.     

Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis

This article reports the case of a 52-year-old woman with septic arthritis and bursitis of her shoulder. Due to a minor musculoskeletal injury and lack of fever, the diagnosis was missed on her first Emergency Department visit. Sonographic guidance of the shoulder arthrocentesis led to successful aspiration of the larger fluid collection in the subacromial bursa and allowed the diagnosis and treatment to proceed more rapidly. Septic arthritis is a challenging clinical diagnosis, and when it occurs in more difficult to aspirate joints, the diagnosis can become more challenging still. Ultrasound provides a means for the emergency physician to establish the diagnosis more readily.     

Surgically treated reactive arthritis of the ankle after COVID-19 infection: A case report

A 37-year-old man developed right ankle pain and swelling six days after being diagnosed with coronavirus disease (COVID-19). Despite conservative treatment, his ankle symptoms persisted. Magnetic resonance imaging and computed tomography showed synovial hypertrophy and bone erosion in the ankle. Following arthroscopic synovectomy, performed 69 days after the COVID-19 diagnosis, the pain improved significantly. The clinical course was consistent with that of reactive arthritis following severe acute respiratory syndrome coronavirus 2 infection. The pathological findings resembled rheumatoid nodules. The bone erosion may have originated from the inflammatory pathway, which resembles the mechanism of rheumatoid arthritis.     

Chlamydia and chronic arthritis

Abstract

Certain bacterial infections have been demonstrated to be causative of reactive arthritis. The most common bacterial trigger of reactive arthritis is Chlamydia trachomatis. Chlamydia pneumoniae is another known cause, albeit far less frequently. Although Chlamydia-induced reactive arthritis will often spontaneously remit, approximately 30% of patients will develop a chronic course. Modern medicine has provided rather remarkable advances in our understanding of the chlamydiae, as these organisms relate to chronic arthritis and the delicate balance between host and pathogen. C. trachomatis and C. pneumoniae both have a remarkable ability to disseminate from the initial site of infection and establish persistently viable organisms in distant organ sites, namely the synovial tissue. How these persistent chlamydiae contribute to disease maintenance remains to be fully established, but recent data demonstrating that long-term combination antimicrobial treatment can not only ameliorate the symptoms but eradicate the persistent infection suggest that these chronically infecting chlamydiae are indeed a driving force behind the chronic inflammation. We are beginning to learn that this all appears possible even after an asymptomatic initial chlamydial infection. Both C. trachomatis and C. pneumoniae are a clear cause of chronic arthritis in the setting of reactive arthritis; the possibility remains that these same organisms are culpable in other forms of chronic arthritis as well.     

Intra-articular chlamydial antigen and inflammatory arthritis

Joint material from 133 patients with well-characterized inflammatory arthritis, including individuals likely to have suffered reactive arthritis, was studied. The majority of patients were also examined for the presence of genital tract infection with Chlamydia trachomatis. Fluorescein-conjugated monoclonal antibodies demonstrated the presence of C. trachomatis antigen in synovial fluid cell deposits or synovial sections from inflamed knee joints of seven patients with reactive arthritis. The significance of these findings is discussed, as is the low rate of detection of chlamydial antigen in either the genital tract or the joint from patients in this study. We emphasize the need for further work aimed at identifying the relevant immunogenic chlamydial antigens responsible for the initiation of reactive arthritis.     

Septic arthritis due to non-tuberculous mycobacterium without effusion

Septic arthritis is an important but difficult to make diagnosis that leads to significant morbidity and mortality. Joint effusion is generally accepted to be a highly sensitive finding in septic arthritis; however, final diagnosis requires synovial fluid studies. Without a significant joint effusion, it is difficult to obtain synovial fluid. In this case report, we describe the presentation and diagnosis of septic arthritis in the first MTP due to mycobacterium chelonae in a 69 year old man with a history of gout and immunosuppression due to a heart transplant. There was notably no significant effusion in the joint on clinical examination or bedside ultrasound. As the patient was immunosuppressed, arthrocentesis was performed under ultrasound guidance. A needle was clearly visualized in the joint; however, minimal synovial fluid was obtained. The fluid grew Mycobacterium chelonae in culture. Subsequent joint washout revealed purulent synovial fluid that grew out the same bacteria. This case emphasizes the importance of obtaining synovial fluid to evaluate for septic arthritis, even when joint effusion is absent. Ultrasound guidance can facilitate this.     

Psittacosis and arthritis

Recent findings justify the opinion that Chlamydia psittaci is the reappearance of a forgotten pathogen. The clinical manifestation and the course of psittacosis are extremely variable, whereas the clinical spectrum of the infection with the different strains of C. psittaci is not known. Reactive arthritis during the course of psittacosis has been rarely described in humans. However, it has been stated that C. psittaci could be added to the list of infectious agents able to induce reactive arthritis. We describe a patient who presented with clinical signs consistent with reactive arthritis during the course of psittacosis, and we emphasize the good therapeutical results with ceftriaxone in the treatment of psittacosis.     

Lymphocytes transformed by Epstein-Barr virus. Induction of nuclear antigen reactive with antibody in rheumatoid arthritis

Sera from approximately two-thirds of patients with rheumatoid arthritis contain an antibody which is reactive with a nuclear antigen present in human B-lymphocyte tissue culture cells. The immunological reaction can be demonstrated by precipitation and immunofluorescence. Evidence is present that the reactive nuclear antigen is associated with Epstein-Barr (EB) virus-transformed lymphocytes. Normal human peripheral blood lymphocytes did not contain the nuclear antigen reactive with rheumatoid arthritis sera, but after infection with EB virus, they showed increasing amounts of reactive nuclear antigen as the cells were transformed into continuous lines. Several established human and simian lymphocyte cell lines known to carry EB viral genomes were shown to contain rheumatoid arthritis-associated nuclear antigen. Evidence is presented which suggests that the rheumatoid arthritis-associated nuclear antigen is different from the previously described EB nuclear antigen.     

Chronic musculoskeletal pain in children: part II. Rheumatic causes

Primary care physicians should have a working knowledge of rheumatic diseases of childhood that manifest primarily as musculoskeletal pain. Children with juvenile rheumatoid arthritis can present with painless joint inflammation and may have normal results on rheumatologic tests. Significant morbidity may result from associated painless uveitis, and children with juvenile rheumatoid arthritis should be screened by an ophthalmologist. The spondyloarthropathies (including juvenile ankylosing spondylitis and reactive arthritis) often cause enthesitis, and patients typically have positive results on a human leukocyte antigen B27 test and negative results on an antinuclear antibody test. Patients with acute rheumatic fever present with migratory arthritis two to three weeks after having untreated group A beta-hemolytic streptococcal pharyngitis. Henoch-Schbnlein purpura may manifest as arthritis before the classic purpuric rash appears. Systemic lupus erythematosus is rare in childhood but may cause significant morbidity and mortality if not treated early. Nonsteroidal anti-inflammatory drugs and physical therapy may be useful early interventions if a rheumatic illness is suspected. Family physicians should refer children when the diagnosis is in question or subspecialty treatment is required. Part I of this series discusses an approach to diagnosis with judicious use of laboratory and radiologic testing.     

Proteomic: new advances in the diagnosis of rheumatoid arthritis

BACKGROUND: Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting the joints. A number of novel treatment modalities have been introduced over the past years, and rheumatologists are now attempting to institute optimal treatment in recent-onset arthritis. To facilitate diagnosis during the early stages of disease, when often not all clinical symptoms are manifest, a good serological marker is needed. METHODS: Antibodies directed to citrullinated proteins provide this ability. The most sensitive assay for detecting these antibodies is the so-called anti-cyclic citrullinated peptide, second generation (CCP II) enzyme-linked immunosorbent assay (ELISA). RESULTS: The diagnostic and prognostic potential of anti-CCP antibodies and the availability of a fully automated assay method lead us to conclude that the test is satisfactory for routine use as a serological marker of RA. In addition, we consider the potential of multiplex autoantibody assays, including miniaturized, high-throughput microarray technology, to improve diagnosis and prognostication in early onset arthritis patients.     

Beyond osteoarthritis: recognizing and treating infectious and other inflammatory arthropathies in your practice

About 15% of patients presenting in a primary care clinic have joint pain as their primary complaint (level B). Disseminated gonorrhea is the most common cause of infectious arthritis in sexually active, previously healthy patients (level B). Prompt arthrocentesis, microscopic examination, and the culture of any purulent material plus appropriate antibiotic therapy are the mainstay of treatment in infectious arthritis (level C). Detailed history, including family history and comprehensive examination, is more useful in accurate diagnosis than expensive laboratory and radiological investigations for noninfectious arthritis (level C). Regarding inflammatory noninfectious arthritis with the potential to cause destructive joint damage, early referral to a subspecialist, when indicated, increases the likelihood of optimal outcome (level C). Nonsteroidal antiinflammatory drugs are the first line of therapeutic agents to reduce pain and swelling in the management of most noninfectious inflammatory arthritis seen in the primary care office (level C).     

Osteomyelitis infection disguised as Reiter's syndrome in a child: A case report

Reiter''s syndrome (reactive arthritis) should always prompt a thorough clinical investigation of a potentially more serious disease condition in every pediatric patient and adults. It should always be regarded as a warning sign and not a disease. This is a case of a 16‐year‐old African boy with osteomyelitis presenting with symptoms of reactive arthritis (Reiter''s syndrome).     

Foibles and fallacies in the diagnosis of arthritis.

The diagnosis of arthritis is usually made on a clinical basis, and laboratory and x-ray aids are only secondary and sometimes misleading tools. Set forth are 11 common fallacies which often mislead the physician in his interpretation of laboratory and x-ray findings in the study of a patient with arthritis. Included are references to the role of x-ray findings, joint fluid and synovial biopsy findings, hyperuricemia, rheumatoid factor, rheumatoid nodules, sedimentation rate, antinuclear antibodies, and other peripheral blood and urinary findings. In most cases, the astute physician should be able to make an accurate diagnosis when he first sees the arthritic patient; in others, any and all of the laboratory and x-ray parameters mentioned, despite their obvious shortcomings, may be of help in leading to a proper diagnosis. In a small percentage of cases, only the passage of time and further observation of the patient will establish the correct diagnosis.