interesting case of reactive arthritis, stanley medical college

1. INTERESTING CASE OF
ARTHRITIS
DR.PROF. ANUSYA ‘(M7) UNIT
DR. PRASADH RAO .L

2. • 40 YR old admitted with chief complaints of fever since 2 weeks, acute
onset, high grade , continuous relieved on drugs for 6 hours, chills +
and no rigors
• Loose stools since 2 weeks; 4 to 5 episodes/day, foul smelling with
blood in stools 2 episode in last 2 days.
• Abdominal pain since 2 weeks; diffuse around umbilicus not radiating
on and off
• Vomiting 4 episodes for last 2 days, aggravated on taking food, not
blood or bile stained
• No hematuria/cough with expectoration/arthralgia/myalgia/chest pain/
syncope/palpitations/
• No h/o rashes/burning micturition/generalized lymphadenopathy/
decreased urine output/ eye discharge/Skin lesions.

3. PAST HISTORY - A known case of RHD- MS+/ mild MR/AR since
MVA – 1.1 CM2
history of similar episodes in past, dysentery followed by arthritis
(joint swelling/ pain) three episodes in past 5 years, diagnosed as ?
rheumatoid arthritis since RF was positive started on steroids and
indomethacin. He stopped drugs for past 7 months. He is also on penicillin
prophylaxis,enalapril, spironolactone.
PERSONAL HISTORY –
smoker and alcoholic (last intake 1 month ago)
normal bowel and bladder habits
mixed diet

4. • On examination
conscious, oriented, afebrile ,thin built,
no pallor/icterus/cyanosis/pedal edema/ lymphadenopathy
clubbing grade 2, dehydration+, jvp – normal
BP- 110/70 mm hg in supine position(right hand)
PR- 112/ min, regularly regular
spo2 – 98% with RA
CVS- s1 loud, MDM heard, palpable p2
RS – bilateral air entry+ /vesicular breath sounds/ no added sounds
P/A – soft , diffuse tenderness
CNS – NFND
MUSKULOSKELETAL SYSTEM – normal

5. COURSE IN HOSPITAL
Afebrile since admission as he was started on iv cipro and metronidazole, later
next day patient developed knee pain and swelling initially right knee followed
by left knee pain, left ankle pain , bilateral elbow pain , interphalangeal right
(3,4,5 th), left wrist and right wrist , left sternoclavicular joint, bilateral hip
pain, with early morning stiffness
on examination:
right knee – swelling, effusion +, tenderness +, rom restricted ,
left ankle, bilateral elbow, left wrist, b/l hip, left knee - painful
restricted range of movements and tenderness +
left sternoclavicular, interphalangeal(left 3, 4, 5 pip joint) tenderness +
No enthesitis

6. INVESTIGATIONS
• Cbc
hb – 12
Tc- 16000
Dc- 90/8/2
Plt – 1.9 L
Rbs-102
T.B -0.5
OT/PT – 101/82
Urea-34
Creat- 1.2
ECG – NSR,RAD/RBBB incomplete, PR- 160
msec
ECHO – PML/AML thickened
mva-1.1 cm2, LA dilated
Severe MS, MR moderate,AR mild
No RWMA, normal LV systolic function
USG ABDOMEN – NORMAL
USG KNEE – synovitis with effusion

7. • STOOL C/S – NEG
• STOOL for OVA/CYST – NEG
• Urine/blood culture - NEG
• HIV - NEGATIVE
• HBSAG, ANTI HCV – NEG
• RPR – NEG
• ESR – ½ HR – 15
• 1 HR – 40

8. • RF – neg
• ASO – neg
• ANA – neg
• CRP – POSITIVE
• ANTI CCP – neg
• HLA B 27 - NEG
Synovial fluid analysis –
straw colored
Protein – 4.3
sugar – low
Uric acid – 4.8
cell count: total – 1600 cells/mm3
N- 60%
L – 10%
degenerated cells – 30%
Gram stain – no pus / no organisms
AFB – smear negative
No crystals

9. Your text here

11. MRI screening of hip joints
done
revealed effusion of left
sacroiliac joint with synovitis

13. Differential diagnosis
• Rheumatic fever
• Reactive arthritis
• Enteropathic arthritis
• Ankylosing spondylitis/PSORIATIC ARTHRITIS
• Palendromic rheumatism
• Rheumatoid arthritis

14. Acute rheumatic fever
• Jones criteria
• recurrent attack in established RHD
2 MINOR WITH EVIDENCE OF PRECEDING GAS INFECTION
( FEVER/POLYARTHRALGIA/ INCREASED ESR)
Arthritis 2 – 3 weeks after throat infection
6 – 16 joints, migratory or additive , asymmetric , involves
1 or both knees (76%)
One or both ankles (50%)
Elbow wrist hips small joints of feet (12 to 15 %0
Shoulder/small joint of hands (7 to 8%)
Lumbosacral 2%
Sternoclavicular 0.5%
Radiographs show effusion no other abnormalities
synovial fluid analysis – sterile inflammatory fluid

15. POINTS AGAINST ARF
no recent fever / throat infection/ skin lesions in past 6 weeks
No response to high dose aspirin for 3 days
ASO TITRE NEGATIVE

16. Points against rheumatoid arthritis
• ACUTE onset
• Asymmetric joint involvement
• Axial joints (sacro iliac involvement)
• Anti ccp, RF negative ,
• No residual deformity
• Palindromic rheumatism
• abortive form of rheumatoid arthritis, presentation similar to
rheumatoid arthritis lasting only for a short period

17. Enteropathic arthritis
• Assosiated with IBD
• Closely resembles ankylosing spondylitis and psoriatic arthritis
• May also run a course independent of bowel activity, It may precede
the onset of IBD by many years
• PAUCIARTICULAR - <5 joints , Self limited attacks of asymmetric
oligoarthritis coincides with relapse of IBD.
• POLYARTICULAR - >5 JOINTS symmetric chronic polyarthritis
independent of bowel activity
• 30 – 70 % carry HLA B 27 positivity
• Controlling intestinal inflammation usually eliminates arthritis.

18. Reactive arthritis
• Acute non purulent arthritis complicating an infection elsewhere in
the body
• Following enteric infection or urogenital infection
• Enteric infection with shigella , salmonella, Yersinia, campylobacter
• Urogenital infections with chlamydia trachomatis
• Although asymptomatic infection with chlamydia can cause arthritis ,
it is termed as undifferentiated spondyloarthropathy as no clinical
infection precedes the episode.

19. • Common between 18 to 40 yrs age, rarely in children occasionally in
older adults.
• Male female ratio 1:1
• Can be a first manifestation of HIV
• Classical Triad of conjunctivitis, arthritis, urethritis in some patients
(reiters syndrome)

20. pathogenesis
• All those organisms share a common feature
• Invade mucosal surface and replicate intracellularly
• Contain lipopolysaccharide in outer membrane
• salmonella ,Chlamydia, Yersinia are found in synovial tissues and fluids in
reactive arthritis.
• HLA B 27 prolongs intracellular survival of Yersinia and salmonella, which
may permit trafficking of intestinal leucocytes to joints , where innate and
adaptive immune response to bacterial antigens promote arthritis
• In patients who are HLA-B27 positive, there is evidence of misfolding of the
HLA-B27 protein inside the endoplasmic reticulum. This results in
heightened cellular stress that leads to activation of NF-kB and release of
proinflammatory cytokines, creating an inflammatory response in the joint.

21. clinical
• Asymmetric , additive with new joints involvement occurring over
few days to weeks
• Usually knee, ankle, subtalar,mtp,toe ip, wrist and fingers
• Painful, rarely tense joint effusion usually in knee
• Peripheral spondyloarthropathy , low back pain with stiffness ,
enthesitis
• Ocular – uveitis or conjunctivitis
• Mucocutaneous – keratoderma blenorhagica, pustules, vesicles that
become hyperkeratotic
• circinate balanitis

22. • HLA B27 predicts a bad outcome, seen associated in 50% ReA
• ESR,CRP elevated during acute phase
• Synovial fluid nonspecifically inflammatory
• Culture organism during enteric infection
• Serology is nonspecific but supportive
• Radiographic – juxta articular osteoporosis
• Sacroilitis and spondylitis as late sequence

23. Diagnostic criteria

24. treatment
• high dose NSAIDS indomethacin 75 to 150 mg/day in divided doses
• Other NSAIDS may also be effective
• Antibiotics in chlamydial reactive arthritis - rifampicin 300 mg daily
with azithromycin 500 mg od daily for 5 days followed by twice
weekly for 6 months
• Chronic course – sulfasalazine 3g/day , azathioprine or methotrexate
also effective
• Counselling the patient to avoid exposure to enteropathogens as they
are prone for recurrent attacks and continued surveillance for
ankylosing spondylitis.

27. Approach to arthritis
articular
• Decreased range of
movements
• Swelling of joint
• Pain on active and passive
movement
• Crepitation, joint instability
deformity may be present
Non articular
Tenderness localized away from joint
Painful active movements, normal
passive motion
Swelling, instability,deformity are
rare

28. Inflammatory non inflammatory
• Infection
• Crystal
• Immunologic
• Reactive
• Idiopathic
• Warmth/pain/swelling/erythema
• Increased esr/crp/thrombocytosis
• Early morning stiffness >1 hr,
relieved on work
• Anemia of chronic disease/
hypoalbuminemia
trauma
Repeated use (bursitis/tendinitis)
Neoplasm (pigmented villonodular
synovitis)
Pain amplification(fibromyalgia)
Gel phenomenon – intermittent
stiffness lasting less than 60 min
precipitated by a brief period of rest

29. take home points
• The differential diagnosis of fever and arthritis is fairly limited in children
and adults.
• ReA usually occurs one to four weeks after gastrointestinal or genitourinary
infection.
• ReA presents with painful arthritis predominantly affecting lower
extremites, and can cause enthesitis, dactylitis, and systemic symptoms.
• ReA is most often caused by Chlamydial infections in adults, while
gastrointestinal infections are the most common cause of ReA in children.
• ReA and the spondylarthropathies appear to fall within the spectrum of the
polygenic autoinflammatory diseases.
• Treatment may include NSAIDs, DMARDs, systemic corticosteroids,
and biologics for recalcitrant disease.
• Prognosis is good, although the presence of HLA-B27 may raise the risk for
severe disease and a more chronic course.