Case presentation (Enemy in shadows )

Enemy in Shadows
(Case Study)
Samar Tharwat Radwan
Assistant Professor of Rheumatology and Immunology
(Internal Medicine Department )
Musculoskeletal Ultrasound –EULAR
Mansoura University

July ,2021
A 63-year-old female was referred to our clinic because of a 2-day-
history of severe polyarthralgia

Her
articular
complaint
• Began less than two days after receiving a
single dose of BBIBP-CorV vaccine
(Sinopharm COVID-19 vaccine)
• The condition was acute on onset
• Additive pattern of arthritis
• With symmetric distribution

The condition was associated with
Constitutional
manifestations:
fatigue, malaise and
low-grade fever
No weight loss No enthesitis
No specific joint
deformities

Past history
Hx of bronchial
asthma 10 years ago
Well-controlled on
bronchodilators

Past history
• There were no previous arthritic complaints
• She had no history of recent infections
• No relevant medical history such as inflammatory low back pain, inflammatory bowel disease, psoriasis
or uveitis
• No history of neurological symptoms, trauma or falling
• No family history of seronegative spondyloarthritis

On examination
Temperature: 37.8 °C
HR:100 Beats/minute
Blood pressure :110/80

On examination
• Swollen tender both hands , wrists , and small
joints of the hands
• Puffy hands with pitting edema

On examination
• Swollen tender both ankles and small
joints of the feet
• With pitting edema

On examination
Tenderness at both shoulders
The range of motion of all these joints was decreased
due to pain and swelling
Global assessment of the patient for pain based on the
visual analog scale (VAS) was 90 mm

Skin and mucosa
• Multiple oral ulcers with fungal infection
• No malar rash, vasculitis rash, psoriasis ,or any specific skin rash
• No genital ulceration
• No Raynaud’s phenomenon

The eye
• No uveitis
• No dryness of the eye

Reticuloendothelial system
• No evidence of lymphadenopathy or hepatosplenomegaly

On Examination
Respiratory system : scattered
wheezes
Cardiovascular system : NAD
Gastrointestinal system : NAD

The patient was admitted at the
Hospital and Investigations were done

Complete blood
count
HGB:10.5 gm/dl
MCV:81.3 fL
WBCs:12.110/mm3
Neutrophils :81.8%
Lymphocytes :10.7%
Plt:156.000/mm3

Creatinine:
• 1.7 mg/dL
Urinalysis:
• no hematuria
• no
proteinuria
• WBCs:20-30
Liver function
tests :
• SGOT: 20 IU/L
• SGPT: 25 IU/L
• Albumin:3.5
gm/dl
Renal and hepatic functions

Acute phase reactants
CRP : 120
mg/L
ESR : 90
mm/hr

Musculoskeletal
Ultrasound
Knee
• Effusion grade 3
• Synovial proliferation Grade 2
• Power Doppler
Lt knee
Rt knee

Both hands
• Synovitis at both Radiocarpal
joints
• Cobble stone appearance
suggestive of subcutaneous
edema

Both ankles
• Both ankle effusion

A case of polyarthritis
?? Remitting seronegative symmetrical
synovitis with pitting edema
(RS3PE)

Differential diagnosis
Reactive arthritis
• Polyarthritis
• Postvaccination
• High acute phase reactants
Infection
• WBCs: to some extent elevated
• Serum creatinine :to some extent
elevated
• ?? Not monoarthritis
New rheumatic /autoimmune
disease
• ?? Flare after COVID-19
vaccine

Nephrology consultation
Antibiotics
Good hydration
Avoid any nephrotoxic drugs including NSAIDs

Work up for infection
• High Resolution CT Chest : NAD
• Echocardiography: NAD
• Abdominal ultrasound
• Blood culture: negative
• Urine analysis : 20-30 /hpf
• ASOT:300 IU/ml

Work up for rheumatic /autoimmune disease
• Rheumatoid factor (RF)
• Anti-citrullinated peptide antibodies (ACPA)
• Antinuclear antibody (ANA)
• Anti-double stranded DNA
• HLA B27
• C3
• C4
• Ferritin
• Hepatitis B virus (HBV), and hepatitis C virus (HCV)
• Uric acid
All were negative

Work up for
rheumatic
/autoimmune
disease
Polymyalgia rheumatica
was excluded from the
start
•No hip pain
•No Musculoskeletal ultrasound
findings suggestive of PMR:
No SASD bursitis
No hip synovitis

Differential
diagnosis
Reactive arthritis
Infection
New rheumatic /autoimmune disease

The patient
was
diagnosed
with ReA
based on
The physical and laboratory
examination
+
The absence of any other
possible etiology

Reactive
arthritis after
vaccination
The pathogenesis of reactive arthritis is not known
The presence of HLA-B27 predicts a prolonged and more severe disease

Reactive arthritis after COVID-19 vaccination

Treatment
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroids
Intraarticular
Systemic

After 5 days
Clinical
The same or even worse
✓ Function
✓ Pain score
Laboratory
To some extent improved
✓ ESR : 50 mm/hr
✓ CRP: 80 mg/L
✓ WBCs :10.000/mm

What is next
Not reactive
Arthritis
Reactive
Arthritis
(not
responding )

Reactive Arthritis
after COVID-19
vaccine not
responding to high
dose of steroids
✓Pulse Solu Medrol
✓sDMARDs: Methotrexate ,Sulfasalazine ,Azathioprine
✓Biological DMARDs: Etanercept , Infliximab

Synovial fluid
aspiration
It is critical in diagnosing
monoarthritis
Has a limited role in the
differential diagnosis of
polyarthritis.

Ultrasound guided synovial fluid aspiration
Right knee Left knee Right ankle

Synovial fluid
analysis
WBCs :70.000-100.000
Crystals :Not detected
Culture and sensitivity test

• Change the antibiotic regimen
• Orthopedic consultation : conservative

QuantiFERON
Urethral swab culture
These tests were all negative

Culture and sensitivity test
Sensitive to
• Ciprofloxacin
• Imipenem
• Amikacin
• Azithromycin
• Gentamicin
• Unasyn
• Cefepime
Resistant to
• Ceftriaxone
• Ceftazeden
Organism :Gram negative bacilli (E coli)

Further
workup
• Human immunodeficiency virus
• Complement levels
• Immunoglobulin G

Polyarthritis after COVID-19
Vaccination Mimicking Reactive
Arthritis Finally Diagnosed as
Septic Arthritis Caused by E-Coli

Several questions need to be
answered

1. Can septic arthritis be presented with polyarthritis ?
2. Who is at a risk septic polyarthritis?
3. Can septic arthritis be presented without any signs of fulminant inflammation (erythema) ?
4. Septic arthritis with negative blood culture?
5. Puffy hands?
6. Septic arthritis after vaccination ?
7. Septic polyarthritis after Vaccination ?
8. Septic polyarthritis after COVID-19 vaccination?
Several questions need to be answered

Can septic arthritis be
presented with
polyarthritis ?
The typical clinical presentation is a rapid
onset of severe joint pain, warmth, and
tenderness in a single joint
Polyarticular involvement is seen in 10–15%
of patients
Gonococcal infections should be suspected
in sexually active patients
The classical triad of disseminated
gonococcal infection (DGI) comprises acute
tenosynovitis, dermatitis, and arthritis

Who is at a risk septic polyarthritis?

Who is at a risk septic polyarthritis?
• Preexisting joint disease : RA
• Immunosuppressed patients are on treatment for active malignancy,
inflammatory bowel disease, or polymyalgia rheumatica.
• Systemic infections
• Hypogammaglobulinemia ,Complement deficiency

A striated, erythematous rash present on the
patient’s bilateral lower extremities

A case of SLE presented with polyarthritis
Resistant to treatment with high dose steroids
Nucleic acid amplification test (NAAT) of the urine for Neisseria gonorrhea was positive
Final Diagnosis :Disseminated gonococcal infection.

Can septic arthritis be
presented without any signs
of fulminant inflammation
(erythema) ?
Elderly patients may not manifest fever or other signs of inflammation

Septic arthritis with negative blood culture?
Blood cultures may be positive in one-third to one-half of patients
with septic arthritis
Negative synovial fluid cultures are the result of recent antibiotics
or infection with a fastidious organism
Can septic arthritis be presented without any signs of fulminant
inflammation (erythema) ?

Puffy hands
Vaccination
Infection

• Here, we report a case of an 80-year- old man with no history of rheumatic
disease who presented with acute onset of bilateral hand pain, pitting oedema
and synovitis after the second dose of the BNT162b2 mRNA C0VID-19 vaccine
• Significant improvement was noted with prednisolone

The patient started oral prednisone (25 mg once daily) and increased
MTX dosage (10 mg weekly), with a rapid clinical improvement
It is known that vaccination itself triggers an IFN-gamma and TNF-α release from Th1 cells, which could
represent a possible mechanism for vaccination-induced inflammation

Septic arthritis after vaccination ?
Septic arthritis of the shoulder following vaccination
Routine skin cleansing practice
before vaccinations
Should there then, as evident in the case report, be any need
for a revision of routine skin cleansing practice before
vaccination in some groups?

Septic arthritis
after COVID-19
vaccination ?

A 68-year-old woman presented for left shoulder pain, decreased range
of motion (ROM) and fever 7 days following COVID-19 vaccination
Septic Arthritis

Septic polyarthritis after Vaccination
Septic polyarthritis after COVID-19
vaccination

Frequent
aspiration
of synovial
fluid

Follow up investigations
1 st week 2 nd week 3rd week 4 th week 5 th week
WBCs in synovial fluid 70.000 65.000 No significant effusion
CRP (mg/L) 70 50 60 27 15
WBCs (/mm3) 11.000 8.000 8.200 9.500 8.400
Creatinine (mg/dL) 1.6 1.3 1.3 1.25 1.32

Following a 6-week course
of antibiotics and intensive
physiotherapy

Pain score decreased to 0 in all
joints except right knee 30

• Rt knee : joint surface
destruction with manageable
pain.

She completely
recovered with a
full range of
movement on
examination of
her joints

We report the first case of
septic polyarthritis in a 63-
year-old female after the first
shot of COVID-19 vaccine

Case presentation (Enemy in shadows )

Case presentation (Enemy in shadows )

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