4Arthritis associated with enteric infection
Section snippets
Epidemiology of enteric-infection-related reactive arthritis
The four most common pathogens implicated in enteric-infection-related reactive arthritis are Yersinia, Salmonella, Campylobacter and Shigella, although a longer list of organisms has been occasionally reported to be associated with the classical syndrome. A recent study investigated the frequency with which each of these pathogens caused arthritis in 33 patients with arthritis and preceding gut infection.7 Of those patients in whom an organism was identified (52%), Salmonella was isolated from
HLA-B27 in enteric-infection-related reactive arthritis
The MHC class I allele HLA-B27 is associated with the spondyloarthropathies, particularly ankylosing spondylitis where it is present in 90–95% of cases.30 The population prevalence of HLA-B27 varies from between 4% in Argentina31, through 4–13% in the European Caucasian population32, to 53% among the Pawaia of Papua New Guinea.33
An association of HLA-B27 with reactive arthritis was first described in 1973.34 Subsequent studies have confirmed the association although the risk of developing
Properties of organisms which influence enteric-infection-associated arthritis
The direct association of reactive arthritis with preceding enteric infection supports an important role for the organisms in pathogenesis. The list of pathogens that are characteristically associated with enteric-associated reactive arthritis is small, and they share certain common features. Yersinia, Salmonella, Shigella and Campylobacter are all intracellular (either obligate or facultative), aerobic (or, in the case of Campylobacter, microaerophilic) Gram-negative bacteria with a
Pathogenesis of enteric-infection-related reactive arthritis
Although the mechanisms are unclear, persistence of the organisms which trigger reactive arthritis is consistently reported. Yersinia antigens have been detected in the peripheral blood up to 4 years after the initial enteric infections.53 In rodent models of reactive arthritis, Y. enterocolitica has similarly been shown to persist for prolonged periods (3–4 months) in the lymph nodes, liver, spleen and lungs.54 Salmonella enteritidis has been shown to persist in intestinal epithelial cells for
Clinical features
Reactive arthritis is usually an asymmetrical oligoarthritis, generally involving less than six joints, with a tendency to affect the lower limbs. However, any synovial joint can be affected and a proportion of patients have a monoarthritis. Patients may also have arthralgias at sites other than those affected by synovitis. Reactive arthritis should be considered in the differential diagnosis of anyone presenting with an oligo- or monoarthritis of unknown cause. Generally the affected joints
Management and prognosis of infection-related reactive arthritis
Patients generally benefit from conventional measures for the treatment of acutely inflamed joints, including NSAIDs, joint aspiration and (when septic arthritis has been excluded) depot steroid injections intra-articularly. Analgesia and physiotherapy will also maintain range of motion and help to regain muscle power and bulk, which is rapidly lost during acute inflammation.85 In view of their commonsense efficacy, none of the above interventions have been subjected to randomized controlled
Management and prognosis of other enteric-infection-related arthritis
Unlike reactive arthritis, there is good evidence for antibiotic treatment in other forms of enteric-infection-related arthritides, with an excellent prognosis for the arthritis.
Clostridium difficile is sensitive to vancomycin and, in a study of C. difficile-associated arthritis, resolution of the diarrhoea after appropriate therapy correlated with resolution of the arthritis in 50% of the patients.21 In this study, the prognosis, even in those whose arthritis did not respond immediately, was
Summary
Reactive arthritis is classically seen following infection with enteric pathogens such as Yersinia, Salmonella, Campylobacter and Shigella, with an incidence of 1:1000 in the general population. It is an important diagnosis to consider in anyone presenting with an undifferentiated oligo- or monoarthritis, particularly as the preceding enteric infection may be mild. The arthritis has a predilection for joints of the lower extremity, particularly the knee and ankle, whatever the triggering
References (99)
- et al.
Post-Salmonella reactive arthritis: late clinical sequelae in a point source cohort
American Journal of Medicine
(1995) - et al.
Ankylosing spondylitis and HL-A 27
Lancet
(1973) - et al.
HL-A antigen 27 and reactive arthritis
Lancet
(1973) - et al.
Persistent Yersinia enterocolitica infection in three rat strains
Microbial Pathogenesis
(1995) - et al.
Salmonella lipopolysaccharide in synovial cells from patients with reactive arthritis
Lancet
(1990) - et al.
Reactive arthritis associated with Clostridium difficile pseudomembranous colitis
Seminars in Arthritis and Rheumatism
(1993) - et al.
Classification of inflammatory arthritis by enthesitis
Lancet
(1998) - et al.
Laboratory diagnosis of central nervous system infections
Infect Disease Clinics of North America
(2001) - et al.
Crohn's disease associated with spondyloarthropathy: effect of TNF- alpha blockade with infliximab on articular symptoms
Lancet
(2000) - et al.
Whipple's disease: staging and monitoring by cytology and polymerase chain reaction analysis of cerebrospinal fluid
Gastroenterology
(1997)
Uber eine bisher unerkannte spirochaeteninfektion
Deutsche Medizinische Wochenschrift
Pathological and Surgical Observations of Diseases of Joints
Contribution a 1'etude d'une epidemie de dysenteric dans la Somme
Bulletins et Memoires de la Societe Medicale des Hopitaux de Paris
On the difficulties of establishing a consensus on the definition of and diagnostic investigations for reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3–6, 1999
Journal of Rheumatology
A hitherto undescribed disease characterised anatomically by deposits of fats and fatty acids in the intestinal and mesenteric lymphatic tissues
John Hopkins Hospital Bulletin
Identification of the uncultured bacillus of Whipple's disease
New England Journal of Medicine
Frequency of triggering bacteria in patients with reactive arthritis and undifferentiated oligoarthritis and the relative importance of the tests used for diagnosis
Annals of the Rheumatic Diseases
Reactive arthritis: incidence, triggering agents and clinical presentation
Journal of Rheumatology
Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis
Clinical Infectious Diseases
Postdysenteric reactive arthritis. A clinical and immunogenetic study following an outbreak of salmonellosis
Arthritis and Rheumatism
Reactive arthritis following an outbreak of Salmonella typhimurium phage type 193 infection
Annals of the Rheumatic Diseases
Modification of disease outcome in Salmonella-infected patients by HLA-B27
Arthritis and Rheumatism
Fast food arthritis–a clinico-pathologic study of post-Salmonella reactive arthritis
Journal of Rheumatology
Low incidence of reactive arthritis in children following a salmonella outbreak
Annals of the Rheumatic Diseases
Campylobacter-triggered reactive arthritis: a population-based study
Rheumatology (Oxford)
An ‘experimental’ epidemic of Reiter's syndrome
JAMA
An outbreak of Yersinia pseudotuberculosis infection
Journal of Infectious Diseases
Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance. The Infectious Intestinal Disease Study Executive
British Medical Journal
Clostridium difficile diarrhea: pathogenesis, epidemiology, and treatment
Gastroenterologist
Clostridium difficile infection in patients with reactive arthritis of undetermined etiology
Scandinavian Journal of Rheumatology
Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature
Medicine (Baltimore)
The reactive arthritis of giardiasis. A case report
JAMA
Reactive arthritis–Giardia lamblia, another new pathogen?
Irish Medical Journal
Beaver fever–a rare cause of reactive arthritis
Journal of Rheumatology
Whipple's Disease
Tropheryma whippelii DNA in saliva of healthy people
Lancet
Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne
Medicine (Baltimore)
Epidemiology of Whipple's disease in Germany. Analysis of 110 patients diagnosed in l965–95
Scandinavian Journal of Gastroenterology
Class I and class II HLA antigens in a homogeneous Argentinian population with Whipple's disease: lack of association with HLA-B 27
American Journal of Gastroenterology
HLA and ankylosing spondylitis
Antigen and haplotype frequencies at three human leucocyte antigen loci (HLA-A, -B, -C) in the Pawaia of Papua New Guinea
American Journal of Physical Anthropology
Long-term prognosis of reactive salmonella arthritis
Annals of the Rheumatic Diseases
Reactive arthritis triggered by Yersinia enterocolitica: a review of l8 pediatric cases
Clinical and Experimental Rheumatology
Rheumatic manifestations of Campylobacter jejuni and C. fetus infections in adults
Scandinavian Journal of Rheumatology
The possible role of Shigella in sporadic enteric reactive arthritis
British Journal of Rheumatology
3rd. HLA antigens in Whipple's disease
Arthritis and Rheumatism
Axial arthropathy in Whipple's disease
Journal of Rheumatology
Lack of association with spondyloarthritis and HLA-B27 in Italian patients with Whipple's disease
Journal of Rheumatology
HLA-B27 expression modulates gram-negative bacterial invasion into transfected L cells
Journal of Immunology
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