4
Arthritis associated with enteric infection

https://doi.org/10.1016/S1521-6942(02)00104-3Get rights and content

Abstract

Reactive arthritis is classically seen following infection with enteric pathogens such as Yersinia, Salmonella, Campylobacter and Shigella. Inflammatory arthritis has also been described following other enteric infection with organisms such as Clostridium difficile, Brucella and Giardia. Furthermore, arthritis is seen in Whipple's disease, caused by the actinomycete Tropheryma whippelii. This chapter reviews the current understanding of these conditions (with the exception of Brucella, which is discussed in a subsequent chapter). The epidemiology is reviewed, and the contribution of both host and organism to the aetiology and pathogenesis is discussed with particular discussion of the role of HLA-B27 in host susceptibility. Recent work exploring evidence for traffic of pathogenic organisms to the joint is highlighted. A practical approach to the diagnosis and management of the condition is then formulated based, where possible, on clinical trial evidence.

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)

  • H Reiter

    Uber eine bisher unerkannte spirochaeteninfektion

    Deutsche Medizinische Wochenschrift

    (1916)
  • B.C Brodie

    Pathological and Surgical Observations of Diseases of Joints

    (1818)
  • N Fiessinger et al.

    Contribution a 1'etude d'une epidemie de dysenteric dans la Somme

    Bulletins et Memoires de la Societe Medicale des Hopitaux de Paris

    (1916)
  • J Braun et al.

    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

    (2000)
  • G.H Whipple

    A hitherto undescribed disease characterised anatomically by deposits of fats and fatty acids in the intestinal and mesenteric lymphatic tissues

    John Hopkins Hospital Bulletin

    (1907)
  • D.A Relman et al.

    Identification of the uncultured bacillus of Whipple's disease

    New England Journal of Medicine

    (1992)
  • C Fendler et al.

    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

    (2001)
  • T.K Kvien et al.

    Reactive arthritis: incidence, triggering agents and clinical presentation

    Journal of Rheumatology

    (1994)
  • M.S Dworkin et al.

    Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis

    Clinical Infectious Diseases

    (2001)
  • R.D Inman et al.

    Postdysenteric reactive arthritis. A clinical and immunogenetic study following an outbreak of salmonellosis

    Arthritis and Rheumatism

    (1988)
  • T Hannu et al.

    Reactive arthritis following an outbreak of Salmonella typhimurium phage type 193 infection

    Annals of the Rheumatic Diseases

    (2002)
  • P Ekman et al.

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

    Arthritis and Rheumatism

    (2000)
  • M.P Samuel et al.

    Fast food arthritis–a clinico-pathologic study of post-Salmonella reactive arthritis

    Journal of Rheumatology

    (1995)
  • M Rudwaleit et al.

    Low incidence of reactive arthritis in children following a salmonella outbreak

    Annals of the Rheumatic Diseases

    (2001)
  • T Hannu et al.

    Campylobacter-triggered reactive arthritis: a population-based study

    Rheumatology (Oxford)

    (2002)
  • H.R Noer

    An ‘experimental’ epidemic of Reiter's syndrome

    JAMA

    (1966)
  • R Tertti et al.

    An outbreak of Yersinia pseudotuberculosis infection

    Journal of Infectious Diseases

    (1984)
  • J.G Wheeler et al.

    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

    (1999)
  • R.D Mitty et al.

    Clostridium difficile diarrhea: pathogenesis, epidemiology, and treatment

    Gastroenterologist

    (1994)
  • I.H Kocar et al.

    Clostridium difficile infection in patients with reactive arthritis of undetermined etiology

    Scandinavian Journal of Rheumatology

    (1998)
  • A Jacobs et al.

    Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature

    Medicine (Baltimore)

    (2001)
  • R.A Shaw et al.

    The reactive arthritis of giardiasis. A case report

    JAMA

    (1987)
  • J.J Barton et al.

    Reactive arthritis–Giardia lamblia, another new pathogen?

    Irish Medical Journal

    (1986)
  • M Tupchong et al.

    Beaver fever–a rare cause of reactive arthritis

    Journal of Rheumatology

    (1999)
  • W.O.I Dobbins

    Whipple's Disease

    (1987)
  • S Streets et al.

    Tropheryma whippelii DNA in saliva of healthy people

    Lancet

    (1999)
  • D.V Durand et al.

    Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne

    Medicine (Baltimore)

    (1997)
  • A von Herbay et al.

    Epidemiology of Whipple's disease in Germany. Analysis of 110 patients diagnosed in l965–95

    Scandinavian Journal of Gastroenterology

    (1997)
  • J.C Bai et al.

    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

    (1991)
  • M.A Khan

    HLA and ankylosing spondylitis

  • K Bhatia et al.

    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

    (1988)
  • M Leirisalo-Repo et al.

    Long-term prognosis of reactive salmonella arthritis

    Annals of the Rheumatic Diseases

    (1997)
  • G Taccetti et al.

    Reactive arthritis triggered by Yersinia enterocolitica: a review of l8 pediatric cases

    Clinical and Experimental Rheumatology

    (1994)
  • M.C Peterson

    Rheumatic manifestations of Campylobacter jejuni and C. fetus infections in adults

    Scandinavian Journal of Rheumatology

    (1994)
  • J Sieper et al.

    The possible role of Shigella in sporadic enteric reactive arthritis

    British Journal of Rheumatology

    (1993)
  • W.O Dobbins

    3rd. HLA antigens in Whipple's disease

    Arthritis and Rheumatism

    (1987)
  • M.A Khan

    Axial arthropathy in Whipple's disease

    Journal of Rheumatology

    (1982)
  • I Olivieri et al.

    Lack of association with spondyloarthritis and HLA-B27 in Italian patients with Whipple's disease

    Journal of Rheumatology

    (2001)
  • K Kapasi et al.

    HLA-B27 expression modulates gram-negative bacterial invasion into transfected L cells

    Journal of Immunology

    (1992)
  • Cited by (116)

    • Human Microbiota and Autoimmune Diseases

      2019, Mosaic of Autoimmunity: The Novel Factors of Autoimmune Diseases
    • Clinical pathologic conference: acute onset malocclusion and facial pain

      2018, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
    • Human campylobacteriosis

      2017, Campylobacter: Features, Detection, and Prevention of Foodborne Disease
    View all citing articles on Scopus
    View full text