Successful use of Tofacitinib in Reactive Arthritis Refractory to Conventional Therapies – A Case Series

Reactive arthritis is an immune mediated aseptic arthritis resulting from either genitourinary or gastrointestinal tract in a genetically susceptible host. It commonly presents as oligoarthritis of the lower limbs with or without extra articular features such as urethritis and non-purulent conjunctivitis. Therapies include NSAIDs, conventional DMARDs and rarely biologics in severe cases. We report successful use of tofacitinib in four cases of reactive arthritis who failed to respond to conventional therapies.

Tonsillitis-Related Arthritis: Advanced Understandings of Tonsillitis and Sterile Inflammatory Arthritis

A 49-year-old man developed acute aseptic arthritis of the nonmigratory and asymmetrical type in his knee, ankle, and bilateral metatarsal joints 13 days after treatment with antibiotics for acute tonsillitis. He was diagnosed with tonsillitis-related arthritis after other rheumatic diseases were ruled out. Treatment with salazosulfapyridine, methotrexate, and methylprednisolone for 3 months did not completely improve. Then, tonsillectomy was undertaken and arthritis rapidly improved. Finegoldia magna (previously Peptostreptococcus magnus) was cultured from the microabscesses of the resected tonsils. After outpatient follow-up, the patient did not experience a relapse of arthritis for more than 2.7 years without any treatment. Poststreptococcal reactive arthritis (PSRA) is well described. However, up to 40% of patients with tonsillitis-related arthritis did not demonstrate evidence of streptococcal infection. It is noted that tonsillectomy is necessary to remove the tonsillar microabscesses and eradicate bacterial infection of the tonsils, especially for patients with a prolonged and/or recurrent course of PSRA and/or tonsillitis-related arthritis.

Effects of Low-Load Blood-Flow Restricted Resistance Training on Functional Capacity and Patient-Reported Outcome in a Young Male Suffering From Reactive Arthritis

Introduction: Reactive arthritis (ReA) is a chronic inflammatory disease usually caused by a preceding gastrointestinal or genitourinary bacterial infection. ReA usually occurs in the lower limbs causing joint pain and joint swelling. Physiotherapy-led exercise is recommended to prevent muscle atrophy. The purpose of this case report is to describe the outcome after 12 weeks of low-load blood flow restricted resistance training (BFR-RT) as a rehabilitation method for a young male suffering from ReA.Methods and materials: A 17-year-old male suffered from ReA in the both knee joints and the left hip joint. 36 months after the incident, he suffered from another ReA incident in his right knee. Non-steroid anti-inflammatory drugs and a new arthrocentesis added with corticosteroid injection was unsuccessful in treating the ReA. The patient performed 12 weeks of BFR-RT on the right lower limb with a low amount of supervision after the first week of training. Assessment of unilateral 30-sec chair stand test (u30-sec CST), low-thigh circumference above apex patella, The Knee Injury and Osteoarthritis Outcome Score (KOOS), The Forgotten Knee Joint Score (FJS), and Numeric Ranking Scale for pain (NRS) was performed at baseline and after 3,6,9, and 12 weeks of BFR-RT.Results: The patient completed all planned exercise sessions. u30-sec CST improved with 7 repetitions (reps) on the right limb and 5 reps on the left leg. Low-thigh circumference decreased 1.1 cm on the right leg and 1.0 on the left leg. KOOS symptoms, ADL, quality of life and FJS demonstrated a clinically relevant change on 10, 14 and 23 points.Conclusion: The present case study indicates that even with low amounts of supervision BFR-RT could increase functional performance, reduce knee joint swelling and improve key patient-reported outcome.

Yersinia enterocolitica Prosthetic Joint Septic Arthritis Successfully Treated with Ceftriaxone

Yersinia enterocolitica is a Gram-negative coccobacillus that is known to cause gastroenteritis and symptoms mimicking appendicitis or terminal ileitis. It is also one of the culprit infections implicated in causing reactive arthritis. Rarely, it can cause musculoskeletal infections including osteomyelitis, septic arthritis, and discitis. We describe the case of a 70-year-old female with multiple comorbidities who presented with left knee pain and swelling after recent gastroenteritis. She was found to have Yersinia enterocolitica septic arthritis in her left knee prosthetic joint. The patient underwent an exchange of her prosthetic material and was successfully treated with a six-week course of ceftriaxone. Our article aims to highlight a rare manifestation of Yersinia enterocolitica infection and to point out an important differential for reactive arthritis after Yersinia enterocolitica infection.

Osteomyelitis infection disguised as Reiter’s Syndrome in a child: A case report

This is a case of a 16-year-old African boy with Osteomyelitis presenting with symptoms of reactive arthritis (Reiter’s syndrome) KEYWORDS Osteomyelitis, Reiter’s syndrome, Fever, Bone pain, Erythema, Ewing sarcoma

Healthcare-seeking behaviour for sexually transmitted infection testing in New Zealand: A mixed methods study

<p>Sexually transmitted infections (STIs) are a global public health problem. Sequelae for infected individuals can be serious and STIs impose a substantial financial burden on healthcare systems. Duration of infection is one factor influencing transmission rates, and is modifiable through secondary prevention methods, namely ‘test and treat’. For this approach to be effective, at-risk individuals must choose to present for testing. New Zealand provides a useful case-study to investigate healthcare-seeking behaviour for STI testing, as incidence rates of common STIs are especially high. The aims of this thesis were to quantify healthcare-seeking behaviour for STI symptoms and assess the risk of transmission in this period, to identify the barriers to STI testing, to understand the personal drivers for getting an STI test, to examine how STI knowledge is associated with testing behaviour, and finally, to collate and critically evaluate the published evidence regarding the incidence of a lesser known sequela of STI, reactive arthritis. This thesis took a mixed method approach, employing both qualitative and quantitative methods to address the research aims. The results showed that delays in healthcare-seeking for STI symptoms were common among patients attending an inner-city Sexual Health Clinic (SHC). Almost half of people with symptoms waited longer than seven days to seek healthcare, although there were no identified predictors of delayed healthcare-seeking. Around a third of people with symptoms continued to have sex after they first thought they may need to seek healthcare. Among these individuals, infrequent condom use was reported more by those who had sex with existing sexual partners than by those who had sex with new partners. Having sex while symptomatic was statistically significantly associated with delaying seeking healthcare for more than seven days (odds ratio (OR) = 3.25, 95% CI 1.225 – 8.623, p = 0.018). Analysis of qualitative interview data revealed three types of barriers to testing. These were personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self-consciousness in genital examination and being too busy), structural (financial cost of test and clinician attributes and attitude) and social (concern of being stigmatised). This work also revealed several drivers for testing including crisis, partners, clinicians, routines, and previous knowledge. Knowledge of the incidence, asymptomatic nature and sequelae of STIs featured prominently in the explanations of those who undertook routine testing. However, at the same time, many of the participants felt they did not have a good knowledge base and that their school-based sex education had been lacking. STI knowledge was investigated further using quantitative methodology. Levels of STI knowledge were generally good and did not differ between a Student Health Service population and an SHC population. Individuals who had tested before had significantly better knowledge than those who were attending for testing for the first time (U = 10089.500, Z = -4.684, p < 0.001). In addition, total knowledge score was an independent predictor of having had a previous test (OR = 1.436, 95% CI 1.217-1.694, p < 0.001). Reactive arthritis can be triggered by STI, thus STI screening patients who present with reactive arthritis has the potential to identify undiagnosed infection. This thesis provides the first assessment of the international literature regarding the incidence of reactive arthritis after STI. The systematic review found only three published studies which had prospectively examined the incidence of reactive arthritis after STI. The studies reported an incidence of reactive arthritis after STI of 3.0% to 8.1% and were found to be of low to moderate quality. In conclusion, this thesis provides healthcare service providers, policy makers and clinicians with data to inform practice and public health interventions aimed at improving healthcare-seeking behaviour for STI testing. It illustrates that delayed healthcare-seeking for STI symptoms is a common behaviour in New Zealand and could potentially be contributing to STI transmission and downstream burden on the health system. This work provides evidence of the drivers of STI testing that can be promoted, and the barriers that need to be removed. Specifically, improving STI knowledge may positively impact on testing rates. Lastly, this research indicates that there is a need for more studies assessing the incidence of reactive arthritis after an STI.</p>

Healthcare-seeking behaviour for sexually transmitted infection testing in New Zealand: A mixed methods study

<p>Sexually transmitted infections (STIs) are a global public health problem. Sequelae for infected individuals can be serious and STIs impose a substantial financial burden on healthcare systems. Duration of infection is one factor influencing transmission rates, and is modifiable through secondary prevention methods, namely ‘test and treat’. For this approach to be effective, at-risk individuals must choose to present for testing. New Zealand provides a useful case-study to investigate healthcare-seeking behaviour for STI testing, as incidence rates of common STIs are especially high. The aims of this thesis were to quantify healthcare-seeking behaviour for STI symptoms and assess the risk of transmission in this period, to identify the barriers to STI testing, to understand the personal drivers for getting an STI test, to examine how STI knowledge is associated with testing behaviour, and finally, to collate and critically evaluate the published evidence regarding the incidence of a lesser known sequela of STI, reactive arthritis. This thesis took a mixed method approach, employing both qualitative and quantitative methods to address the research aims. The results showed that delays in healthcare-seeking for STI symptoms were common among patients attending an inner-city Sexual Health Clinic (SHC). Almost half of people with symptoms waited longer than seven days to seek healthcare, although there were no identified predictors of delayed healthcare-seeking. Around a third of people with symptoms continued to have sex after they first thought they may need to seek healthcare. Among these individuals, infrequent condom use was reported more by those who had sex with existing sexual partners than by those who had sex with new partners. Having sex while symptomatic was statistically significantly associated with delaying seeking healthcare for more than seven days (odds ratio (OR) = 3.25, 95% CI 1.225 – 8.623, p = 0.018). Analysis of qualitative interview data revealed three types of barriers to testing. These were personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self-consciousness in genital examination and being too busy), structural (financial cost of test and clinician attributes and attitude) and social (concern of being stigmatised). This work also revealed several drivers for testing including crisis, partners, clinicians, routines, and previous knowledge. Knowledge of the incidence, asymptomatic nature and sequelae of STIs featured prominently in the explanations of those who undertook routine testing. However, at the same time, many of the participants felt they did not have a good knowledge base and that their school-based sex education had been lacking. STI knowledge was investigated further using quantitative methodology. Levels of STI knowledge were generally good and did not differ between a Student Health Service population and an SHC population. Individuals who had tested before had significantly better knowledge than those who were attending for testing for the first time (U = 10089.500, Z = -4.684, p < 0.001). In addition, total knowledge score was an independent predictor of having had a previous test (OR = 1.436, 95% CI 1.217-1.694, p < 0.001). Reactive arthritis can be triggered by STI, thus STI screening patients who present with reactive arthritis has the potential to identify undiagnosed infection. This thesis provides the first assessment of the international literature regarding the incidence of reactive arthritis after STI. The systematic review found only three published studies which had prospectively examined the incidence of reactive arthritis after STI. The studies reported an incidence of reactive arthritis after STI of 3.0% to 8.1% and were found to be of low to moderate quality. In conclusion, this thesis provides healthcare service providers, policy makers and clinicians with data to inform practice and public health interventions aimed at improving healthcare-seeking behaviour for STI testing. It illustrates that delayed healthcare-seeking for STI symptoms is a common behaviour in New Zealand and could potentially be contributing to STI transmission and downstream burden on the health system. This work provides evidence of the drivers of STI testing that can be promoted, and the barriers that need to be removed. Specifically, improving STI knowledge may positively impact on testing rates. Lastly, this research indicates that there is a need for more studies assessing the incidence of reactive arthritis after an STI.</p>

UNUSUAL PRESENTATION OF REACTIVE ARTHRITIS AFTER SALMONELLA ENTERITIS IN A 6-YEAR-OLD BOY

ABSTRACT: Reactive arthritis, formerly called Reiter’s syndrome is extra-articular oligoarthropathy, which can be due to bacterial infection or genetic predisposition. The infections are either urogenital (chlamydia being most notorious) or gastrointestinal (e.g. salmonella, yersinia, etc.). The human leukocyte antigen (HLA-B27) antigen has been implicated as the most common predisposing factor. Reactive arthritis often involves the joints of the lower limb. Bacterial enteric infections are a potential threat in a Pediatric population that can be due to an acute illness or its sequelae. Reactive arthritis following outbreaks of enteric infections with Salmonella is uncommon in the pediatric population. We report a rare case of a 6 years old boy who came to ER with high-grade fever and severe pain in the right iliac fossa. Clinical diagnosis of appendicitis was made by the physicians on physical exam but after radio-pathological investigation like CBC, ESR, CRP, Blood culture, USG abdomen, CT abdomen, and MRI, diagnosis of reactive arthritis secondary to salmonella enteritis was made and the patient underwent right hip arthrotomy after which he was discharged. Thus, imaging played a pivotal role in the right diagnosis of a patient with proper management guidelines. This also showed that salmonella enteritis can present atypically mimicking septic arthritis or acute appendicitis. Reactive arthritis after salmonella infection is a very rare and one of its kind case reported in Pakistan.