Reactive arthritis after SARS-CoV-2 infection

18 Jul 2021 Ayurveda, Lifestyle, Rehabilitation

DEAR EDITOR, ReA, a subtype of SpA, is a sterile inflammatory arthritis, predominantly involving the lower extremities. It usually occurs 1–3 weeks after a remote mucosal infection (gastrointestinal or genitourinary). It is also known as Reiter’s syndrome in the presence of the classical triad: urethritis in men and cervicitis in women, ocular inflammation (conjunctivitis or uveitis) and arthritis of large joints. Chlamydia trachomatis, Campylobacter, Salmonella, Shigella and Yersinia are a few of the common bacterial infections that can cause ReA [1]. A few other bacteria and viruses have also been associated with the pathogenesis of ReA. The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a cause of ReA has been reported previously in six cases [2–7]. Here, we report a case of ReA after SARS-CoV-2 infection. Written informed consent was obtained from the patient.

A 27-year-old female was hospitalized after 2 days of fever and body aches. On evaluation, SARS-CoV-2 RT-PCR from a nasopharyngeal swab was positive, and CT imaging of the chest showed bilateral peripheral ground glass opacities COVID-19 Reporting and Data System (CO-RADS-4). Other laboratory parameters during hospitalization showed leucopenia (3200/mm3), elevated CRP (114 mg/l) and D-dimer (three times upper normal limit), and normal levels of lactate dehydrogenase, ferritin and IL-6. She was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia and received 1 mg/kg CS in the form of oral methylprednisolone and favipiravir. Oxygen saturation was well maintained on room air throughout the disease course. Fever subsided on day 3 of hospitalization, and she was discharged on day 8 with tapering doses of CS. Two weeks after testing positive for SARS-CoV-2 infection, while on 0.25 mg/kg of CS, she developed acute onset arthritis in both lower extremities and relatively mild arthritis in the small joints of the right hand. She did not have any history of recent diarrhoea, cervicitis or uveitis.

On examination, bilateral knee, ankle and midfoot joints were extremely tender and swollen. Mild tenderness was also noted in the small joints of the right hand (wrist, MCP and PIP joints). The rest of the physical examination was normal. RT-PCR for SARS-CoV-2 was negative. RF was positive in low titres. ACPA, ANA and HLA-B27 were negative. A probable diagnosis of ReA secondary to SARS-CoV-2 infection was made. She received NSAID and additionally required oral opioid analgesic to manage the pain. CS was gradually tapered and stopped over next 3 weeks. At 4-week follow-up, the arthritis had improved significantly, allowing withdrawal of opioid analgesic and tapering of NSAID.

Although ReA causes asymmetric oligoarthritis in the lower extremities, a mild form of upper limb arthritis can also occur, as seen in our patient [6]. In contrast to this, Danssaert et al. [5] reported arthritis of unilateral hand joints without involvement of lower extremities. Liew et al. [4] described a patient with acute right knee arthritis manifesting 3 days after fever and simultaneously being positive for SARS-CoV-2 infection. Schenker et al. [6] and De Stefano et al. [7] described cases of ReA associated with cutaneous vasculitis and psoriatic skin lesions, respectively. The patient reported by Ono et al. [2] had severe respiratory distress requiring mechanical ventilation, whereas respiratory involvement was milder in the other five patients [3–7], including our patient. All these cases are summarized in Table 1.

Table 1

Reported cases of possible reactive arthritis after SARS-CoV-2 infection

Parameter Ono et al. [2] Saricaoglu et al. [3] Liew et al. [4] Danssaert et al. [5] Schenker et al. [6] De Stefano et al. [7] Our case
Age, years 50 73 47 37 65 30 27
Sex Male Male Male Female Female NA Female
Onset of ReA after SARS-CoV-2 infection, days 22 14 Simultaneous 12 ˃10 20 14
Musculoskeletal manifestations Ankles, right Achillis enthesitis Hands, feet Knee Hand Knees, ankles, wrists Right elbow Knees, ankles, feet, hand
Other manifestations – – Balanitis – Cutaneous vasculitis Psoriatic skin lesions –
RF − − NA − − − +
ACPA − − NA NA − − −
HLA-B27 − NA NA NA + − −
ANA − NA NA + − − −
Arthrocentesis No crystals, sterile NA No crystals, sterile NA NA No crystals Not done
Radiograph Normal Normal Normal NA NA NA Not done
Treatment NSAID, IA CS NSAID NSAID, IA CS Opioid, gabapentin CS NSAID, topical CS for skin NSAID, opioid
Parameter Ono et al. [2] Saricaoglu et al. [3] Liew et al. [4] Danssaert et al. [5] Schenker et al. [6] De Stefano et al. [7] Our case
Age, years 50 73 47 37 65 30 27
Sex Male Male Male Female Female NA Female
Onset of ReA after SARS-CoV-2 infection, days 22 14 Simultaneous 12 ˃10 20 14
Musculoskeletal manifestations Ankles, right Achillis enthesitis Hands, feet Knee Hand Knees, ankles, wrists Right elbow Knees, ankles, feet, hand
Other manifestations – – Balanitis – Cutaneous vasculitis Psoriatic skin lesions –
RF − − NA − − − +
ACPA − − NA NA − − −
HLA-B27 − NA NA NA + − −
ANA − NA NA + − − −
Arthrocentesis No crystals, sterile NA No crystals, sterile NA NA No crystals Not done
Radiograph Normal Normal Normal NA NA NA Not done
Treatment NSAID, IA CS NSAID NSAID, IA CS Opioid, gabapentin CS NSAID, topical CS for skin NSAID, opioid

NA: not available.

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Table 1

Reported cases of possible reactive arthritis after SARS-CoV-2 infection

Parameter Ono et al. [2] Saricaoglu et al. [3] Liew et al. [4] Danssaert et al. [5] Schenker et al. [6] De Stefano et al. [7] Our case
Age, years 50 73 47 37 65 30 27
Sex Male Male Male Female Female NA Female
Onset of ReA after SARS-CoV-2 infection, days 22 14 Simultaneous 12 ˃10 20 14
Musculoskeletal manifestations Ankles, right Achillis enthesitis Hands, feet Knee Hand Knees, ankles, wrists Right elbow Knees, ankles, feet, hand
Other manifestations – – Balanitis – Cutaneous vasculitis Psoriatic skin lesions –
RF − − NA − − − +
ACPA − − NA NA − − −
HLA-B27 − NA NA NA + − −
ANA − NA NA + − − −
Arthrocentesis No crystals, sterile NA No crystals, sterile NA NA No crystals Not done
Radiograph Normal Normal Normal NA NA NA Not done
Treatment NSAID, IA CS NSAID NSAID, IA CS Opioid, gabapentin CS NSAID, topical CS for skin NSAID, opioid
Parameter Ono et al. [2] Saricaoglu et al. [3] Liew et al. [4] Danssaert et al. [5] Schenker et al. [6] De Stefano et al. [7] Our case
Age, years 50 73 47 37 65 30 27
Sex Male Male Male Female Female NA Female
Onset of ReA after SARS-CoV-2 infection, days 22 14 Simultaneous 12 ˃10 20 14
Musculoskeletal manifestations Ankles, right Achillis enthesitis Hands, feet Knee Hand Knees, ankles, wrists Right elbow Knees, ankles, feet, hand
Other manifestations – – Balanitis – Cutaneous vasculitis Psoriatic skin lesions –
RF − − NA − − − +
ACPA − − NA NA − − −
HLA-B27 − NA NA NA + − −
ANA − NA NA + − − −
Arthrocentesis No crystals, sterile NA No crystals, sterile NA NA No crystals Not done
Radiograph Normal Normal Normal NA NA NA Not done
Treatment NSAID, IA CS NSAID NSAID, IA CS Opioid, gabapentin CS NSAID, topical CS for skin NSAID, opioid

NA: not available.

Other manifestations of ReA include inflammatory back pain, dactylitis, enthesitis, tendinitis and bursitis. There are no specific laboratory tests for ReA, and diagnosis relies on the typical clinical presentation with detection of the triggering infection [8]. Arthritis persists for >6 months in 30–50% of patients [1]. The most effective treatment for ReA is NSAID. IA glucocorticoid can be used for mono- or oligoarticular disease. In chronic cases, SSZ can be effective when started within 3 months of disease onset [8].

Our patient developed lower limb predominant inflammatory arthritis, 2 weeks after SARS-CoV-2 infection. The presence of RF in low titres was possibly attributable to an immune response to the recent infection. The classical clinical picture, a preceding infection, absence of other autoantibodies, absence of autoimmunity in the family and response to NSAID, supported the diagnosis of ReA.

This case, along with previously reported cases, suggest SARS-CoV-2 infection as an aetiology in the pathogenesis of ReA. More observations are required to strengthen this association.

Key message

• ReA should be considered in patients with acute arthritis after SARS-CoV-2 infection.

Funding: No specific funding was received from any funding bodies in the public, commercial or not for-profit sectors to carry out the work described in this manuscript.

Disclosure statement: The authors have declared no conflicts of interest.

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article.

Recurrent scleritis as a presenting manifestation of asymptomatic occult Takayasu arteritis

18 Jun 2021 Cardiac, Lifestyle

DEAREDITOR, Takayasu arteritis is a rare chronic granulomatous large-vessel vasculitis with preferential involvement of the aorta, its major branches and the pulmonary arteries [1]. Ocular involvement in Takayasu arteritis is seen as Takayasu retinopathy, which is the result of ocular hypoperfusion and chronic ischaemia [2]. Scleritis in Takayasu arteritis is extremely rare, reported in only six cases [3–6]. We report a case of previously undiagnosed asymptomatic Takayasu arteritis presenting with bilateral recurrent anterior scleritis.

A 48-year-old woman presented with redness and pain in the right eye for 15 days. Pain radiated around the eye and was exacerbated by eye movements. She had history of multiple episodes of inflamed, painful eyes for past 6 years, involving the left eye for the initial 4 years and the right eye thereafter. She received topical CSs and NSAIDs, and oral CSs at variable doses during these episodes.

Examination of the eyes showed temporal congestion in the right eye (Fig. 1A) and a normal left eye. Ophthalmic assessment confirmed nodular anterior scleritis of the right eye. Visual acuity, the cornea, anterior and posterior chambers were normal in both eyes. Further physical examination revealed absent pulses in the left radial, ulnar, brachial and subclavian arteries. Right radial and brachial pulses were diminished. Bruits were heard over bilateral carotid and left subclavian arteries. Blood pressure was not recordable in the left arm, 90/60 mmHg in the right arm and 130/80 mmHg in both lower limbs.

Fig. 1

Scleritis in Takayasu arteritis

(A) Anterior scleritis. (B) CT angiogram, showing circumferential wall thickening in ascending (arrow) and descending thoracic aorta (arrowhead). (C) CT angiogram, showing stenosis in right common carotid and bilateral subclavian arteries (arrowheads), with complete occlusion in proximal part of left subclavian artery (arrow).

On evaluation, ESR was 49 mm/h, CRP was 20.4 mg/l, and ANCAs (ELISA and immunofluorescence) and ANA tests were negative. Chest radiographs and echocardiographs were normal. CT angiogram showed circumferential wall thickening in the ascending (arrow in Fig. 1B), arch and descending thoracic aorta (arrowhead in Fig. 1B) and the brachiocephalic, left common carotid and left subclavian arteries. Complete occlusion was seen in the proximal part of the left subclavian artery (arrow in Fig. 1C), with collaterals filling the distal segment. Stenosis was seen in the right common carotid and bilateral subclavian arteries (arrowheads in Fig. 1C). A diagnosis of Takayasu arteritis with anterior nodular scleritis was made, and oral prednisolone was started at 1 mg/kg in combination with oral MTX 15 mg/week. Ocular symptoms improved markedly over the next few days, and gradual tapering of prednisolone dose was planned.

We have found only six published cases of Takayasu arteritis associated with scleritis [3–8]. Akhtar et al. [3] reported a case with a 10-year history of Takayasu arteritis. The patient was in prolonged remission before developing scleritis as a presenting manifestation of disease flare. Scleritis was refractory to MMF and required adalimumab for CS weaning. Scleritis as a presenting manifestation in an asymptomatic occult Takayasu arteritis was reported only once [7]. This patient succumbed to ischaemic colitis 3 weeks after presentation, and necrotizing granulomatous vasculitis of the thoracic and abdominal aorta was demonstrated on autopsy. Similar to our case, Chaudhary et al. [8] also reported a case of Takayasu arteritis with a 6-year-long history of fluctuating scleritis. But unlike their patient, our patient was asymptomatic for Takayasu arteritis and had occult vascular inflammation for an unknown duration, leading to stenosis and occlusion of vessels. This presentation makes our case extremely unusual and also emphasizes the importance of detailed physical examination even in patients presenting with isolated scleritis.

Small vessel vasculitis in Takayasu arteritis is less well described. Different cutaneous manifestations with histopathological evidence of vasculitis have been reported in Takayasu arteritis [9]. Scleritis in our patient could also be a small vessel manifestation of Takayasu arteritis. However, the possibility of these two conditions coexisting cannot be excluded.

Key message

  • Takayasu arteritis should be in the list of differential diagnoses in patients with isolated scleritis.

Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Disclosure statement: The authors have declared no conflicts of interest.

Data availability statement

Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article.

Synovial chondromatosis of suprapatellar bursa in a case of rheumatoid arthritis

30 May 2021 Uncategorized

A 70-year-old female, hypertensive and diabetic for 15 years, presented with symmetrical inflammatory polyarthritis of the small and large joints of the upper and lower limbs of 8 months duration. She had multiple tender and swollen joints and painful, restricted movement of the left knee. The ESR was elevated, and RF was negative. She was diagnosed as seronegative RA and was initiated on oral MTX and low-dose CS. She also received IA CS in the left knee in view of the severe debilitating pain. At 2 months follow-up, she continued to have left knee pain with tenderness and had no other tender or swollen joints. Radiographs of the knees showed bilateral grade three OA with chondromatosis of the left suprapatellar bursa (Fig. 1A and B, arrow). Surgical removal of cartilaginous bodies while performing a total knee arthroplasty is planned at later date.

Fig. 1

Synovial chondromatosis

Anteroposterior (A) and lateral (B) radiographic views of knees, showing synovial osteochondromatosis of left suprapatellar bursa (arrowed).

Synovial chondromatosis is a rare, tumour-like, benign lesion of the synovium, which may occur in the synovial membrane of a joint, bursa or tendon sheath. It usually presents unilaterally in large joints. The knee is the joint most commonly involved, but chondromatosis can also manifest in other joints, such as the shoulder, elbow, hip and ankle [1]. It is uncommon in RA, and only a few cases have been reported.

Funding: No specific funding was received from any funding bodies in the public, commercial or not for-profit sectors to carry out the work described in this manuscript.

Disclosure statement: The authors have declared no conflicts of interest.

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