Artritis reactiva secundaria a fiebre por mordedura de rata: reporte de un caso clínico / Reactive arthritis secondary to rat-bite fever: report on a clinical case

Caso clínico: Paciente de sexo masculino, de 69 años, sin otros antecedentes. Debuta con dolor en zona de la cadera derecha transitorio, evolucionando con cuadro de seis días de desarrollo de fiebre hasta 39,2ºC, calofríos, artralgias en tarso derecho, rodillas, hombros y astenia, por lo que fue hospitalizado. Al examen destacaba aumento de volumen doloroso en rodilla izquierda y hombro derecho. El estudio de líquido articular descartó artritis infecciosa y presencia de cristales intraarticulares. Los exámenes séricos mostraban parámetros inflamatorios alterados con leucocitosis, VHS y PCR elevados. Panel viral negativo. Sin otro foco inflamatorio evidente, se inició manejo antibiótico empírico con Ceftriaxona y Cloxacilina, con buena respuesta, mejorando su sintomatología y parámetros inflamatorios. Cultivos articulares negativos. El Gram de hemocultivos demostró la presencia de bacilos Gram negativos, aislando en los hemocultivos Streptobacillus moniliformis. El paciente evoluciona favorablemente, con regresión total de su cuadro articular. Discusión y conclusión: La Fiebre por Mordedura de Rata es una enfermedad sistémica que típicamente se presenta con fiebre, rash cutáneo y poliartralgias migratorias. Uno de sus principales agentes causales es el Streptobacillus moniliformis, que coloniza la nasofaringe de ratas y otros roedores. Casos aislados han sido reportados en Chile. En la Fiebre por Mordedura de Rata hasta un 50 por ciento de los pacientes desarrolla artritis con derrame articular o sin él. Puede afectar cualquier articulación, pero la más comúnmente comprometida es la rodilla. El dolor articular disminuye en las primeras tres semanas del uso de antibióticos, pero la articulación en ocasiones puede llegar a ser destruida. En sujetos sanos se han reportado tasas de mortalidad de 10 por ciento a 15 por ciento. Mientras todos los síntomas se resuelven puede haber recaídas con graves complicaciones, como meningitis, endocarditis...

Clinical case: Male patient, 69 years old and no previous record. First episode with transitory pain in the right hip zone, going on to 6 days of fever that evolves to 39.2 ºC, shivers, articular pain in the right tarsus, knees, shoulders and asthenia, so he was hospitalized. Upon examination, painful swellings of the left knee and right shoulder stood out. A study of synovial fluid ruled out infectious arthritis and presence of intra-articular crystals. Blood tests showed altered inflammatory parameters with high leukocytes, VHS and CRP. Negative viral panel. Without another evident inflammatory focus, an empirical management was initiated by means of antibiotics with Ceftriaxone y Cloxaciline, which had a good response relieving symptoms and inflammatory panels. Negative articular culturing. The blood culture Gram showed presence of negative Gram bacilli, with the isolation of Streptobacillus moniliformis in the blood cultures. Patient evolves favorably, with full regression of his articular symptoms. Discussion and conclusion: Rat-bite fever is a systemic sickness that typically presents itself with high fever, skin rash and migratory poly-articular pain. One of its main causing agents is the Streptobacillus moniliformis that colonize the nasopharynx of rats and other rodents. Isolated cases have been reported in Chile. In Rat-bite Fever up to 50 percent of patients develop arthritis with and without joint effusion. It may affect any joint, but that most commonly compromised is the knee. Articular pain subsides in the first 3 weeks of use of antibiotics, but the joint may sometimes even be destroyed. Mortality rates in healthy individuals have been reported at 10 percent to 15 percent. While all symptoms disappear there might be relapses with serious complications such as meningitis, endocarditis, myocarditis, pneumonia and fulminant sepsis that may cause the patient to die. Timely diagnose and treatment are paramount to avoid its serious...

Bases infecciosas de la artritis reactiva / Infectious basis of reactive artritis

La artritis reactiva es un trastorno clínico en el cual se conoce con bastante certidumbre el o los agentes etiológicos que precipitan el proceso. Este conocimiento básico del inicio de la enfermedad ha permitido grandes avances en nuestro conocimiento de su patogenia. Sin embargo, a pesar de un mejor entendimiento de la patogenia que conduce al cuadro clínico, el tratamiento específico de la enfermedad permanece elusivo. Por otro lado, la introducción de agentes biológicos, especialmente los inhibidores del factor de necrosistumoral-alfa (TNFa), ha facilitado un mejor control tanto de la artritis periférica como axial. Inhibidores del TNFa son de gran utilidad, sobre todo en el control de las manifestaciones clínicas comprometiendo las articulaciones sacroilíacas y espondilíticas. Cierta reservación queda, sin embargo, a las complicaciones potenciales secundaria a la inhibición a largo plazo del TNFa teniendo en cuenta el papel importante que juega esta citoquina en la protección delhuésped contra agentes infecciosos

Post-streptococcal reactive arthritis [PSRA]: Clinical features and risk of carditis

Post-streptococcal reactive arthritis [PSRA] is a poorly understood clinical syndrome in which oligoor polyarthritis occurs following a group Astreptococcal pharyngitis. There is lack of universally accepted guidelines for diagnosis and management of these patients. Long-term data regarding risk of carditis within this population are insufficient. To study the clinical features, risk of subsequent carditis and the need for prophylactic antibiotics in this population. Forty-five patients with the diagnosis of PSRA w e re identified at the pediatric immunology clinic in King Hussein Medical Center, Jordan between January 1999 and April 2003. They all had evidence of preceding streptococcal infection and joint disease at initial presentation. However, none fulfilled the updated revised Jones criteria for diagnosis of acute rheumatic fever [ARF]. Common viral causes of reactive arthritis were excluded and all patients had cardiac evaluation at presentation. Follow up was for a minimum of two years, focusing on clinical recurrences and the clinical and/or echocardiographic evidence of carditis. Forty patients, 21 male and 19 female, aged between six and 17 years with a mean age of 10 years were included in the follow up study. All patients had persistent arthritis lasting 2-6 weeks at presentation, which did not respond to conventional therapy with salicylates. Symmetrical polyarthritis of large joints was predominant. Small and axial joints were involved in 45% and 33% cases respectively. Cardiac evaluation at initial presentation was normal. They all had evidence of preceding group Astreptococcal infection. During follow up, four patients developed evidence of carditis with recurrence of arthritis. They were found to be noncompliant with prophylactic antimicrobials. Post-streptococcal reactive arthritis may be considered a separate entity from acute rheumatic fever. However, because of the risk of subsequent carditis in certain percentage of patients, we recommend long-term antimicrobials prophylaxis as advised for patients with acute rheumatic fever

arthrites reactionnelles

Reactive arthritis are definied as steriles arthropathies using classic bacteriological techniques. They are due to extra articular infection and are often associated with HLA B27. the outcome of these arthritis is caracterised by the recurrence of flares with sometimes appearition of ankylosing spondylitis. The pathogenesis of reactive arthritis is modified when bacterial antigens or alive micro-organisms are discovered in involved joints. Several current works have underlined the interest of antibiotic therapy in the chlamydial reactive arthritis. Chronic forms can justify the use of anti-rheumatic drugs such as salazopyrine

Reactive arthritis, psoriasiform lesions and protein loosing enteropathy secondary to Strongyloidiasis.

Reactive arthritis is associated with demonstrable infection at a distant site without evidence of sepsis at the affected joint(s). We present a rare case reactive arthritis where no bacterial or chlamydial infections could be established, rather larvae of Strongyloides stercoralis could be demonstrated in the stool and duodenal biopsy. Reactive arthritis, psoriasiform lesions and malabsorption with hypoproteinaemia, responded to successful treatment with antihelminthic drugs. Early recognition and adequate treatment for gastrointestinal infections and infestations before complications is important.

Síndrome de Reiter / Reiter's syndrome

Presentamos un caso de un paciente de 14 años de edad, de sexo masculino, en quien los hallazgos clínicos, histopatológicos y de laboratorio confirmaron el diagnóstico de síndrome de Reiter. Realizamos una extensa revisión bibliográfica, en la cual observamos que aún hoy se discuten pautas diagnósticas, mecanismos fisiopatogénicos, terapéutica y asociaciones de este síndrome, particularmente en aquellos pacientes en quienes no se manifiesta totalmente

Acne fulminans associated with reactive polyarthritis: report of a case and review of the literature

We describe a 16year old boy with acne fulminans associated with axial and peripheral polyarthritis. The patient's clinical course and therapy with isotretinoin, prednisolone and oxytetracycline are described. A possible association between the presence ofHLA-B27 antigen and reactive arthritis with acne fulminans in this case is evaluated. A review of the literature is included

Some parasitic diseases as a cause of rheumatic pains

It was found that some parasitic diseases could precipitate a wide complaint of rheumatic like pains. So, one hundred cases were chosen, among the patients who presented to the Outpatient Clinics of Rheumatology and Rehabilitation Department at Zagazig University Hospitals, [complaining of chronic, recurrent rheumatic pains, not responding to the usual non-steroidal antirheumatic treatment. They aged 25 - 50 years, of both sexes and from rural and urban areas. Full history taking, thorough physical and clinical examinations and complete laboratory investigations were done to: exclude other causes of rheumatic pains, diagnose and confirm the parasitic infections [using stool and urine analysis then IHAT]. 24% were found suffering from parasitic infections: 6 cases[6%] schistosomiasis, 4 amaebiasis [4%], 3 Toxoplasma infection [3%] and 2 toxocariasis [2%],3 cases had mixed parasitic infection [3%] 2 cases schistosomiasis and amaebiasis, 1 case shistosomiasis and toxoplasmosis], 6 cases [6%] were suffering from parasitic infection in addition to other cause of rheumatic pains. No significant difference were found among these different groups, regarding age, sex and residence.The usual clinical parasitic manifestations of dysentery diarrhoea, nausea'etc., were good criteria to evoke the diagnosis. Considering the erythrocyte sedimentation rate [E.S.R.] readings, a significant difference was found among schistosomal arthropathy group and other parasitic groups, that showed unsignificant differences.The clinical picture of arthritis induced by parasitic infections was non specific because it was usually accompanied by myalgia, sometimes knee joint effusion, as the clinical picture of different inflammatory rheumatic diseases.The role of Immune Complex [IC] in the pathogenesis of parasitic arthropathy, myopathy and joint effusion was discussed, on basis of the results of specific IC level estimation by micro-ELISA in the sera of the cases harbouring parasitic infections and synovial fluids [in cases with joint effusion], and compared with the results control group, a highly significant elevation was recorded in toxocariasis, significant rises reported in schistosomiasis and amaebiasis and a moderately significant increase noticed in toxoplasmosis. Also, IC was highly elevated in the synovial fluids above serum levels in cases of schistosomiasis, toxoplasmosis and toxocariasis with knee joint effusion, suggesting a secondary local immunological reactions. Therefore, it can be concluded that rheumatic like pains, related to some parasitic infections in our country as schistosomiasis, amaebiasis, toxoplasmosis and toxocariasis were due to immunological reactions, that IC, either in the serum or in the synovial fluid plays the major role, with probable minor roles played by excretory toxic metabolites of some parasites, others may cause limited direct catabolic effects in the joints and muscles. Thus, these parasitic infections as aetiological causes of chronic, and recurrent rheumatic - like pains should be considered wider than previously thought