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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 1250-1252  

Shigella flexneri associated reactive arthritis - GI transmitted or sexually transmitted?


1 Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of General Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. Manish Kumar
Department of General Medicine, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_30_19

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  Abstract 


The pathogenic association of reactive arthritis with human immunodeficiency virus (HIV) needs more attention. In this case report we described a case of 22 year old male patient suffering from severe HIV infection. He presented with the complaints of left knee joint pain associated with swelling and tenderness. He also developed keratotic papules on palms and soles and polycyclic erosions on the glans penis. He was diagnosed as a case of reactive arthritis with HIV infection. The patient was treated with sulfasalazine and anti retroviral therapy. We, hereby discuss the underlying pathogenesis and treatment modalities in patients of reactive arthritis with underlying HIV infection. The treatment of reactive arthritis with HIV is a challenge due to limited options of immunosupressive agents.

Keywords: HIV, reactive arthritis, shigella flexneri


How to cite this article:
Kaeley N, Kumar M, Bhardwaj BB, Nagasubramanyam V. Shigella flexneri associated reactive arthritis - GI transmitted or sexually transmitted?. J Family Med Prim Care 2019;8:1250-2

How to cite this URL:
Kaeley N, Kumar M, Bhardwaj BB, Nagasubramanyam V. Shigella flexneri associated reactive arthritis - GI transmitted or sexually transmitted?. J Family Med Prim Care [serial online] 2019 [cited 2019 Apr 23];8:1250-2. Available from: http://www.jfmpc.com/text.asp?2019/8/3/1250/254875




  Introduction Top


Multiple musculoskeletal manifestations of human immunodeficiency virus (HIV) have been described. They are HIV-associated arthropathy, seronegative spondyloarthropathies (SPA), which includes reactive arthritis, psoriatic arthritis (PsA), undifferentiated arthritis, and painful articular syndrome.[1] Management of musculoskeletal disorders in HIV positive patients is challenging in view of safety profile of immunosuppressive drugs. We present a case of reactive arthritis in a patient suffering from HIV infection secondary to  Shigella flexneri Scientific Name Search nfection and its management.


  Case Report Top


A 22-year-old male patient was presented with the complaints of right toe dactylitis and redness of bilateral eyes since the last six months. After four months he developed pain and swelling of left knee and right heel with morning stiffness. History revealed to be positive for MSM. Two months later he developed bilaterally symmetrical erythematous keratotic papules on palms and soles suggestive of keratoderma blenorrhagicum [Figure 1] and [Figure 2]. He also developed lesions on glans penis which were polycyclic erosions suggestive of circinate balanitis. The patient was diagnosed as a case of HIV positive one year back for which started on zidovudine.
Figure 1: Keratoderma blenorrhagicum lesions over palm

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Figure 2: Keratoderma blenorrhagicum lesions over sole

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At time of admission his CD4 count was 85 cells/mm 3. He gave history of loose stools six months back which lasted for five days. Stools were watery in consistency and blood tinged. Stool cultures were positive for Shigella flexneri. There was no family history or past history psoriasis and arthritis.

On examination, his vitals were normal except for tachypnea. The respiratory system examination was suggestive of right sided infrascapular crepitation. Rest of systemic examination was normal.

Complete hemogram revealed mild anaemia and leucocytosis. Kidney function and liver function test were within normal range. Inflammatory markers ESR and CRP were significantly raised. HLA - B27 was positive. Tests for hepatitis B and C were negative. Rheumatoid factor (RF) was negative. The sputum test was positive for AFB (acid fast bacilli). Screening for chlamydia, gonorrhoea, and syphilis was negative. Urethral, rectal and pharyngeal swab cultures were negative for  Neisseria More Details gonorrhoea. Chest x-ray showed left lower zone consolidation. Left knee x-ray was normal. Left knee synovial fluid aspiration was suggestive of leucocytosis with no organisms and growth in cultures. Skin biopsy from palm showed regular acanthosis, parakeratosis, neutrophilic abscesses in stratum corneum, supra papillary thinning of epidermis and dilated capillaries in papillary dermis, which was consistent with reactive arthritis.

Diagnosis of reactive arthritis with AIDS with pulmonary tuberculosis was made. Intra-articular corticosteroid (triamcinolone 20 mg) was started. The patient's joint pain did not show any improvement. Hence, he was started on non-steroidal anti-inflammatory drugs (NSAIDS) and oral sulfasalazine (one gram twice daily). The patient's joint pains and skin lesions gradually improved. Since CD4 count was low anti-tubercular therapy was initiated and anti-retroviral therapy was discontinued for eight weeks.


  Discussion Top


This patient fulfilled the criteria of reactive arthritis (oligoarthritis, enthesitis, circinate balanitis and keratoderma blenorrhagicum). HIV infection is associated with multiple opportunistic infections. Thus, use of immunosuppressive drugs is controversial in these patients. There are varied manifestations of HIV associated arthritis. They range from asymmetrical oligoarthritis to symmetrical polyarthritis. Oligoarthritis mainly involves knees and ankles.[2],[3] Spondyloarthropathies can present as reactive arthritis, psoriatic arthritis, undifferentiated arthropathies, and painful articular syndrome. Other articular manifestations of HIV are avascular necrosis of bone, hypertrophic pulmonary osteoarthropathy, osteopenia and osteoporosis.[4]

Reactive arthritis was first described by Hans Reiter in 1916. It was called as Reiter's syndrome and constituted of arthritis, urethritis and conjunctivitis. It was later termed as reactive arthritis in 2003 when Hans Reiter was held responsible for war crimes in Second World War.[5] HLA B-27 is strongly associated with reactive arthritis. When reactive arthritis is seen in children and adolescents less than 16 years of age, termed as juvenile idiopathic arthritis (JIA).[6]

It is common in age group of 20-40 years and usually occurs in few days to six weeks after preceding urogenital or enteric tract infection.[7] Most probable causative organisms in patients with reactive arthritis are Chlamydia trachomatis, Shigella flexneri,  Salmonella More Details enteritidis, Salmonella typhimurium,  Yersinia More Details enterocolitica, Yersinia pseudo typhimurium, and Campylobacter jejuni. Very rarely caused by haemophilus parainluenza.[8] Various components of these organisms have been observed in synovium of the patients with reactive arthritis. HLA-B27 positivity in these patients is directly related to increased severity of reactive arthritis and increased probability of developing various extra-articular manifestations.[9] Apart from HLA B-27, IL-10 and IL-12 also play a pivotal role in predisposing inflammatory response in the synovial fluid.[10] Another theory proposed is role of IFN-Ý in clearing pathogenic bacteria causing reactive arthritis.[11] HIV positive patients having reactive arthritis have increased probability of developing extra-articular manifestations such as dactylitis, achilles tendonitis and plantar fasciitis. They have more severe mucocutaneous manifestations in form of keratoderma blennorrhagica and circinate balanitis. Various inflammatory dermatoses also manifested with HIV.[12] Treatment of reactive arthritis in HIV positive patients is same as that of HIV negative patients. NSAIDS and sulfasalazine are mainstay of treatment.[13] However, TNF-α blockers should be used with caution in these patients.[14] It has been proposed that patients with resistant arthritis respond better with highly active retroviral therapy (HAART).[15]

In HIV related infection, exposure to opportunistic infections is increased. This leads to inflammatory reaction but there is sparing of CD8-T cells. These multiple biochemical factors lead to localisation of primary disease.[16] As per previous studies, association of HIV and reactive arthritis is rare. Berman et al. described reactive arthritis in 10% cases of HIV.[17] Shigella flexneri is a known micro-organism to cause reactive arthritis. It is usually transmitted by contaminated food and water. However, it is also transmitted by sexual route in 3 to 8.1% cases of reactive arthritis.[18]


  Conclusion Top


HIV infection is associated with multiple complex rheumatological manifestations. Early identification and treatment can prevent comorbidities and improve their disability index. Family physicians will be frequently encountering HIV associated with arthritis as prevalence of STD steadily growing. Steroids use in this group is highly discouraged and NSAID and sulfasalazine are highly beneficial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kole AK, Roy R, Kole D. Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis 2013;34:107-12.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Weeratunge NC, Roldan J, Anstead GM. Jaccoud arthropathy: A rarity in the spectrum of HIV-associated arthropathy. Am J Med 2004;328:351-3.  Back to cited text no. 2
    
3.
Plate A-M, Boyle B. Musculoskeletal manifestations of HIV. AIDS Read 2003;13:62.  Back to cited text no. 3
    
4.
Gupta N, Mandal SK. Joint manifestations in HIV infection: A review. J Infect Dis Ther 2015;3;6:1-3.  Back to cited text no. 4
    
5.
Panush R, Wallace D, Dorff R, Engleman EP. Retraction of the suggestion to use the term “Reiter’s syndrome” sixty-five years later: The legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum 2007;56:693.  Back to cited text no. 5
    
6.
Petty R, Southwood T, Manners P, Baum J, Glass DN, Goldenberg J, et al. International league of associations for rheumatology classification of juvenile idiopathic arthritis: Second revision, Edmonton, 2001. J Rheumatol 2004;31:390-2.  Back to cited text no. 6
    
7.
Leirisalo-Repo M, Sieper J. Reactive arthritis: Epidemiology, clinical features, and treatment. In: Weisman M, van der Heijde D, Reveille J, editors. Ankylosing Spondylitis and the Spondyloarthropathies. Philadelphia: Mosby Elsevier; 2006. p. 53-64.  Back to cited text no. 7
    
8.
Eguchi T, Horino T, Amano E, Ichii O, Terada Y. Reactive arthritis caused by haemophilus parainfluenzae in a diabetic patient. Am J Med 2018. pii: S0002-9343(18) 31130-6. doi: 10.1016/j.amjmed.2018.11.007.  Back to cited text no. 8
    
9.
Hamadulay S, Glynne S, Keat A. When is arthritis reactive? Postgrad Med J 2006;82:446-53.  Back to cited text no. 9
    
10.
Yin Z, Braun J, Neure L, Wu P, Liu L, Eggens U, et al. Crucial role of interleukin-10/interleukin- 12 balance in the regulation of the type 2 T-helper cytokine response in reactive arthritis. Arthritis Rheum 1997;40:1788-97.  Back to cited text no. 10
    
11.
Bas S, Kvien T, Buchs N, Fulpius T, Gabay C. Lower level of synovial fluid interferong in HLA-B27-positive than in HLA-B27-negative patients with Chlamydia trachomatis reactive arthritis. Rheumatology 2003;42:461-7.  Back to cited text no. 11
    
12.
Garg T, Sanke S. Inflammatory dermatoses in human immunodeficiency virus. Indian J Sex Transm Dis AIDS 2017;38:113-20.  Back to cited text no. 12
    
13.
Carrington M, O'Brien SJ. The influence of HLA genotype on AIDS. Annu Rev Med 2003;54:535-51.  Back to cited text no. 13
    
14.
Gill H, Majithia V. Successful use of infliximab in the treatment of Reiter's syndrome: A case report and discussion. Clin Rheumatol 2008;27:121-3.  Back to cited text no. 14
    
15.
Rowe IF, Forster SM, Seifert MH, Youle MS, Hawkins DA, Lawrence AG, et al. Rheumatological lesions in individuals with human immunodeficiency virus infection. Q J Med 1989;73:1167-84.  Back to cited text no. 15
    
16.
Schulz LC, Schaening U, Pena M, Hermanns M. Borderline-tissues as sites of antigen deposition and persistence—a unifying concept for rheumatoid inflammation? Rheumatol Int 1985;5:21-7.  Back to cited text no. 16
    
17.
Berman A, Reboredo G, Spindler A, Lasala ME, Lopez H, Espinoza LR. Rheumatic manifestations in populations at risk for HIV infection: The added effect of HIV. J Rheumatol 1991;18:1564-7.  Back to cited text no. 17
    
18.
Hannu T, Matila L, Siitonen A, Leirisalo-Repo M. Reactive arthritis attributable to Shigella infection: A clinical and epidemiological nationwide study. Ann Rheum Dis 2005;64:594-8.  Back to cited text no. 18
    


    Figures

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