Reactive arthritis following an outbreak of Salmonella bovismorbificans infection

doi:10.1016/S0163-4453(98)94243-8

Journal of Infection

Volume 36, Issue 3, May 1998, Pages 289-295

https://doi.org/10.1016/S0163-4453(98)94243-8 Get rights and content

A large, single-source Salmonella outbreak caused by a rare serovar Bovismorbificans (6,8:r:1,5) occurred in southern Finland in 1994. The origin of the outbreak was sprouted alfalfa seeds. A questionnaire was mailed to all 210 subjects with positive stool culture.

Ninety-one percent (191/210) returned the questionnaire. One hundred and fifty-three (80%) were adults. One hundred and fifty-nine out of one hundred and ninety-one (83%) reported diarrhoea, 109 (57%) fever, 104 (54%) abdominal pains, 83 (43%) fatigue, 66 (35%) articular symptoms and 20 (10%) had no symptoms. The median duration of diarrhoea was 5 days (range 1–35), that of other symptoms 4 days (range 1–30).

Those reporting articular symptoms were examined (51 patients) or contacted by telephone (13 patients). Twelve percent (22/191) fulfilled the criteria for reactive arthritis (ReA). The difference in the incidence of ReA between children and adults was not significant (8% vs. 12%). The median onset of joint symptoms was 8.5 days; symptoms were oligoarticular in 14 (67%) and polyarticular in four (19%) patients. Mostly ReA was mild, but in four patients (18%) the joint symptoms lasted for more than 4 months. Ten (45%) ReA patients had HLA-B27 tissue type. The duration and severity of ReA did not differ between HLA-B27 positive and negative patients. Fourteen (64%) ReA patients had received fluoroquinolone treatment before reactive joint or tendon symptoms manifested, but this treatment did not prevent ReA symptoms.

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Cited by (69)

Factors Associated with Sequelae of Campylobacter and Non-typhoidal Salmonella Infections: A Systematic Review
2017, EBioMedicine
Citation Excerpt :
One study assessing the use of PPI in the development of ReA following Campylobacter and NTS infection found a significant association after adjustment for age, sex and degree of urbanization (adjusted OR 2.9 (95% CI 1.4–6.1)) (Doorduyn et al., 2008). The prescription/usage of antibiotics was reported in 17 studies (n = 7 for Campylobacter and n = 11 for NTS) (Arnedo-Pena et al., 2010, Buxton et al., 2002, Rudwaleit et al., 2001, Ekman et al., 2000, Schonberg-Norio et al., 2010, Dworkin et al., 2001, Mattila et al., 1998, Hannu et al., 2002b, Townes et al., 2008b, Tuompo et al., 2013, Lee et al., 2005, Pitkanen et al., 1981, 1983, Ponka et al., 1984, Locht and Krogfelt, 2002, Locht et al., 1993, Uotila et al., 2014). Seven studies considered the risk of ReA development following antibiotics usage (Arnedo-Pena et al., 2010; Buxton et al., 2002; Dworkin et al., 2001; Mattila et al., 1998; Hannu et al., 2002b; Locht and Krogfelt, 2002; Townes et al., 2008b).
Despite the significant global burden of gastroenteritis and resulting sequelae, there is limited evidence on risk factors for sequelae development. We updated and extended previous systematic reviews by assessing the role of antibiotics, proton pump inhibitors (PPI) and symptom severity in the development of sequelae following campylobacteriosis and salmonellosis. We searched four databases, including PubMed, from 1 January 2011 to 29 April 2016. Observational studies reporting sequelae of reactive arthritis (ReA), Reiter's syndrome (RS), irritable bowel syndrome (IBS) and Guillain-Barré syndrome (GBS) following gastroenteritis were included. The primary outcome was incidence of sequelae of interest amongst cases of campylobacteriosis and salmonellosis. A narrative synthesis was conducted where heterogeneity was high. Of the 55 articles included, incidence of ReA (n = 37), RS (n = 5), IBS (n = 12) and GBS (n = 9) were reported following campylobacteriosis and salmonellosis. A pooled summary for each sequela was not estimated due to high level of heterogeneity across studies (I2 > 90%). PPI usage and symptoms were sparsely reported. Three out of seven studies found a statistically significant association between antibiotics usage and development of ReA. Additional primary studies investigating risk modifying factors in sequelae of GI infections are required to enable targeted interventions.
Juvenile-onset spondyloarthritis
2015, Rheumatology: Sixth Edition
Reactive arthritis induced by intravesical BCG therapy for bladder cancer: Our clinical experience and systematic review of the literature
2013, Autoimmunity Reviews
Citation Excerpt :
The knee and ankle are by far the most affected joints irrespective of the arthritis pattern but more frequently involved in asymmetric arthritis. This is consistent with what is generally reported [85,86] but, in ivBCG ReA, the prevalence of the knee and ankle arthritis is definitely higher than it is described in other forms of ReA [81,87]. The spinal involvement and sacroilitis (defined as spinal pain, low back pain, clinical or radiological sacroilitis) are more rare if compared with ReA from enteric and urogenital infections [81,87–89].
Intravesical instillation of BCG (ivBCG) is an effective and safe immunotherapy of bladder carcinoma but it may have, as side effect, a reactive arthritis (ReA). The authors describe 5 cases observed during their own clinical experience along with the updated review of the literature on this topic.
Seventy-three papers were present in the world literature, each reporting almost 1 case for a total of 112 patients. However, the review focused on 61 papers, selected on the basis of reporting suitable for a correct clinical evaluation; thus, a total of 89 patients, including the cases observed in our clinic, were carefully analyzed.
Among the 89 patients identified 73 were males and 16 females. Europe is the geographical area with the higher number of reports, namely 80.6% of the papers including 74.2% of the patients. The Mediterranean area accounts for 62.9% of the papers and 59.6% of the cases. The symptoms of ReA appeared after a mean number of instillations of 5.8. Polyarthritis was present in 55.1%, oligoarthritis in 37.0% and monoarthritis in 7.9%. Polyarthritis was symmetric in 51.0% and asymmetric in 49.0% of the cases; oligoarthritis was symmetric in 33.3% and asymmetric in 66.7% of the cases. Overall, an asymmetric distribution of arthritis was present in 59.6%. Knee and ankle were the joints most frequently involved. The antigen HLA B27 was positive in 42.6%. The synovial fluid analysis was defined as flogistic–aseptic in 71.9% of the patients. Arthritis was recovered within 6 months in 93.2% of the cases and in 70.5% of the patients within the first two months. NSAIDs and corticosteroids, alone or in conjunction with other drugs, are used in 65.1% and in 40.4% of the cases, respectively. The clinical features of ivBCG ReA are compared with ReA from other triggering agents, from which it differs for some clinical aspects and overlaps for others.
Compared with a previous report, this review allows to modify some figures of this topic as a reduced prevalence of polyarthritis (from 70% to 55.1%) and of spinal and sacroiliac involvement; polyarthritis remains the more frequent clinical pattern of ivBCG ReA that, however, is characterized by rather asymmetrical distribution and involvement of the large joints of lower limbs. A definite linkage to HLA B27 is present, although without prognostic value. Moreover, arthritis is aseptic, has a latency time from antigen exposure, and is associated with extra-articular features as commonly observed in ReA from other triggering agents. Arthritis is usually benign and rarely develops into a chronic form. NSAIDs and/or corticosteroids are largely effective. Noteworthy, the overall clinical picture of arthritis triggered by ivBCG emerging from this updated review is comparable to that of ReA from other bacterial agents.
Reactive arthritis
2011, Best Practice and Research: Clinical Rheumatology
Reactive arthritis (ReA) can be defined as the development of sterile inflammatory arthritis as a sequel to remote infection, often in the gastrointestinal or urogenital tract. Although no generally agreed-upon diagnostic criteria exist, the diagnosis is mainly clinical, and based on acute oligoarticular arthritis of larger joints developing within 2–4 weeks of the preceding infection. According to population-based studies, the annual incidence of ReA is 0.6–27/100 000. In addition to the typical clinical picture, the diagnosis of ReA relies on the diagnosis of the triggering infection. Human leucocyte antigen (HLA)-B27 should not be used as a diagnostic tool for a diagnosis of acute ReA. In the case of established ReA, prolonged treatment of Chlamydia-induced ReA may be of benefit, not only in the case of acute ReA but also in those with chronic ReA or spondylarthropathy with evidence of persisting chlamydia antigens in the body. In other forms of ReA, there is no confirmed evidence in favour of antibiotic therapy to shorten the duration of acute arthritis. The outcome and prognosis of ReA are best known for enteric ReA, whereas studies dealing with the long-term outcome of ReA attributable to Chlamydia trachomatis are lacking.
Chlamydia-induced reactive arthritis: Hidden in plain sight?
2011, Best Practice and Research: Clinical Rheumatology
Reactive arthritis belongs to the group of arthritidies known as the spondyloarthritides. There are two main types of reactive arthritis: post-venereal and post-enteric. Chlamydia trachomatis is felt to be the most common cause of reactive arthritis, in general. Until recently, even the terminology for the condition itself was unclear as multiple eponyms and names have been associated with reactive arthritis. In recent years, a great deal has been learnt about the epidemiology, pathophysiology and treatment of reactive arthritis and Chlamydia-induced reactive arthritis, specifically. Prospective epidemiologic data suggest that Chlamydia-induced reactive arthritis is underdiagnosed. Other truths being actively revealed include data suggesting that the pathogen itself (i.e., Chlamydia) might play an equally important role, or perhaps even more important, than the host with disease susceptibility; asymptomatic chlamydial infections might be a common cause of ReA and the two variants of reactive arthritis might respond differently to treatment in spite of the congruent clinical presentation. However, much about this syndrome remains shrouded in mystery. Data covered in this review suggest that Chlamydia-induced reactive arthritis might be a common condition that clinicians fail to recognise. An emphasis is placed on disease awareness since viable treatment options are emerging.
Reactive Arthritis: Clinical Aspects and Medical Management
2009, Rheumatic Disease Clinics of North America
Citation Excerpt :
A large study in Denmark comparing the different enteric pathogens known to cause ReA suggested that Salmonella was the second most common triggering infection (behind Campylobacter) and the second most arthritogenic, after Yersinia.25 There also has been one outbreak of S bovismorbificans that resulted in 12% of individuals developing ReA, of whom 45% were HLA-B27 positive.71 All four of the species of Shigella (S flexneri, S dysenteriae, S sonnei, and S boydii) can cause ReA.

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^*: This study was approved by the Ethical Committee of the National Public Health Institute, Helsinki.

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Journal of Infection

References (29)

Foodborne diseases in the 1980s and 1990s

Food Control

Salmonella in alfalfa sprouts

Lancet

Immunoepidemiology of post-Salmonella reactive arthritis in a cohort of women

Clin Immunol Immunopathol

Serological diagnosis of Salmonella infections by enzyme immunoassay

Lancet

Infection as a cause of reactive arthritis, ankylosing spondylitis, and rheumatic fever

Curr Opin Rheumatol

Followup study on patients with Reiter's disease and reactive arthritis, with special reference to HLA-B27

Arthritis Rheum

Evidence of Chlamydia trachomatis infection in sexually acquired reactive arthritis

Ann Rheum Dis

Salmonella-triggered reactive arthritis

Scand J Rheumatol

Reactive arthritis after Salmonella among medical doctors — study of an outbreak

J Rheumatol

Epidemic Reiter's syndrome following an outbreak of Shigellosis

Eur J Epidemiol

Reactive arthritis after Campylobacter jejuni enteritis

J Rheumatol

Reiter's syndrome after Campylobacter jejuni enteritis

Arthritis and Rheumatism

Ten-year followup study of patients with Yersinia arthritis

Arthritis Rheum

Reiter's syndrome in children

Cited by (69)

Factors Associated with Sequelae of Campylobacter and Non-typhoidal Salmonella Infections: A Systematic Review

Juvenile-onset spondyloarthritis

Reactive arthritis induced by intravesical BCG therapy for bladder cancer: Our clinical experience and systematic review of the literature