Articles, Issue 2/2024

Reactive Arthritis a Rare Manifestation of Clostridioides Difficile Infection, contributed by one Case

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K. Lisichki, V. Gabrovska, V. Kenderova

Abstract

Reactive arthritis is an aseptic acute inflammatory arthritis that occurs after an infection outside the joint. It most often develops after intestinal infections caused by Salmonella, Shigella, Yersinia, Campylobacter, rarely after Clostridioides (Clostridium) difficile colitis. Only 7 cases of Clostridioides difficile reactive arthritis (CDRkA) in childhood have been described in the literature to date. An immune system response develops to CD antigens that cross the intestinal mucosa and enter the bloodstream. The interleukin-23/interleukin-17 axis is activated with stimulation of B-lymphocytes and production of antibodies. The role of the HLA – B27 antigen is unclear, as unlike the other categories of reactive arthritis, here over 40% of patients are HLA – B27 negative. Asymmetric oligoarthritis is observed mainly in the lower limbs 1-2 weeks after the gastrointestinal symptoms. It can be of a migratory or cumulative type and lasts an average of 1 to 4 weeks. The main extra-articular manifestations are fever and skin rashes of various characteristics, including urticaria. Laboratory tests usually reveal normal or increased acute phase reactants, negative antinuclear antibodies, and rheumatoid factors. Diagnosis is based on diagnostic criteria requiring the presence of sterile inflammatory arthritis developing in the course of and/or preceded by diarrhea/colitis, combined with prior antibiotic treatment, detection of CD or its toxins in the stool, and absence of an alternative explanation. Treatment is carried out with metronidazole, vancomycin and non-steroidal anti-inflammatory drugs, the prognosis is good. We present a clinical case of a 5-year-old girl with normal premorbid history, who was treated twice with antibiotic therapy ( augmentin and ximebac) for a period of 40 days due to infection with vomiting and after that acute tonsillitis. On the 5th day after stopping the second course of antibiotic treatment she developed fever, diarrheal stools and an itchy, urticaria-like rash and was medicated with methylprednisolone one dose and probiotics. Routine microbiological tests for pathogenic intestinal flora were negative. Two days later, on the seventh day since the onset of diarrhea, the child had a low-grade fever, an urticarial rash on the face and back, and severe pain in the left knee and hip joints with impaired gait. Moderately elevated acute-phase reactants were found and treatment was started with voltaren and augmentin (three doses), which after receiving a positive CD result from the stool (screening and toxin A and B) was changed to metronidazole. In the next 48 hours, migrating arthritis appeared, successively affecting the right knee and both wrist joints. After a 10-day hospital treatment, the joint syndrome was negated and the indicators of inflammation normalized, CD was not detected in the feces on further tests. In the next 2 months, the child had no complaints.

Key words: reactive arthritis, Clostridioides (Clostridium) difficile colitis, childhood

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Address for correspondence

Pediatric clinic, Acibadem City Clinic Tokuda Hospital

51 B, “Nikola Vaptsarov”, Blvd.

1407, Sofia

Bulgaria

e-mail: kalinlisichki@abv.bg