Post COVID-19 Reactive Arthritis: an Emerging Existence in the Spectrum of Musculoskeletal Next 10 Days

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Mukarram IG, et al. J Clin Stud Med Case Rep 2020, 7: 101 DOI: 10.24966/CSMC-8801/100101 HSOA Journal of Clinical Studies and Medical Case Reports

Case Report

patient [1]. It usually takes 1-4 weeks for ReA (Reactive arthritis) Post COVID-19 Reactive to occur after an infection [2]. ReA is triggered by an extra-articular infection not present in the synovial fluid of the joint [1]. It occurs Arthritis: An Emerging classically secondary to sexually transmitted or gastro intestinal infections. Common causative agents are Chlamydia Trichomatis, Shi- Existence in the Spectrum of gella, Salmonella, Yersinia and Compylobacter species [3]. However, other viral infections may also cause ReA. A case of clinical ReA Musculoskeletal Complications occurring after HIV infection was reported by Kishimoto, et al. in 2006 [4]. A syndrome consistent with ReA has also been reported of SARS-CoV-2 Infection with Dengue, Chickungunya and Parvo virus B19 [5]. Case Presentation Muhammad Ishaq Ghauri, Muhammad Shariq Mukarram*, Khiz- ra Ishaq and Syeda Urooj Riaz A 34 year old male patient with no prior known co-morbid or sig- Department of Medicine, Jinnah Medical College Hospital, Karachi, Pakistan nificant past medical history presented to the outpatient department with complaints of low grade fever, dry cough, and severe fatigue/ lethargy, loss of appetite and taste sensation for last 6 days. Although Abstract there was no travelling history, he recently had a direct contact with a COVID-19 patient. At presentation his temperature was 100F, heart Reactive arthritis is commonly preceded by a gastrointestinal or a rate was 95bpm, blood pressure 100/60mmhg, and respiratory rate of sexually transmitted infection. However, its association with different 20bpm. His oxygen saturation at room air was 96%. Physical exam- viral infections has also been reported. Herein, we report a case of a ination including chest examination was unremarkable. 34 year old male who developed Reactive arthritis few days after the severe acute respiratory Syndrome Corona Virus 2 infection (SARS- Laboratory investigations showed a TLC count of 4.2x109/L, lym- CoV-2). The patient was positive for COVID-19 infection from naso- phocytes 12x109/L, platelets 205x109/L. His C-reactive protein, D-di- pharyngeal swab specimen. He was advised self-isolation/quaran- mer and serum Ferritin levels were 20mg/l, 0.5mcg/ml and 750ng/ml tine, considering his mild form of disease, along with medication. Ten respectively. Nasopharyngeal swab for COVID-19 PCR turned out to days later he developed severe pain and tenderness in his right knee be positive. Three days later antibody (IgM) for COVID-19 was also joint. His MRI of the affected joint revealed mild effusion (secondary tested which turned out to be positive. Patient was discharged on Azi- to inflammation) in the patella-femoral compartment. Patient was diagnosed with Reactive arthritis and was prescribed Non-Steroidal thromycin (for 5 days), zinc and multivitamins. Patient was advised Anti-Inflammatory Drugs (NSAIDs). Intra articular glucocorticoid was self-quarantine/isolation for 14 days. injected, to which he responded dramatically. His symptoms com- Ten days later, patient returned with swelling, severe pain and pletely resolved in next ten days. tenderness in his right knee which was more marked in the morn- Keywords: COVID-19; Reactive arthritis; Viral infections ing (Figure 1). There was no history of urinary complaints, visual disturbances or loose stool. At the same time he had elevated levels of C-reactive protein and serum Ferritin. Plain radiograph (X-Ray) Introduction of the joint was unremarkable (Figure 2). However, the MRI of the Reactive arthritis belongs to a group of diseases called Spondy- affected joint revealed mild effusion especially in patella-femoral compartment which extended to the supra-patellar region (Figure 3). loarthropathies typically causing monoarthritis or oligoarthritis that There was also associated pre-patellar soft tissue swelling with subcu- usually involves the lower limbs (ankles and knees) as seen in our taneous edema and blurring of myofascial planes. Because of typical findings and clinical presentation patient was diagnosed with Reac- *Corresponding author: Muhammad Shariq Mukarram, Department of Medi- cine, Jinnah Medical College Hospital, Karachi, Pakistan, Email: shariq.msm@ tive arthritis secondary to COVID-19 infection. Patient was treated gmail.com with Non-steroidal anti-inflammatory drugs and intra articular steroid was injected. His symptoms of arthritis resolved completely within Citation: Mukarram IG, Mukarram MS, Ishaq K, Riaz SU (2020) Post COVID-19 Reactive Arthritis: An Emerging Existence in the Spectrum of Musculoskeletal next 10 days. Complications of SARS-CoV-2 Infection. J Clin Stud Med Case Rep 7: 101. Discussion Received: December 10, 2020; Accepted: December 15, 2020; Published: December 22, 2020 ReA commonly occurs in men aged between 20 to 50 years, as also evident in our case. A 30-50% patients have associated HLA-B27 Copyright: © 2020 Mukarram IG, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits un- [6-7]. The disease is five times more prevalent than general popula- restricted use, distribution, and reproduction in any medium, provided the original tion in patients who are HLA-B27 positive [8-9]. However, it can also author and source are credited. occur in patients who are negative for HLA-B27. Citation: Mukarram IG, Mukarram MS, Ishaq K, Riaz SU (2020) Post COVID-19 Reactive Arthritis: An Emerging Existence in the Spectrum of Musculoskeletal Complications of SARS-CoV-2 Infection. J Clin Stud Med Case Rep 7: 101.

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50’s who was admitted for COVID pneumonia. Three weeks later he developed acute bilateral arthritis in his ankles along with mild enthesitis in Right Achilles tendon [5,13]. Management of acute Reactive arthritis involves the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) as first line therapy. It has proven efficacy in treatment of peripheral arthritis occurring due to ReA [14-16]. Treatment with glucocorticoids is considered in patients who have inadequate response to NSAIDs or persistent ac- FFigure 1: A) Images of arthritis in the right knee; B) Images of affected joint tive disease for more than 4 weeks. In case of mono or oligoarthritis, after NSAID treatment and Glucocorticoid infiltration. steroid infiltration has a remarkable symptomatic response as seen in our case [17-19]. Conclusion COVID-19 infection is now presumed to target the musculoskeletal system in its post infectious stage, especially the joints, causing acute Reactive arthritis. Therefore the treating physician or rheuma- tologist should have a high index of suspicion while treating any post infectious COVID-19 patient who presents with joint pain or arthral- gia.

References

1. Selmi C, Gershwin ME (2014) Diagnosis and classification of reactive arthritis. Autoimmune Rev 2014; 13: 546-549. Figure 2: Plain radiograph (X-Ray) of the affected joint which is unremarkable. 2. Toivanen A, Toivanen P (2014) Reactive arthritis. Best pract Res Clin Rheumatol 18: 689-703.

3. Leirisalo M, Skylv G, Kousa M, Voipio-Pulkki LM, Suoranta H, et al. (1982) Followup study on patients with Reiter’s disease and reactive arthritis, with special reference to HLA-B27 Arthritis Rheum 25: 249-259.

4. Kishimoto M, Mur A, Abeles AM, Solomon G, Pillinger MH, et al. (2006) Syphilis mimicking Reiter’s syndrome in an HIV positive patient. AmJ Med Sci 332: 90-92.

5. Ono K, Kishimoto M, Shinasaki T, et al (2020) Reactive arthritis, after COVID -19 infection. RMD Open 6: 001350.

6. Hannu T (2011) Reactive arthritis. Best Pract Res Clin Rheumatol 25: 347- 357.

7. Carter JD, Hudson AP (2009) Reactive arthritis: Clinical aspects and medical management. Rheum Dis Clin North Am 35: 21-44.

Figure 3: MRI of the affected joint showing mild effusion in the patella-fem- 8. Colmegna I, Cuchacovich R, Espinoza LR (2004) HLA-B27-associated oral compartment extending to the supra-patellar region. A) MRI T1 weighted reactive arthritis: pathogenetic and clinical considerations. Clin Microbial image; B) MRI T2 weighted image. Rev 17: 348-369. 9. Feltkamp TE (1995) Factors involved in pathogenesis of HLA B27 associated arthritis. Scand J Rheumatol Suppl 101: 213-217. COVID-19 infection is now known to cause a host of complications that are extra pulmonary. This includes cardiovascular, neurologic 10. Wang L, Wang Y, Ye D, Liu Q, et al. (2020) Review of the 2019 novel and skin manifestations [10]. The gastrointestinal tract may serve as coronavirus (SARS-CoV-2) based on current evidence. Int J Antimicrob Agents 55: 105948. a secondary site for COVID-19 infection in relation to the expression of the Angiotensin converting enzyme-2 in the gastrointestinal tract 11. Gheblawi M, Wang K, Viveiros A, et al. (2020) Angiotensin-converting [11]. Nearly 12% of COVID-19 patients reported gastrointestinal enzyme 2: SARS-CoV-2 receptor and regulator of the renin angiotensin symptoms [12]. system. Circ Res 126: 1457-1475. 12. Parasa S, Desai M, Thoguluva C, Patel HK, Kennedy KF, et al. (2020) Very recently two cases of ReA occurring secondary to COVID-19 Prevalence of gastrointestinal symptoms and fecal viral shedding in pa- infection were reported. The first case was a 73 year old man with tients with coronavirus disease 2019. JAMA Network Open 3: 2011335. multiple co morbid conditions who was test (PCR) positive for COVID-19. Eight days after completing the treatment he developed 13. Saricaoglu EM, Hasanoglu I, Guner R (2020) The first reactive arthritis case associated with COVID-19. J Med Viral Pg no: 1-2. ReA in his left first metatarsophalyngeal, proximal and distal interphalyngeal joints. The second case was also an old male in his 14. Douados M, Baeten D (2011) Spondyloarthritis. Lancet 37: 2127-2137.

Volume 7 • Issue 4 • 100101 J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal DOI: 10.24966/CSMC-8801/100101 Citation: Mukarram IG, Mukarram MS, Ishaq K, Riaz SU (2020) Post COVID-19 Reactive Arthritis: An Emerging Existence in the Spectrum of Musculoskeletal Complications of SARS-CoV-2 Infection. J Clin Stud Med Case Rep 7: 101.

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15. Koehler L, Kuipers JG, Zeidler H (2000) Managing seronegative spondar- 18. Lassus A (1976) A comparative pilot study of azapropazone and indometh- thritides. Rheumatology 39: 360-368. acin in the treatment of psoriatic arthritis and Reiter’s disease. Curr Med Res Opin 4: 65-69. 16. Reveille JD, Arnett C (2005) Spondyloarthritis: Update on pathogenesis and management. Am J Med 118: 592-603. 19. Palazzi C, Oliveri I, D’amico E, Penese E, Petricca A (2004) Management of reactive arthritis. Expert Opin Pharmacother 5: 61-70. 17. Toivanen A (2000) Managing reactive arthritis. Rheumatology 39: 117- 119.

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