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Home , Reactive arthritis

Reactive Caused by Clostridioides difficile Enterocolitis Morris Kim, MD1; Brandon Mauldin, MD, MHS2 1Department of Medicine, Oregon Health & Science University, Portland, OR 2Department of Medicine, Tulane University, New Orleans, LA

Introduction DiagnosticHospital Workup Course Discussion

• Reactive arthritis is an inflammatory • Treated with metronidazole for C. difficile and possible This case illustrates the importance of arthritis that develops in response to an Day 1 septic joint including reactive arthritis due to C. difficile in a different part of the body. in the differential diagnosis for a patient with • New onset and swelling of right elbow otherwise unexplained acute inflammatory • Though most commonly associated with Day 3 caused by , arthritis in the setting of recent use , Shigella, Campylobacter, and and diarrhea. C. difficile reactive arthritis is • New onset pain and swelling of left elbow, wrist, and , a small number of reports have Day 4 often polyarticular and not related to the shown association with Clostridioides patient’s underlying HLA-B27 status.1 The difficile. • Right knee and ankle pain improving most commonly affected joints are the knee Day 7 and wrist.1 Though uncommon, multiple Case Description cases of reactive arthritis due to C. difficile • Complete resolution of right knee and ankle pain infection have been reported. Day 8

• 40-year-old man with a history of The hypothesized pathogenesis of reactive presented to the ED with swelling and pain • Right elbow pain improving in his right knee and ankle. Day 9 arthritis due to C. difficile is considered to be • an immunological response in joints to Earlier that day, he presented to the ED with • Discharged: diarrhea significantly improved; remaining joint five days of diarrhea and abdominal pain bacterial antigens which gain access into the Day 11 pain improving bloodstream via increased intestinal and was diagnosed with Clostridioides 2 difficile enterocolitis by stool PCR. permeability. • Patient receive pain management and metronidazole throughout admission • He was discharged on metronidazole only to • NSAIDs were not given due to a reported Early diagnosis and management focusing on return to the ED with sudden onset of right • were not given due to concern for exacerbating enterocolitis knee and ankle swelling and pain. He was eradication of C. difficile in addition to admitted to the hospital a month ago for supportive therapy can reduce unnecessary suspected cellulitis over his right knee and hospital work-up and improve patient Yellow/hazy, 17,905 WBCs, 93% PMNs, no crystals or was treated with clindamycin. His joint pain outcomes. organisms, no growth on culture felt different from past gout episodes. • On physical exam, the patient was febrile Infectious workup and tachycardic with erythematous, warm, Teaching Points and swollen right knee and ankle, which RPR Non-reactive were exquisitely tender to palpation. HIV Negative • Internists should consider the diagnosis of Parvo-B19 Negative reactive arthritis in patients with acute Chlamydia Negative Notable Initial Labs in the setting of C. Hepatitis A/B/C Negative difficile infection N. gonorrhoeae Negative • Reactive arthritis due to C. difficile can CBC/BMP Elevated WBC occur in patients who are HLA-B27 Rheumatologic workup negative C-reactive protein Elevated Anti-streptolysin O Within normal limits Urinalysis Negative References Rheumatoid factor Within normal limits 1. Jacobs A, Barnard K, Fishel R, Gradon JD. Extracolonic manifestations of Clostridium difficile infections. Imaging anti-CCP antibody Within normal limits Presentation of 2 cases and review of the literature. Medicine (Baltimore).2001;80:88-101. X-rays of right knee and ankle ANA Within normal limits 2. Putterman C, Rubinow A. Reactive arthritis associated Soft tissue swelling; no fractures HLA-B27 Negative with Clostridium difficile pseudomembranous colitis. Semin Arthritis Rheum. 1993;22:420-426.