Reactive arthritis after Helicobacter pylori eradication

A 47-year-old man was admitted in September, 1999 for evaluation of watery diarrhoea after taking clarithromycin, amoxycillin, and lansoprazole for Helicobacter pylori infection. 2 weeks after the onset of diarrhoea he noticed pain in his right hip and, a swollen, tender, and erythematous right ankle. He complained of fever, malaise, and loss of appetite, but denied abdominal pain, ocular, urogenital, or back symptoms. There was no history of trauma, recent infection, sexually transmitted disease, tick bites, previous or family history of arthritis. On examination he was febrile (37·9°C). The right ankle was warm, red, and tender, with a tense effusion. Movement of the right hip was painful, as was palpation over the sacroiliac joints. He had no evidence of conjunctivitis, oral ulcers, rash, urethritis, or penile discharge. Laboratory tests revealed white blood cell count of 12 10/L with a left shift. Serum uric acid level was normal, but erythrocyte sedimentation rate and C-reactive protein were 103 mm/h and 34 mg/L, respectively. Urethral gram stain and culture for both gonococci and chlamydia were negative. Rheumatoid factor, antinuclear antibody, HIV, lyme titres, and blood cultures were negative. Serological tests showed no evidence of recent viral infection. Aspiration of the right ankle revealed non-purulent fluid with a leukocyte count of 15·5 10/L, mostly neutrophils. No crystals were detected under polarised light, and gram stain and culture were negative. Histocompatibility testing confirmed the presence of HLA-B27 antigen. Radiography of the right ankle, hip, lumbosacral spine, and sacroiliac joints showed no bony abnormality. Stool culture for common enteric pathogens including Salmonella, Shigella, Yersinia, and Campylobacter spp was negative. However, the specimen was positive for Clostridium difficile toxin. The patient was diagnosed with reactive arthritis associated with C difficile infection. He was treated with sulfazalazine, celecoxib and metronidazole. His diarrhoea resolved over 7 days. His arthritis persisted and required intra-articular administration of corticosteroids to his right ankle. There was slight improvement in his arthritis in the next 3 months, but he was unable to return to work. There was no evidence of development of a systemic rheumatologic disease during this time. When last seen in January, 2000 he still had moderate pain and oral steroids were added. Reactive arthritis is defined as the occurrence of an acute, aseptic, inflammatory arthropthy arising during or after an infectious process at a remote site. It usually occurs 1–2 weeks after onset of primary infection, and most patients are positive for the HLA-B27 antigen. Whereas reactive arthritis is a well known complication of enteric infections with Salmonella, Shigella, Yersinia, and Campylobacter spp, less than 25 documented cases associated with C difficile have been reported. C difficile causes a toxin-mediated enteric infection which usually follows antibiotic therapy, resulting in its unrestrained growth. C difficile causes an asymmetric migratory polyarthritis, which predominantly affect the large joints, and less commonly the wrist and fingers. Analysis of the synovial fluid usually shows neutrophilic leucocytosis with negative gram stains and cultures. Corticosteroids and non-steroidal anti-inflammatory drugs are used to treat the arthritis and are usually combined with antibiotics to treat the C difficile infection. The arthritis is usually self-limited and in most cases resolves within several weeks or months. No progression to a systemic rheumatological disease has been reported. C difficile infections are increasing because of widespread use of broad spectrum antibiotics. However, its relation with reactive joint disease is not widely recognised.