PDF(Pubmed)
Abstract：
BACKGROUND: Reactive arthritis and septic arthritis rarely present concomitantly in the same joint and patient. Reactive arthritis presenting after coronavirus disease 2019 is also exceedingly rare, with less than 30 cases reported thus far. Less common pathogens such as Clostridium difficile have been reported to cause reactive arthritis, especially in patients with a positive human leukocyte antigen B27, and therefore should be considered in diagnostic algorithms. The aim of this case report is to highlight the difficulties and precautions in discerning and diagnosing patients presenting with sudden swelling of the knee.
METHODS: We report the case of a 70-year-old Caucasian male with a recent history of coronavirus disease 2019 upper respiratory infection and diarrhea and negating trauma, who presented with a swollen and painful knee. Pain and swelling worsened and inflammatory parameters increased after an intraarticular corticosteroid injection. The patient was therefore treated with arthroscopic lavage and intravenous antibiotics for suspected septic arthritis. Synovial fluid and synovium samples were taken and sent for microbiological analysis. Synovial fluid cytology showed increased leukocytes at 10,980 × 106/L, while polymerase chain reaction and cultures came back sterile. Clostridium difficile toxin was later detected from a stool sample and the patient was treated with oral vancomycin. The patient was tested for the presence of human leukocyte antigen B27, which was positive. We present a review of the literature about the challenges of distinguishing septic from reactive arthritis, and about the mechanisms that predispose certain patients to this rheumatological disease.
CONCLUSIONS: It is still a challenge to differentiate between septic and reactive arthritis of the knee, and it is even more challenging to identify the exact cause of reactive arthritis. This case report of a human leukocyte antigen-B27-positive patient highlights the necessity of contemplating different, less common causes of a swollen knee joint as a differential diagnosis of an apparent septic infection, especially in the coronavirus disease 2019 era. Treating the patient for septic arthritis prevented any possible complications of such a condition, while treating the C. difficile infection contributed to the substantial relief of symptoms.
METHODS: We report the case of a 70-year-old Caucasian male with a recent history of coronavirus disease 2019 upper respiratory infection and diarrhea and negating trauma, who presented with a swollen and painful knee. Pain and swelling worsened and inflammatory parameters increased after an intraarticular corticosteroid injection. The patient was therefore treated with arthroscopic lavage and intravenous antibiotics for suspected septic arthritis. Synovial fluid and synovium samples were taken and sent for microbiological analysis. Synovial fluid cytology showed increased leukocytes at 10,980 × 106/L, while polymerase chain reaction and cultures came back sterile. Clostridium difficile toxin was later detected from a stool sample and the patient was treated with oral vancomycin. The patient was tested for the presence of human leukocyte antigen B27, which was positive. We present a review of the literature about the challenges of distinguishing septic from reactive arthritis, and about the mechanisms that predispose certain patients to this rheumatological disease.
CONCLUSIONS: It is still a challenge to differentiate between septic and reactive arthritis of the knee, and it is even more challenging to identify the exact cause of reactive arthritis. This case report of a human leukocyte antigen-B27-positive patient highlights the necessity of contemplating different, less common causes of a swollen knee joint as a differential diagnosis of an apparent septic infection, especially in the coronavirus disease 2019 era. Treating the patient for septic arthritis prevented any possible complications of such a condition, while treating the C. difficile infection contributed to the substantial relief of symptoms.
摘要：
背景：反应性关节炎和脓毒性关节炎很少在同一关节和患者中同时出现。2019年冠状病毒病后出现的反应性关节炎也极为罕见，到目前为止，报告的病例不到30例。据报道，不常见的病原体如艰难梭菌可引起反应性关节炎，特别是在人白细胞抗原B27阳性的患者中，因此应在诊断算法中考虑。本病例报告的目的是强调辨别和诊断膝盖突然肿胀的患者的困难和预防措施。
方法：我们报告了一名70岁的高加索男性，近期有冠状病毒疾病史，2019年上呼吸道感染和腹泻以及消除创伤，膝盖肿胀疼痛。关节内注射皮质类固醇后疼痛和肿胀恶化，炎症参数增加。因此，患者接受关节镜灌洗和静脉注射抗生素治疗，怀疑是化脓性关节炎。采集滑液和滑膜样品并送去进行微生物学分析。滑液细胞学见白细胞增多,10,980×106/L,而聚合酶链反应和培养物又无菌了。后来从粪便样品中检测到艰难梭菌毒素，患者口服万古霉素治疗。对患者进行了人类白细胞抗原B27的检测，该抗原为阳性。我们回顾了有关区分脓毒症和反应性关节炎的挑战的文献。以及某些患者易患这种风湿病的机制。
结论：区分感染性和反应性膝关节关节炎仍然是一个挑战，确定反应性关节炎的确切原因更具挑战性。这个人类白细胞抗原B27阳性患者的病例报告强调了考虑不同的必要性，作为明显的败血症感染的鉴别诊断，膝关节肿胀的少见原因。特别是在2019年冠状病毒病时代。对患者进行化脓性关节炎的治疗可预防此类疾病的任何可能的并发症，而治疗艰难梭菌感染有助于症状的实质性缓解。
方法：我们报告了一名70岁的高加索男性，近期有冠状病毒疾病史，2019年上呼吸道感染和腹泻以及消除创伤，膝盖肿胀疼痛。关节内注射皮质类固醇后疼痛和肿胀恶化，炎症参数增加。因此，患者接受关节镜灌洗和静脉注射抗生素治疗，怀疑是化脓性关节炎。采集滑液和滑膜样品并送去进行微生物学分析。滑液细胞学见白细胞增多,10,980×106/L,而聚合酶链反应和培养物又无菌了。后来从粪便样品中检测到艰难梭菌毒素，患者口服万古霉素治疗。对患者进行了人类白细胞抗原B27的检测，该抗原为阳性。我们回顾了有关区分脓毒症和反应性关节炎的挑战的文献。以及某些患者易患这种风湿病的机制。
结论：区分感染性和反应性膝关节关节炎仍然是一个挑战，确定反应性关节炎的确切原因更具挑战性。这个人类白细胞抗原B27阳性患者的病例报告强调了考虑不同的必要性，作为明显的败血症感染的鉴别诊断，膝关节肿胀的少见原因。特别是在2019年冠状病毒病时代。对患者进行化脓性关节炎的治疗可预防此类疾病的任何可能的并发症，而治疗艰难梭菌感染有助于症状的实质性缓解。
