Sexually Transmitted Diseases:
Reactive Arthritis Associated With Proctitis Due to Chlamydia trachomatis Serovar L2b
Pendle, Stella MSc, MBBCH, DTM&H, FRCPA*; Gowers, Andrew BHB, MBCHB, FRACGP†
From the *Department of Microbiology, Pathology NSW, Bella Vista, Sydney, Australia; and †Holdsworth House Medical Practice, Darlinghurst, Sydney, Australia
The authors thank Mala Ratnamohan at the Institute for Clinical Pathology and Medical Research, Westmead Hospital for performing the LGV sequencing.
Correspondence: Stella Pendle, MSc, MBBCH, DTM&H, FRCPA, Clinical Microbiologist, Pathology NSW, Unit 104, 14 Lexington Drive, Bella Vista NSW 2153, Australia. E-mail: email@example.com.
Received for publication June 14, 2011, and accepted September 1, 2011.
We report the first case of reactive arthritis associated with lymphogranuloma venereum (LGV) proctitis in Australia. Since 2004, LGV proctitis has emerged as an important infection worldwide in men who have sex with men. While reactive arthritis is usually associated with serovars D to K of Chlamydia trachomatis, association with LGV serovars is historically rare. Screening for chlamydial infection should be considered in this group if they present with an acute arthritis otherwise the condition could go undiagnosed. Asymptomatic infections are being increasingly reported in Europe and prolonged treatment is required to ensure a cure.
Chlamydia trachomatis is an important cause of human infections worldwide, and includes trachoma (serovars A to C), urogenital infections (serovars D to K), and lymphogranuloma venereum (LGV) serovars L1 to L3. Reactive arthritis associated with the non-LGV serovars D to K of C. trachomatis usually presents as part of a triad of symptoms including urethritis and conjunctivitis commonly known as Reiters syndrome.1 However, reactive arthritis associated with LGV serovars has only recently been reported in men who have sex with men (MSM) following an episode of proctitis.2,3 LGV proctitis emerged as a new infection in Europe in 20044 and soon spread to North America.5,6 LGV was first reported in Australia in 2007.7 We present the first case of reactive arthritis associated with LGV proctitis occurring in Australia.
A 55-year-old white man who has sex with men presented, to his general practitioner, with diarrhea in June 2010. He had been diagnosed with HIV infection in 1987 and had a long history of HIV therapy with monotherapy and sequential combination therapy. His highest recorded HIV viral load was greater than 250000 copies/mL and lowest CD4 lymphocyte count <200 cells/μL. Since 2000, he has had an undetectable viral load while taking lamivudine and boosted protease inhibitors with excellent immune reconstitution. Other regular medications include rosuvastatin, rabeprazole, valacyclovir, and allopurinol prophylaxis for gout.
One week after an episode of unprotected sex, he presented with a mucopurulent rectal discharge, pain, and diarrhea. His partner had been diagnosed with chlamydia the previous week. The clinical presentation was consistent with a diagnosis of proctitis, and he was commenced on oral doxycycline (100 mg twice daily). Polymerase chain reaction (PCR) amplification from a rectal swab was positive for C. trachomatis and negative for N. gonorrhoeae. The sample was genotyped as LGV variant L2b by sequencing of the outer membrane protein gene.8 Two weeks after the diagnosis of proctitis, he presented with acute multijoint arthritis affecting the right second finger, the right knee, and right ankle. Physical examination revealed swelling of the finger with reduced flexion and slight tenderness, swelling of the right knee with tenderness of the joint margin, and moderate swelling of the right ankle.
Laboratory investigations revealed a CD4 lymphocyte count of 800 cells/μL (32%) and HIV viral load less than 50 copies /mL. Serology for Yersinia and Salmonella was negative, while stool cultures were negative for Salmonella, Shigella, Yersinia, and Campylobacter. HLA B27 testing was positive while an immune screen for rheumatoid factor, antinuclear antibodies, and anticyclic citrullinated peptide antibodies was negative. Serum uric acid was normal and there was no evidence of acute gout. Analysis of a synovial fluid sample drained from the right knee showed a leucocytosis. A differential cell count was not obtained as the sample had clotted. No crystals were seen and culture for bacteria including Neisseria gonorrhoeae was negative. PCR of the joint fluid was negative for C. trachomatis. X-ray examinations of the 3 joints revealed no abnormalities apart from the right-knee effusion.
Repeat cultures for bacterial pathogens including N. gonorrhoeae from rectal swabs were negative. A first void urine sample was negative for both N. gonorrhoeae and C. trachomatis by PCR. The C-reactive protein continued to rise over the next 2 weeks and peaked at 222 mg/L. A diagnosis of reactive arthritis secondary to LGV infection was considered. Oral doxycycline was continued for 21 days. The proctitis settled over 2 weeks and the multijoint arthritis resolved within 3 months. Repeat rectal swabbing at this time showed no evidence of C. trachomatis by PCR or N. gonorrhoeae by culture. PCR testing of a first void urine sample was also negative for both pathogens. A month later, he presented with a right eye anterior uveitis. This was treated with prednisolone acetate eye drops and resolved. The patient remained well after 6 months of follow-up with no recurrences.
The patient presented with multijoint arthritis 2 weeks after being diagnosed with proctitis due to C. trachomatis serovar L2b. This was followed by the development of unilateral anterior uveitis that resolved without further sequelae and was only treated with steroid eye drops making another infectious etiology unlikely. An effort was made to rule out other bacterial triggers including gonococci that may cause sexually reactive arthritis either by serological tests, PCR, or culture. C. trachomatis has been demonstrated in up to 50% of patients who have had a preceding urogenital symptomatic infection and who developed reactive arthritis.1 However, the majority of patients do not present with the classic triad of symptoms and the diagnosis may easily be missed if the initial infection is asymptomatic. Asymptomatic infections with LGV serovars have been increasingly detected in Europe as the outbreak evolves9 and providers need to have a heightened awareness for this condition, particularly in HIV-infected MSM. Currently, in Australia, routine LGV typing of chlamydial infections in asymptomatic MSM has not been justified.10 However, it is very likely that more cases of LGV-associated reactive arthritis will be seen worldwide in this group. The 2 cases that have been recently reported are remarkably similar to this one and suggest that these cases of LGV-associated reactive arthritis may be a newly emerging manifestation of an old disease.
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