Clostridium difficile: an under-recognized cause of reactive arthritis?

Abstract

Reactive arthritis usually presents as a sterile, inflammatory, asymmetric oligoarthritis, affecting large lower extremity joints. Extra-articular features (conjunctivitis, uveitis, enthesopathy, urethritis, balanitis, keratoderma blenorrhagicum) may occur. Common causes of enteric reactive arthritis are preceding infections attributable to Salmonella, Shigella, Campylobacter, and Yersinia. In contrast, Clostridium difficile is an uncommon cause of reactive arthritis, with only approximately 40 reported cases. We describe a patient with an intense additive, asymmetric oligoarthritis after an antecedent C. difficile infection. The potential contribution of C. difficile to more insidious cases of undifferentiated oligoarthritis is discussed, with emphasis on corresponding therapeutic interventions.

Clostridium difficile ribotype 078 cultured from post-surgical non-healing wound in a patient carrying ribotype 014 in the intestinal tract

“…In a recent review encompassing 59 patients with extra-intestinal C. difficile infection (CDI) (Bedimo and Weinsten 2003), three major forms of clinical manifestation were described: bacteraemia with or without focal infection (Bedimo and Weinsten 2003;Feldman et al 1995;Libby and Bearman 2009;Lee et al 2010;Gerard et al 1989;Hemminger et al 2011;Choi et al 2013), intra-abdominal infection, and extraabdominal abscesses (Bedimo and Weinsten 2003), such as a splenic abscess (Stieglbauer et al 1995;Studemeister et al 1987;Saginur et al 1983) and a brain abscess (Gravisse et al 2003). C. difficile has also been associated with reactive arthritis (Loffler et al 2004;Birnbaum et al 2008;Prati et al 2010), osteomyelitis (Al-Najjar et al 2013;Pron et al 1995;Riley and Karthigasu 1982), and prosthetic shoulder and knee joint infection (Pron et al 1995;Ranganath and Midturi 2013;McCarthy and Stingemore 1999). Necrotizing fasciitis (Bhargava et al 2000;Duburcq et al 2013) and posttraumatic wound infections with C. difficile have been reported in two case reports (Deptula et al 2009;Urbán et al 2010).…”

Invading beyond bounds: extraintestinalClostridium difficileinfection leading to pancreatic and liver abscesses

“…Our patient did not receive local instillation of antimicrobials and was different from these prior reported cases due to polymicrobial growth from abscess fluid. Ulger et al reported another case of liver abscess in a 80-year-old, non-hospitalised woman who had no reported diarrhoea or antibiotic use prior to diagnosis of multiple liver abscesses due to the organism 32. Though our patient had the well-known risk factors of recent hospitalisation and antibiotic use prior to the extraintestinal manifestations, increased reporting of abscesses due to the organism in the absence of diarrhoea is a concerning finding and may be a sign of emergence of new toxigenic strains in the asymptomatic carriers.…”

Clostridium difficile infection: clinical spectrum and approach to management

“…Boice [31] reported a case of C. difficile-associated reactive arthritis in a 66-year old man treated with oral penicillin for tooth abscess. C. difficile-related oligoarticular and polyarticular arthritis may involve knee and wrist joints in about 50% of cases [32]. Arthritis begins at an average of 11.3 days after the onset of diarrhea and resolves over a period of average 68 days [33].…”