COMMENTARY

Joint Pain, Inflammation, and a Caribbean Vacation: A Case

Stephen A. Paget, MD

Disclosures

August 13, 2015

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My name is Dr Stephen Paget. I'm the physician-in-chief emeritus at Hospital for Special Surgery in the Division of Rheumatology.

I'd like to talk to you about a patient that I saw in the past few days. This is a 33-year-old woman who presented to me with severe joint pain and inflammation.

Let's go back a little bit. She went on a cruise to the Caribbean about 2 months ago where she goes to St Martin, St Barts, and other islands and gets a few mosquito bites there. As soon as she returns home, she develops some mild diarrhea, and then about a week later she develops severe pain in a migratory nature. The pain is so severe that she cannot get off the toilet and her husband has to lift her into the car.

She is seen by a rheumatologist who does some blood tests. She is found to be mildly anemic. Her sedimentation rate and C-reactive protein are normal. She is HLA-B27 positive. Interestingly enough, her ancestry is germane. Her father has ankylosing spondylitis and is HLA-B27 positive. Another family member has systemic lupus erythematosus and an uncle has sarcoidosis. She has negative antibodies for Chikungunya virus, which you can get in those islands and is often associated with fever, skin rash, and joint pains. She is started on prednisone 40 mg daily, with only a moderate response. She is then started on sulfasalazine because of the possibility of reactive arthritis.

When I saw her yesterday, she still had some abdominal symptoms. She had significant synovitis of her elbows, wrists, knees, ankles, and feet, with Achilles tendinitis, plantar fasciitis, and bilateral sacroiliac tenderness—right more than left—and restricted range of motion of her lumbar spine with her fingers to the mid-calf area.

So, what is going on here? Chikungunya is probably ruled out with the appropriate IgG and IgM titers. The HLA-B27 positivity, especially in the setting of a father with ankylosing spondylitis, is quite compelling. The presence of sacroiliac inflammation, as well as enthesitis, in many ways nails the diagnosis of reactive arthritis, probably due to some enteric organism. Interestingly enough, when her husband got back from the trip with her, he had severe diarrhea that lasted for 2 weeks. Her diarrhea was not as severe, but she has continued having mild diarrhea since then.

My approach is the following: First of all, she is incapacitated and I'm going to give her some mini-pulses of intravenous methylprednisolone 250 mg, just to try to calm down the inflammation and bring down the noise in the thermostat. Second, I've done a culture for Salmonella, Shigella, Yersinia, and Campylobacter species because there may be something to treat there. We usually don't treat Salmonella enteritis because it actually prolongs the carrier state, which is the last thing we want because it is the presence of the antigen that triggers the problem.

This is a woman with an interesting differential diagnosis of chikungunya vs reactive arthritis—the latter of which, I think, is the correct diagnosis. She will probably be placed on methotrexate and may even need an anti–tumor necrosis factor medication if this persists. Thank you.

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