Reactive arthritis May develop in patients with HIV infection
BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6939.1302 (Published 14 May 1994) Cite this as: BMJ 1994;308:1302
- S J Winceslaus
- Department of Genitourinary Medicine, Maidstone General Hospital, Kent ME20 7NJ.
- Helsinki University Central Hospital, IV Department of Medicine, Division of Rheumatology, Unioninkatu 38, FIN-00170 Helsinki 17, Finland.
EDITOR, - B Svenungsson's editorial on reactive arthritis fails to draw attention to the fact that the disease may develop in patients with HIV infection and AIDS.1 Arthritis in patients infected with HIV is usually septic and caused by a variety of secondary pathogens, although bacterial septic arthritis is more commonly encountered.2 Reactive arthritis has also been described in AIDS, with HIV being isolated from the synovial fluid.3 Patients infected with HIV are more prone to acquire several sexually transmitted infections or even enteric infections, some of which could potentially evoke a reactive arthritis. In case of reactive arthritis clinicians need to be aware of the possibility of HIV infection as this may have implications not only in the management of the arthritis but also for staff handling specimens from these patients.
Another debatable issue is the use of intrarticular steroids to treat sexually acquired reactive arthritis. Since the detection of chlamydial elementary bodies in material from the affected joints in patients with sexually acquired reactive arthritis was reported4, many clinicians have become wary of using intra-articular steroids to treat this condition for fear of exacerbating the infection, even though the reported inclusions may not have represented live chlamydia. The implications may be even more severe in HIV infected patients with reactive arthritis. With early, adequate antibiotic treatment for the triggering infection, use of non- steroidal anti-inflammatory drugs, and resting of the affected joints in the acute phase with subsequent mobilisation and physiotherapy, most patients with sexually acquired reactive arthritis cope well without recourse to intra-articular steroids. Although the implications are not clear, the chronic destruction of the joints that was seen in some patients with sexually acquired reactive arthritis decades ago is now fairly rare. One important aspect of management is advice about future avoidance of the triggering infection. In addition to contact tracing and treatment of partners, adequate counselling is mandatory.
Consider combination treatment
- A Lauhio
- Department of Genitourinary Medicine, Maidstone General Hospital, Kent ME20 7NJ.
- Helsinki University Central Hospital, IV Department of Medicine, Division of Rheumatology, Unioninkatu 38, FIN-00170 Helsinki 17, Finland.
EDITOR, - B Svenungsson's editorial on the treatment of reactive arthritis1 drew attention to the important fact that large prospective studies are needed to establish the best treatment, as advocated previously.2
In a double blind, placebo controlled study of three months' treatment with lymecycline we found that the combination of lymecycline with a non- steroidal anti-inflammatory drug shortened the duration of reactive arthritis triggered by Chlamydia trachomatis, which suggests that C trachomatis may persist as prolonged or chronic infection.2 In addition, of the 40 patients with reactive arthritis (not only those with chlamydia arthritis), eight patients in the placebo group and two in the lymecycline group had radiological changes (P=0.028 by Fisher's exact test).2 The table shows the clinical characteristics of the 10 patients. Because the x ray pictures were not taken during the course of the disease according to standard protocol, the finding is only preliminary and needs to be confirmed by standard methods and in more patients. **table without heading 2**
Clinical characteristics of 10 patients with reactive arthritis and with radiologically determined tissue destruction
Our recent results suggest that the possible anti-inflammatory and anticollagenolytic potential of long term treatment with tetracycline or doxycycline in combination with a non-steroidal anti-inflammatory drug is not restricted only to postvenereal arthritis*RF 2-5* as described by Svenungsson. I agree with Svenungsson that prospective case-control studies in patients with well defined disease are needed before antibiotic treatment for reactive arthritis can be firmly recommended. I suggest that the anti-inflammatory and anticollagenolytic aspects of combined treatment with tetracycline and doxycycline with a non-steroidal anti- inflammatory and their possible role in tissue destruction and radiological changes also be taken into account when large, possibly multicentre, studies on treating reactive arthritis are being planned.