2002 The Journal of Rheumatology 2005; 32:10 Case Report Poststreptococcal Reactive Arthritis with Thoracic Spine Involvement in an Adult ALEXANDRAALEXOPOULOU, SPYROS P. DOURAKIS, NIKOLAOS D. STAMOULIS, DIMITRIOS VASSILOPOULOS, and ATHANASIOS J. ARCHIMANDRITIS ABSTRACT. It is controversial whether poststreptococcal reactive arthritis (PSReA) is an entity separate from acute rheumatic fever (ARF) or is a forme fruste of ARF. Although there are many case series of PSReA in children, this entity is not common in adults. We describe an adult patient with poly- arthritis and thoracic spine involvement attributed to PSReA. (J Rheumatol 2005;32:2002–5) Key Indexing Terms: POSTSTREPTOCOCCAL REACTIVE ARTHRITIS THORACIC SPINE INVOLVEMENT GROUPA BETA-HEMOLYTIC STREPTOCOCCUS From the 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Athens, Greece. A. Alexopoulou, MD; S.P. Dourakis, MD, Associate Professor of Medicine; N.D. Stamoulis, MD; D. Vassilopoulos, MD, Assistant Professor of Medicine; A.J. Archimandritis, Professor of Medicine. Address reprint requests to Dr. A. Alexopoulou, 20 N. Politi St., 16346 Athens, Greece. E-mail: alexopou@ath.forthnet.gr Accepted for publication May 30, 2005. Acute rheumatic fever (ARF), poststreptococcal reactive arthritis (PSReA), erythema nodosum, erythema multi- forme, and poststreptococcal glomerulonephritis are consid- ered the nonsuppurative sequelae of group A ß-hemolytic streptococcal infections. The first case series of PSReA was described in 1982 1 . Non-group A ß-hemolytic streptococci were also considered as causative organisms of PSReA 2 . It is still debatable whether PSReA is an entity separate from ARF or is a forme fruste of ARF 3,4 . Although there are many case series of PSReA in chil- dren, this entity is not common in adults. Involvement of the thoracic spine is a very rare clinical manifestation of PSReA. We describe an adult patient with polyarthritis and thoracic spine involvement attributed to PSReA. CASE REPORT A 60-year-old woman presented with high fever, backache, and arthritis in the left knee and ankle. Pharyngitis without fever had developed one month previously. Roxithromycin and then amoxicillin-clavulanate for 10 days were prescribed. Two weeks before admission, she complained of pain in the thoracic spine and 24 hours later she developed arthritis in the left knee and ankle and fever to 39°C. Three days later, pain on mastication due to left temporomandibular joint (TMJ) involvement was added. Ketoprofen and clarithromycin were administered, without improvement. Examination revealed tenderness of the left TMJ and synovitis of the left knee and ankle joints. Severe localized tenderness at the level of lower thoracic vertebrae (T7–T8) was also noted. No cardiac murmur was found. Laboratory inves- tigations showed hemoglobin 11.3 g/dl, white blood cell count 13.5 × 10 3 /µl with normal differentiation, PLT 551 × 10 3 /µl, erythrocyte sedimen- tation rate (ESR) 130 mm, C-reactive protein (CRP) 97.3 mg/l (normal < 5 mg/l), antistreptolysin-O (ASO) 2115 IU/ml (normal < 200 IU/ml), normal complement levels, and negative Wright agglutination test, rheumatoid fac- tor and antinuclear antibody testing. One week before admission, ASO val- ues were elevated at 616 IU/ml. Her initial treatment consisted of daily naproxen 1000 mg, vancomycin 2 g, and ciprofloxacin 1200 mg. A left knee joint aspiration showed a moderately inflammatory synovial fluid (SF, 12,400 leukocytes/mm 3 , 90% neutrophils). Microscopic analysis of the SF showed no crystals. Throat swab, blood, and SF cultures were negative. Chest and joint radiographs and electrocardiography showed no abnormal- ities. Doppler ultrasound of the heart was negative for carditis. Magnetic resonance imaging (MRI) of the thoracic spine showed low signal in T1 weighted images and high signal in T2 images of the adjacent intervertebral plateaus at T7–T8 level and narrowing of the disk space (Figures 1 and 2). A 99m Tc bone scan on admission showed increased uptake at the T8 verte- bral body (Figure 3). At the 8th hospital day, arthritis of the first right metatarsophalangeal (MTP) joint was noted. Antibiotics were discontinued when the negative SF culture became available and the patient continued taking nonsteroidal antiinflammatory drugs. There was gradual improvement of her arthritic complaints and res- olution of the fever. She was discharged home afebrile with minimal pain of her left knee. Two months later, she was asymptomatic with normal ESR and CRP values, while her ASO level had dropped to near normal. Fifteen months later she is still asymptomatic with no recurrence of her arthritis. DISCUSSION Reactive arthritis is defined as a sterile inflammatory arthri- tis occurring in association with a primary infection at a dis- tant site of the body. Although there are many case series of PSReA in children there are only 2 in adults, one of 23 5 and the other of 17 cases 6 . The investigators described the clini- cal picture of PSReA and attempted to differentiate it from ARF. There are various speculations on the development of PSReA instead of ARF. Human host factors such as age and sex, differences in streptococcal virulence, or change in prevalence of certain serotypes in Western countries may be related to the variation of clinical manifestations of post- streptococcal diseases 3 . PSReA was the most likely diagnosis in our patient. The late age of onset, history of sore throat, the increase and sub- sequent gradual decrease of the ASO titer, the asymmetric polyarticular involvement, high ESR and CRP, the subacute Personal non-commercial use only. 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