Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Arthritis Associated with Yersinia Enterocolitica Infections Sten Winblad To cite this article: Sten Winblad (1975) Arthritis Associated with Yersinia Enterocolitica Infections, Scandinavian Journal of Infectious Diseases, 7:3, 191-195, DOI: 10.3109/ inf.1975.7.issue-3.07 To link to this article: http://dx.doi.org/10.3109/inf.1975.7.issue-3.07
Published online: 02 Jan 2015.
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Citing articles: 3 View citing articles
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Date: 07 April 2016, At: 22:21
Scand J Infect Dis 7: 191-195,1975
Arthritis Associated with Yersinia enterocolitica Infections STEN WINBLAD
Downloaded by [RMIT University Library] at 22:21 07 April 2016
From the Department of Clinical Bacteriology, University of Lund, the General Hospital, Malmo, Sweden
ABSTRACT. 74 patients, 42 females, 32 men-all over 10 years of age, witIt acute a..rthritis associated with infection with Yersinia enterocolitica are presented. The diagnosis was based on serological evidence in all cases (an agglutinin titre of 320 or m~~e), and in 18 of the cases also a positive culture of Y. ent. from faeces. The erythrocyte sedimentation rate was ¥err hig!Lin...m.llst cases. Acute enteritis, sometimes with abdominal pain, preceded the acute arthritis with a latent period of about 1-14 days. In 50 % of the cases only one or two joints were involved, most often large joints such as knee, ankle and wrist. The symptoms were long-standing (2 months or longer) in two-thirds of the cases. Arthritis in connection with yersiniosis must therefore be considered. a serions complication to an otherwise rather benign infection.
INTRODUCTION Arthritis connected with infections may be divided into two groups: septic and postinfectious. The first group includes such infections as those caused by haemolytic streptococci or Staphylococcus aureus. The postinfectious arthritis is related to infections with Neisseria gonorrhoeae, brucellae, rubella virus, urogenital infections, shigella, salmonella and haemolytic streptococci (rheumatic fever). Since the discovery in 1964 by Winblad that infections with Yersinia enterocolitica (Y. ent.) are rather common in human beings, it has subsequently also been shown that such infections may result in arthritis with different clinical localizations and symptoms. Recent intensive research on the clinical symptoms of yersiniosis in Sweden has resulted in a large body of information. Small children contract gastroenteritis and young people pseudoappendicitis, which often manifests itself as acute terminal ileitis and which is caused only by infections with Y. ent. or Y. pseudotuberculosis, In adults, cases of acute abdominal pain, acute enteritis, postinfectious arthritis or erythema nodosum will often be seen. On the other hand many cases will be mild, without serious symptoms. Postinfectious arthritis associated with Y. ent. infection was first mentioned from Finland by Ahvonen et al. (3). They described 19 cases with the diagnosis established from a screening study of ag-
glutinins in sera from patients with rheumatic symptoms. Three of those patients had antibodies in their sera against Y. ent. antigen 03, and 16 against 09. Infections with serotype 09 are more common in Finland than in Sweden. Laitinen et al. (10) have described 9 other similar cases with rheumatic symptoms from Finland. One case is described from Denmark (4), and one from France (7). A clinical report from Sweden (5) includes also cases with arthritic complications. During 1967-1972, 74 cases of arthritic complication of infections with Y. ent. were diagnosed serologically at the bacteriological laboratory in Malmo and 25 of these cases were preliminarily reported in 1973 (18). A summary of clinical and laboratory findings in all the 74 patients is now presented. An infection with Y. ent. is ordinarily not a serious infection. However, the complication of postinfectious arthritis must be considered as serious with its symptoms of long duration and disability for the patient. For this reason it is important to recognize this "new" cause of postinfectious arthritis. MATERIALS AND METHODS Patients
The diagnoses were made on the basis of specific high agglutinin titres (320 or more) against Y. ent. type 03 in sera from different patients with joint symptoms. These sera had been sent to our laboratory from various hospiScand J Infect Dis 7
192 S. Winblad
Table 1. Maximal Y. ent . agglutinin titre and positive cultures of Yersinia enterocolitica in 74 patients with arthritis Y. ent. agglutinin titre
Downloaded by [RMIT University Library] at 22:21 07 April 2016
No. of patients Pos. culture of Y. ent from faeces
320
640
1280
2560 5 120 10 240
Total
II
11
21
14
12
5
74
0
5
4
2
3
4
18
tals, mostly from southern Sweden, for estimation of antistreptolysin or antistaphylolysin titres and presence of rheumatoid factor, or for the Widal reaction, but also sometimes with special requests for agglutinins against Y. ent. Patients with agglutinin titres of 320 or more were investigated with reference to their clinical symptoms. In 74 cases joint symptoms dominated the clinical picture; these cases are summarized below regarding some clinical details. Patients with erythema nodosum or mild joint symptoms are not included in this patient material. In most of the cases attempts at cultivation of Y. ent. from faeces had been made. Antigen for the agglutinin reaction Y. ent. human type 3, strain "Winblad", was cultivated on blood agar for 48 hours at 22"Cand was controlled to be growing in the S-form. The strain was suspended in saline and autoclaved for 1 hour at 120"C, washed and resuspended in saline to a density suitable for agglutination studies. The antigen of Y. ent. was an O-antigen. Agglutination reaction Serum was inactivated for 30 min at 56°C and diluted with saline to give dilutions of 1/10 to 1/5120 in tubes. 0.25 m1 antigen was added to 0.25 ml of diluted serum. The reaction was read after 18hours in a waterbath at 52"C. A titre of 320 or more was interpreted as evidence of a recent infection. Bacterial culture Faecal samples were cultured on LSD-agar medium (8) for 2 days at 22"C. A second culture in Rappaport's broth for enrichment was also carried out. Suspect colonies were investigated by fermentation according to the method of Nilehn and examined on slides for agglutination against absorbed factor sera from hyperimmunized rabbits.
Antistreptolysin titre (AST) The AST titre was determined in betalipoid-free serum as previously described by Winblad (14). Other investigations Further laboratory results and clinical signs were taken from the hospital records. The patients were evaluated with particular regard to sex, age, prodromal infection, time between prodromal infections and joint symptoms, maximal erythrocyte sedimentation rate (ESR), AST titre, presence of rheumatoid factor, location of arthritis and duration of joint symptoms.
RESULTS Evidence of infection with Y. ent.
Agglutinins against type 03 of Y. ent. are very specific when animals are experimentally inoculated with living strains ofY. ent. Because of this as well as of the absence of a cross antigen in Y. ent. determination of the agglutinin titre is a good, available, diagnostic method. A titre of 320 or more corresponds well to actual infections. The distribution of the agglutinin titres in the patient material is shown in Table 1. Culture of Y. ent. from faeces was made in almost all cases. In 18 of the 74 cases the culture was positive. According to earlier experience the most suitable period for culturing Y. ent. from faeces is during the acute stage. Cases of arthritic complication were mostly investigated several weeks after the acute enteric infection. Neverthe-
Table II. Sex and age in 74 cases with arthritis connected with Y. ent infection Age (years)
Male Female Total
0-10
11-20
21-30
31-40
0 0 0
5 3 8
8 7 15
II
Scand J Infect Dis 7
6 17
41-50 5 6 11
51-60 4
9 13
61-70
>70
Total
4 4 8
0 2 2
32 (43.2%) 42 (56.8%) 74
Arthritis associated with Yersinia enterocolitica infections 193
Downloaded by [RMIT University Library] at 22:21 07 April 2016
Table III. Maximal ESR in cases of Y, ent. infection with arthritis
Table V. Time period between prodromal symptoms andjoint symptoms
ESR (mm/! hr)
No. of cases
Time(days)
No. of patients
0- 20 21- 40 41- 60 61- 80 81-100 >100 Total
6 10 19 14 8 16 73
1- 3 4-6 7- 9 10-12 >12 Total
9 6 10
less, positive cultures were obtained in 18 cases, proving the diagnosis of current infection with Y. ent.
Sex and age The distribution of the patients by sex and age is shown in Table II. It is worth noting that arthritic complications have not been observed in children under the age of 10. There was no special age prevalence in adults. A slight female predominance was seen, not so marked, however, as in cases ofY. ent. infection complicated with erythema nodosum (16). Erythrocyte sedimentation rate (ESR) The maximal ESR observed in the cases is shown in Table III. The ESR was most often greatly elevated, as also was the experience in erythema nodosum cases (16).
3
7 35
Unfortunately, 22 patients had not been sufficiently analysed concerning their prodromal symptoms. It is interesting to note that only 2 patients had had pharyngitis or tonsillitis before the appearance of arthritic symptoms. In both these cases the AST titre was low.
Antistreptolysin titre The AST titre had been determined in 59 of the 74 cases. In 18% there was an elevation of the AST titre (>200 antistreptolysin units), a figure comparable with that of the normal population of Sweden. The possibility of a double infection with both haemolytic streptococci and Y. ent. could not be excluded, however.
The time between prodromal symptoms and joint symptoms In 35 cases it was possible to calculate the duration of the prodromal period (Table V). Between 4-10 days was the usual period between enteric and joint symptoms.
Prodromal symptoms Enteric disturbances were the dominant symptoms in 43 of 52 cases analysed (Table IV). Some patients had only abdominal pain. One patient had appendicitis with a very slight involvement of the appendix. Seven patients denied enteric symptoms.
Type of arthritis In 12 cases, only one joint was involved (Table VI), in 25 cases 2joints, and in 26 cases? or more joints, large as well as small ones. The ankle and knee were most often involved (Table VII); in some
Table IV. Prodromal symptoms prior to or in close connection with the acute arthritis
Table VI. No. of joints involved in cases of yersiniosis enterocolitica with arthritis
Appendicitis Abdominal pain Abdominal pain withenteritis Enteritis Pharyngitis or tonsillitis Enteric symptoms denied Unknown Total 13-751959
No. of cases
I
6 16 20 2 7
22 74
Monarthritis Twojoints Threejoints Fourjoints > Fourjoints Total
12 25 10 15 12 74 Scand J Infect Dis 7
194 S. Winblad Table VII. Distribution of joints involved in 74 cases of yersiniosis enterocolitica with acute arthritis Joint Knee Foot Hand Toe Finger Shoulder Hip Elbow Sternoclavicular Mandibular
No. of cases 38
44 22 8 15 9 7 5
2 2
Downloaded by [RMIT University Library] at 22:21 07 April 2016
Other symptoms
Achilles tendonitis Conjunctivitis Urethritis Myocarditis Myositis
8 5 5 3 2
patients also the small joints of the hands and the feet. Some patients had Achilles tendon pains. Conjunctivitis, urethritis and ECG abnormalities as in myocarditis were also observed. The patients seldom suffered from muscular pain. No correlation has been found between the duration of the symptoms and the type of arthritis (one, two or several joints involved), nor between the maximal ESR and duration of the symptoms.
Prognosis The symptoms were mostly of a long duration, as is seen in Table VIII. One-third of the patients were free from symptoms after I month, in one-third the symptoms continued for 2 or 3 months, and in onethird the symptoms persisted for 4 months or longer. The antibody titre against Y. ent. antigen decreased steadily in the cases of long duration but the symptoms were persistent. Two patients had been transferred to special hospitals for chronic rheumatoid patients. However, in no case was there a development of rheumatoid serum factor. There was no possibility to predict the prognosis in the acute phase of the disease. When the knee was involved there was usually marked hydrops. Few attempts were made to cultivate Y. ent. from the synovial fluid, but all such attempts gave negative results. The antibody titres in the synovial fluids, studied in 2 of the cases, were at the same level as in the sera. Scand J Infect Dis 7
DISCUSSION Intestinal disorders may be of prominence in postinfectious arthritis. Cases of arthritis after salmonella and shigella infections are well known as also are those cases connected with chronic intestinal diseases such as colitis ulcerosa and Crohn's disease. The number of Clostridia perfringens in faeces was investigated by Olhagen and Mansson (13) who found that a great number of such bacteria may be correlated with cases of arthritis. This has also been shown experimentally in pigs by these authors. Enteric infection with Y. ent., which may be regarded as a rather common disease in Sweden, also gives acute arthritis as a complication as has been shown in the present study. It may be noted that children infected with Y. ent. do not seem to get arthritis. Infection with Y. ent. generally seems to be a non-serious condition and many times such infections are associated with only mild symptoms. Arthritis after or in direct connection with yersiniosis is, however, a serious complication. Arthritic symptoms had a duration of more than 1 month in two-thirds of the cases presented above, and more than 4 months in one-third. There were also cases with tendencies to develop chronic arthritis without the development of rheumatoid arthritic factor. The study group presented above is not intended to form the basis of a discussion on therapy. It is possible, however, that tetracycline treatment in the acute stage may be useful in preventing the arthritic complication or in shortening duration of the symptoms. As a conclusion it may be stressed that acute
Table VIII. Duration of symptoms of arthritis in cases of yersiniosis enterocolitica Duration 1week 2 weeks 3 weeks I month 2 months 3 months 4 months 5 months 6 months or longer Total
No. of cases I 8
6 10 25
19 6 25 7
6 8 21 71
Arthritis associated with Yersinia enterocolitica infections arthritis developing shortly after an acute enteric disturbance must be suspected as being caused by infection with Y. ent., and attempts must be made to confirm this diagnosis by investigating the development of antibodies and also by culturing faeces for the presence of Y. ent.
195
17. - Yersiniosis enterocolitica. Lakartidningen 70: 270, 1973. 18. - Acute joint symptoms in Yersinia enterocolitica. Scand J Rheumatol 2: 4, 1973. Address for reprints: S. Winblad, M.D., Allmiinna Sjukhuset, S-214 0/ Malmo, Sweden
Downloaded by [RMIT University Library] at 22:21 07 April 2016
REFERENCES I. Acute rheumatic fever and yersinia arthritis. Lancet 2: 1408, 1971. 2. Aho, K., Ahvonen, P., Lassus, A., Sievers, K. & Tiilikainen, A.: HL-A antigen 27 and reactive arthritis. Lancet 2: 21, 1973. 3. Ahvonen, P., Sievers, K. & Aho, K.: Arthritis associated with Yersinia enterocolitica infection. Acta Rheumatol Scand IS: 232, 1969. 4. Andersen, L. A., Andersen Bach, R. & Friis, J.: Yersinia-arthritis. Ugeskr Laeger 134:9, 1972. 5. Arvastson, B., Damgaard, K. & Winblad, S.: Clinical symptoms of infection with Yersinia enterocolitica. Scand J Infect Dis 3: 37, 1971. 6. Bergstrand, C. G. & Winblad, S.: Clinical manifestation of infection with Yersinia enterocolitica in children. Acta Paediatr Scand 63:875, 1974. 7. Bregeon, C., Renier, J. C., Fonty, P., Leduc, G. & Mollaret, H. H.: Une observation de polyarthrite severe en rapport avec une infection par Yersinia enterocolitica. Med Malad Infect 3-4: ISO, 1973. 8. Juhlin, I. & Ericson, c.: A new medium for the bacteriologic examination of stools (LSU-agar). Acta Pathol Microbiol Scand 52: 185, 1961. 9. Killander, J., Philipson, L. & Winblad, S.: Studies on non-specific antistreptolysin 0 titre. 2. Comparison of specific and non-specific antistreptolysins by gel filtration and dextran sulphate precipitation. Acta Pathol Microbiol Scand 65: 587, 1966. 10. Laitinen, 0., Tuuhea, J. & Ahvonen, P.: Polyarthritis associated with Yersinia enterocolitica infection. Ann Rheum Dis 31: 34, 1972. II. Mansson, I. & Olsson, B.: The intestinal flora in pigs. Acta Agricult Scand 11: 197, 1961. 12. Mansson, I. & Olhagen, B.: Intestinal Clostridium perfringens in rheumatoid arthritis and other connective tissue disorders. Acta Rheumatol Scand 12: 167, 1966. 13. Olhagen, B. & Mansson, I.: Intestinal Clostridium perfringens in rheumatoid arthritis and other collagen diseases. Acta Med Scand 184:395, 1968. 14. Winblad, S.: Studies on non-specific antistreptolysin titre O. I. The influence of serum-S-lipoproteins on the non-specific antistreptolysin 0 titre. Acta Pathol Microbiol Scand 66: 93, 1966. IS. Winblad, S., Nilehn, B. & Sternby, N. H.: Yersinia enterocolitica (Pasteurella X) in human enteric infections. Br Med J 2: 1363, 1966. 16. Winblad, S.: Erythema nodosum associated with infection with Yersinia enterocolitica. Scand J Infect Dis I: 11,1969. Scand J Infect Dis 7
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Arthritis Associated with Yersinia Enterocolitica Infections Sten Winblad To cite this article: Sten Winblad (1975) Arthritis Associated with Yersinia Enterocolitica Infections, Scandinavian Journal of Infectious Diseases, 7:3, 191-195, DOI: 10.3109/ inf.1975.7.issue-3.07 To link to this article: http://dx.doi.org/10.3109/inf.1975.7.issue-3.07
Published online: 02 Jan 2015.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [RMIT University Library]
Date: 07 April 2016, At: 22:21
Scand J Infect Dis 7: 191-195,1975
Arthritis Associated with Yersinia enterocolitica Infections STEN WINBLAD
Downloaded by [RMIT University Library] at 22:21 07 April 2016
From the Department of Clinical Bacteriology, University of Lund, the General Hospital, Malmo, Sweden
ABSTRACT. 74 patients, 42 females, 32 men-all over 10 years of age, witIt acute a..rthritis associated with infection with Yersinia enterocolitica are presented. The diagnosis was based on serological evidence in all cases (an agglutinin titre of 320 or m~~e), and in 18 of the cases also a positive culture of Y. ent. from faeces. The erythrocyte sedimentation rate was ¥err hig!Lin...m.llst cases. Acute enteritis, sometimes with abdominal pain, preceded the acute arthritis with a latent period of about 1-14 days. In 50 % of the cases only one or two joints were involved, most often large joints such as knee, ankle and wrist. The symptoms were long-standing (2 months or longer) in two-thirds of the cases. Arthritis in connection with yersiniosis must therefore be considered. a serions complication to an otherwise rather benign infection.
INTRODUCTION Arthritis connected with infections may be divided into two groups: septic and postinfectious. The first group includes such infections as those caused by haemolytic streptococci or Staphylococcus aureus. The postinfectious arthritis is related to infections with Neisseria gonorrhoeae, brucellae, rubella virus, urogenital infections, shigella, salmonella and haemolytic streptococci (rheumatic fever). Since the discovery in 1964 by Winblad that infections with Yersinia enterocolitica (Y. ent.) are rather common in human beings, it has subsequently also been shown that such infections may result in arthritis with different clinical localizations and symptoms. Recent intensive research on the clinical symptoms of yersiniosis in Sweden has resulted in a large body of information. Small children contract gastroenteritis and young people pseudoappendicitis, which often manifests itself as acute terminal ileitis and which is caused only by infections with Y. ent. or Y. pseudotuberculosis, In adults, cases of acute abdominal pain, acute enteritis, postinfectious arthritis or erythema nodosum will often be seen. On the other hand many cases will be mild, without serious symptoms. Postinfectious arthritis associated with Y. ent. infection was first mentioned from Finland by Ahvonen et al. (3). They described 19 cases with the diagnosis established from a screening study of ag-
glutinins in sera from patients with rheumatic symptoms. Three of those patients had antibodies in their sera against Y. ent. antigen 03, and 16 against 09. Infections with serotype 09 are more common in Finland than in Sweden. Laitinen et al. (10) have described 9 other similar cases with rheumatic symptoms from Finland. One case is described from Denmark (4), and one from France (7). A clinical report from Sweden (5) includes also cases with arthritic complications. During 1967-1972, 74 cases of arthritic complication of infections with Y. ent. were diagnosed serologically at the bacteriological laboratory in Malmo and 25 of these cases were preliminarily reported in 1973 (18). A summary of clinical and laboratory findings in all the 74 patients is now presented. An infection with Y. ent. is ordinarily not a serious infection. However, the complication of postinfectious arthritis must be considered as serious with its symptoms of long duration and disability for the patient. For this reason it is important to recognize this "new" cause of postinfectious arthritis. MATERIALS AND METHODS Patients
The diagnoses were made on the basis of specific high agglutinin titres (320 or more) against Y. ent. type 03 in sera from different patients with joint symptoms. These sera had been sent to our laboratory from various hospiScand J Infect Dis 7
192 S. Winblad
Table 1. Maximal Y. ent . agglutinin titre and positive cultures of Yersinia enterocolitica in 74 patients with arthritis Y. ent. agglutinin titre
Downloaded by [RMIT University Library] at 22:21 07 April 2016
No. of patients Pos. culture of Y. ent from faeces
320
640
1280
2560 5 120 10 240
Total
II
11
21
14
12
5
74
0
5
4
2
3
4
18
tals, mostly from southern Sweden, for estimation of antistreptolysin or antistaphylolysin titres and presence of rheumatoid factor, or for the Widal reaction, but also sometimes with special requests for agglutinins against Y. ent. Patients with agglutinin titres of 320 or more were investigated with reference to their clinical symptoms. In 74 cases joint symptoms dominated the clinical picture; these cases are summarized below regarding some clinical details. Patients with erythema nodosum or mild joint symptoms are not included in this patient material. In most of the cases attempts at cultivation of Y. ent. from faeces had been made. Antigen for the agglutinin reaction Y. ent. human type 3, strain "Winblad", was cultivated on blood agar for 48 hours at 22"Cand was controlled to be growing in the S-form. The strain was suspended in saline and autoclaved for 1 hour at 120"C, washed and resuspended in saline to a density suitable for agglutination studies. The antigen of Y. ent. was an O-antigen. Agglutination reaction Serum was inactivated for 30 min at 56°C and diluted with saline to give dilutions of 1/10 to 1/5120 in tubes. 0.25 m1 antigen was added to 0.25 ml of diluted serum. The reaction was read after 18hours in a waterbath at 52"C. A titre of 320 or more was interpreted as evidence of a recent infection. Bacterial culture Faecal samples were cultured on LSD-agar medium (8) for 2 days at 22"C. A second culture in Rappaport's broth for enrichment was also carried out. Suspect colonies were investigated by fermentation according to the method of Nilehn and examined on slides for agglutination against absorbed factor sera from hyperimmunized rabbits.
Antistreptolysin titre (AST) The AST titre was determined in betalipoid-free serum as previously described by Winblad (14). Other investigations Further laboratory results and clinical signs were taken from the hospital records. The patients were evaluated with particular regard to sex, age, prodromal infection, time between prodromal infections and joint symptoms, maximal erythrocyte sedimentation rate (ESR), AST titre, presence of rheumatoid factor, location of arthritis and duration of joint symptoms.
RESULTS Evidence of infection with Y. ent.
Agglutinins against type 03 of Y. ent. are very specific when animals are experimentally inoculated with living strains ofY. ent. Because of this as well as of the absence of a cross antigen in Y. ent. determination of the agglutinin titre is a good, available, diagnostic method. A titre of 320 or more corresponds well to actual infections. The distribution of the agglutinin titres in the patient material is shown in Table 1. Culture of Y. ent. from faeces was made in almost all cases. In 18 of the 74 cases the culture was positive. According to earlier experience the most suitable period for culturing Y. ent. from faeces is during the acute stage. Cases of arthritic complication were mostly investigated several weeks after the acute enteric infection. Neverthe-
Table II. Sex and age in 74 cases with arthritis connected with Y. ent infection Age (years)
Male Female Total
0-10
11-20
21-30
31-40
0 0 0
5 3 8
8 7 15
II
Scand J Infect Dis 7
6 17
41-50 5 6 11
51-60 4
9 13
61-70
>70
Total
4 4 8
0 2 2
32 (43.2%) 42 (56.8%) 74
Arthritis associated with Yersinia enterocolitica infections 193
Downloaded by [RMIT University Library] at 22:21 07 April 2016
Table III. Maximal ESR in cases of Y, ent. infection with arthritis
Table V. Time period between prodromal symptoms andjoint symptoms
ESR (mm/! hr)
No. of cases
Time(days)
No. of patients
0- 20 21- 40 41- 60 61- 80 81-100 >100 Total
6 10 19 14 8 16 73
1- 3 4-6 7- 9 10-12 >12 Total
9 6 10
less, positive cultures were obtained in 18 cases, proving the diagnosis of current infection with Y. ent.
Sex and age The distribution of the patients by sex and age is shown in Table II. It is worth noting that arthritic complications have not been observed in children under the age of 10. There was no special age prevalence in adults. A slight female predominance was seen, not so marked, however, as in cases ofY. ent. infection complicated with erythema nodosum (16). Erythrocyte sedimentation rate (ESR) The maximal ESR observed in the cases is shown in Table III. The ESR was most often greatly elevated, as also was the experience in erythema nodosum cases (16).
3
7 35
Unfortunately, 22 patients had not been sufficiently analysed concerning their prodromal symptoms. It is interesting to note that only 2 patients had had pharyngitis or tonsillitis before the appearance of arthritic symptoms. In both these cases the AST titre was low.
Antistreptolysin titre The AST titre had been determined in 59 of the 74 cases. In 18% there was an elevation of the AST titre (>200 antistreptolysin units), a figure comparable with that of the normal population of Sweden. The possibility of a double infection with both haemolytic streptococci and Y. ent. could not be excluded, however.
The time between prodromal symptoms and joint symptoms In 35 cases it was possible to calculate the duration of the prodromal period (Table V). Between 4-10 days was the usual period between enteric and joint symptoms.
Prodromal symptoms Enteric disturbances were the dominant symptoms in 43 of 52 cases analysed (Table IV). Some patients had only abdominal pain. One patient had appendicitis with a very slight involvement of the appendix. Seven patients denied enteric symptoms.
Type of arthritis In 12 cases, only one joint was involved (Table VI), in 25 cases 2joints, and in 26 cases? or more joints, large as well as small ones. The ankle and knee were most often involved (Table VII); in some
Table IV. Prodromal symptoms prior to or in close connection with the acute arthritis
Table VI. No. of joints involved in cases of yersiniosis enterocolitica with arthritis
Appendicitis Abdominal pain Abdominal pain withenteritis Enteritis Pharyngitis or tonsillitis Enteric symptoms denied Unknown Total 13-751959
No. of cases
I
6 16 20 2 7
22 74
Monarthritis Twojoints Threejoints Fourjoints > Fourjoints Total
12 25 10 15 12 74 Scand J Infect Dis 7
194 S. Winblad Table VII. Distribution of joints involved in 74 cases of yersiniosis enterocolitica with acute arthritis Joint Knee Foot Hand Toe Finger Shoulder Hip Elbow Sternoclavicular Mandibular
No. of cases 38
44 22 8 15 9 7 5
2 2
Downloaded by [RMIT University Library] at 22:21 07 April 2016
Other symptoms
Achilles tendonitis Conjunctivitis Urethritis Myocarditis Myositis
8 5 5 3 2
patients also the small joints of the hands and the feet. Some patients had Achilles tendon pains. Conjunctivitis, urethritis and ECG abnormalities as in myocarditis were also observed. The patients seldom suffered from muscular pain. No correlation has been found between the duration of the symptoms and the type of arthritis (one, two or several joints involved), nor between the maximal ESR and duration of the symptoms.
Prognosis The symptoms were mostly of a long duration, as is seen in Table VIII. One-third of the patients were free from symptoms after I month, in one-third the symptoms continued for 2 or 3 months, and in onethird the symptoms persisted for 4 months or longer. The antibody titre against Y. ent. antigen decreased steadily in the cases of long duration but the symptoms were persistent. Two patients had been transferred to special hospitals for chronic rheumatoid patients. However, in no case was there a development of rheumatoid serum factor. There was no possibility to predict the prognosis in the acute phase of the disease. When the knee was involved there was usually marked hydrops. Few attempts were made to cultivate Y. ent. from the synovial fluid, but all such attempts gave negative results. The antibody titres in the synovial fluids, studied in 2 of the cases, were at the same level as in the sera. Scand J Infect Dis 7
DISCUSSION Intestinal disorders may be of prominence in postinfectious arthritis. Cases of arthritis after salmonella and shigella infections are well known as also are those cases connected with chronic intestinal diseases such as colitis ulcerosa and Crohn's disease. The number of Clostridia perfringens in faeces was investigated by Olhagen and Mansson (13) who found that a great number of such bacteria may be correlated with cases of arthritis. This has also been shown experimentally in pigs by these authors. Enteric infection with Y. ent., which may be regarded as a rather common disease in Sweden, also gives acute arthritis as a complication as has been shown in the present study. It may be noted that children infected with Y. ent. do not seem to get arthritis. Infection with Y. ent. generally seems to be a non-serious condition and many times such infections are associated with only mild symptoms. Arthritis after or in direct connection with yersiniosis is, however, a serious complication. Arthritic symptoms had a duration of more than 1 month in two-thirds of the cases presented above, and more than 4 months in one-third. There were also cases with tendencies to develop chronic arthritis without the development of rheumatoid arthritic factor. The study group presented above is not intended to form the basis of a discussion on therapy. It is possible, however, that tetracycline treatment in the acute stage may be useful in preventing the arthritic complication or in shortening duration of the symptoms. As a conclusion it may be stressed that acute
Table VIII. Duration of symptoms of arthritis in cases of yersiniosis enterocolitica Duration 1week 2 weeks 3 weeks I month 2 months 3 months 4 months 5 months 6 months or longer Total
No. of cases I 8
6 10 25
19 6 25 7
6 8 21 71
Arthritis associated with Yersinia enterocolitica infections arthritis developing shortly after an acute enteric disturbance must be suspected as being caused by infection with Y. ent., and attempts must be made to confirm this diagnosis by investigating the development of antibodies and also by culturing faeces for the presence of Y. ent.
195
17. - Yersiniosis enterocolitica. Lakartidningen 70: 270, 1973. 18. - Acute joint symptoms in Yersinia enterocolitica. Scand J Rheumatol 2: 4, 1973. Address for reprints: S. Winblad, M.D., Allmiinna Sjukhuset, S-214 0/ Malmo, Sweden
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