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a 19-year-old male from Morocco&#44; who had a personal history of alopecia areata and pitytriasis versicolor&#44; came to the emergency department on 13 December 2020 reporting additive polyarthralgias&#44; which had started in the left knee two months earlier and were later added to the right knee&#44; ankles and wrists&#46; They were of an inflammatory nature with functional impotence and a feeling of stiffness that improved with mobilisation&#44; but persisted throughout the day&#46; The pain interrupted sleep&#46; In addition&#44; he reported a weight loss of about 10&#8239;kg&#44; with initial hyporexia&#44; which had resolved at the time of the first consultation&#46; Fever of up to 38&#8239;C&#44; predominantly in the evening&#44; which lasted 15 days at the onset&#46; He presented with a rash on his back&#44; already assessed by the Dermatology Department of the Hospital Universitario Virgen de las Nieves &#40;HUVN&#41; &#40;compatible with pityriasis rosea Gibert&#41;&#44; which appeared after symptoms compatible with COVID-19 &#40;nausea&#44; vomiting&#44; arthromyalgia and headache&#44; without associated respiratory symptoms&#41;&#46; Maxillary pain on chewing and difficulty opening the jaw&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the rest of the anamnesis by systems and apparatus&#58; dry cough predominantly at night&#44; no haemoptysis&#46; No chest or abdominal pain&#46; No diarrhoeal stools&#46; No dysphagia&#46; No dysuria&#46; No oral or genital aphthae&#44; no signs of uveitis&#44; no difficulty with mobility of the shoulder girdle or pelvis&#44; nor with flexion of the dorsal spine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Epidemiologically&#58; Denied foreign travel&#46; No consumption of toxic substances&#46; No risky sexual relations&#46; He has had a cat since February 2021&#46; He is originally from a rural area where there are ca-prino cattle&#44; but his family does not own or consume unprocessed dairy products&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On examination&#44; the vitals were stable&#44; with BP 115&#47;73&#8239;mmHg&#44; HR 94 bpm&#44; temperature 37&#46;1&#8239;C&#44; SaO2 96&#37; with FiO2 of 21&#37;&#46; Diuresis not quantified in the ED&#44; but maintained&#44; according to the patient&#46; Cardiorespiratory auscultation&#58; pure rhythmic tones&#44; with slightly elevated frequency&#44; without tachycardia&#46; Bilateral vesicular murmur was preserved&#44; with no extra sounds&#46; The abdomen was soft&#44; depressible&#44; with no palpable masses or megaliths&#46; There were no signs of peritonism and the hydro-aerial sounds were preserved and not increased&#46; At ENT level and in the head and neck&#44; the pharynx was non-erythematous&#44; with no alterations of interest&#46; There were no cervical&#44; retroauricular&#44; supraclavicular or axillary lymphadenopathies&#46; No palpable goitre&#46; There were no focal or neurological alterations&#46; No oedema or signs of venous thrombosis were observed in the lower limbs&#46; Examination of the locomotor system revealed distal symmetrical polyarthritis with four painful and swollen small joints &#40;PIJ&#41; and two painful large joints &#40;wrist and elbow&#41; in URL&#59; and four painful and swollen joints &#40;PIJ&#41; in ULL&#46; Both ankles were also affected&#46; The knees were unchanged&#46; The rest of the examination was unremarkable&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Among the complementary tests carried out&#44; the following stands out&#58; microcytic anaemia &#40;Hb 11&#46;6&#8239;g&#47;dL with MCV of 72&#46;4&#8239;fL&#41;&#44; without significant alterations in the white series &#40;11&#44;000 leukocytes&#47;L with 52&#37; neutrophils &#40;absolute count of 5&#44;730&#47;L&#41;&#44; 38&#46;9&#37; lymphocytes &#40;count of 4&#44;280&#47;L&#41; and 6&#46;8&#37; monocytes &#40;count of 690&#47;L&#41; and thrombocytosis with 930&#44;000 platelets&#47;mm3&#46; The CRP value was 66&#8239;mg&#47;L&#44; the ESR was 39&#8239;mm&#47;h&#46; Biochemistry&#44; lipid&#44; thyroid and ferric profile values were within normal ranges in our laboratory&#44; with uric acid at 3&#46;4&#8239;mg&#47;dL&#46; 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Rheumatoid factor was 6&#46;2 IU&#47;mL&#44; complement values were 139&#8239;mg&#47;dL for C3 and 23&#46;9&#8239;mg&#47;dL for C4&#46; The proteinogram showed a pattern with no abnormalities outside normality and the IgA value was 256&#8239;mg&#47;dL&#46; In the autoimmunity section&#44; the antinuclear antibodies were negative&#44; as well as the anti-extractable nuclear antigen&#44; anti-double-stranded DNA&#44; anti-myelopeptide oxidase&#44; anti-proteinase-3&#44; anti-cyclic citrullinated peptide and anti-transglutaminase antibodies were negative&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Radiographic series&#58; Chest X-ray shows no parenchymal condensation&#44; no signs of interstitial fibrosis&#44; no pleural effusion&#44; no calcifications&#44; no mediastinal masses and no thickening of the pleura&#46; The cardiothoracic index is less than &#46;5&#46; No bone alterations&#46; The radiograph of the hands and wrists shows slight soft tissue enlargement&#44; but no loss of alignment of the bony structures&#44; destructuring of the distal radioulnar&#44; carpal-radial or carpal-ulnar joints&#44; nor of the proximal or distal metacarpophalangeal or interphalangeal joints&#46; No osteopenia&#46; No bone erosions&#46; No fractures or dislocations&#46; The radiograph of the knees also shows a radiographic pattern within normality&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Using the anamnesis and PPCC described above&#44; we acceptably ruled out a wide variety of rheumatic diseases&#44; and given the history&#44; the compatible clinical features&#44; the positive serology for SARS-CoV-2 and the absence of other more plausible alternatives&#44; we established the diagnosis of reactive arthritis following SARS-CoV-2 viral infection&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Antibiotic treatment was initially prescribed with doxycycline plus gentamicin&#44; which did not improve the patient&#8217;s condition&#46; Prednisone 30&#8239;mg&#47;d was also prescribed in a tapering regimen&#44; which improved the clinical condition&#44; but the symptoms worsened when prednisone was reduced to 5&#8239;mg&#47;d&#44; and were controlled again at 10&#8239;mg&#47;d&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This is not the first case of SARS-CoV-2 reactive arthritis&#44; as there are other articles describing this phenomenon&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; to our knowledge&#44; it is the first to describe such an entity in a patient in the age range described&#44; as the others were over 50 years of age&#46; Reactive arthritis&#44; although typically described as oligoarticular involvement of large joints of the lower limbs following urogenital or gastrointestinal infections&#44; can also occur atypically for many other infections&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Some studies even link coronavirus infection with the development of RA&#44; although only in women over 60 years of age with no previous history of respiratory pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The limitations of this study include the lack of synovial fluid analysis&#44; which was not performed because there was no significant joint effusion to allow sample extraction&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">SARS-CoV-2 infection may be a mechanism of atypical reactive arthritis in patients of multiple age ranges&#44; which can be managed with low-dose oral corticosteroids&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Financing</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors of this article used the resources of the Andalusian Health System to carry out the complementary studies mentioned above&#46; The authors did not receive any additional funding from other entities or third parties&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest with respect to the information provided in the following case report&#46; For this purpose&#44; they have the express agreement of the patient to publicly disclose the clinical data and results of complementary tests provided&#46;</p></span></span>"
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Case Report
Reactive arthritis with SARS-COV-2 as a trigger
Artritis reactiva con SARS-CoV-2 como desencadenante
Víctor Ruiz-del-Vallea,
Corresponding author
victor.ruizdelvalle@gmail.com

Corresponding author.
, Luis Sarabia de Ardanaza, Míriam Navidad-Fuentesa, Irene Martín-Martína, Rubén Lobato-Canob
a Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
b Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Viral infections have the capacity to cause arthritis and arthralgia&#44; usually of the poliarticular type and in an acute form&#44; concurrent with the infection by the corresponding micro-organism&#46; However&#44; on many occasions there is a time delay between the joint manifestations and the other clinical phenomena usually associated with these infections&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this study&#44; we suggest SARS-CoV-2 as a causative agent of reactive viral arthritis and present the case of a patient with distal symmetric polyarthritis as a late manifestation of COVID-19 disease&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical observation</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient&#44; a 19-year-old male from Morocco&#44; who had a personal history of alopecia areata and pitytriasis versicolor&#44; came to the emergency department on 13 December 2020 reporting additive polyarthralgias&#44; which had started in the left knee two months earlier and were later added to the right knee&#44; ankles and wrists&#46; They were of an inflammatory nature with functional impotence and a feeling of stiffness that improved with mobilisation&#44; but persisted throughout the day&#46; The pain interrupted sleep&#46; In addition&#44; he reported a weight loss of about 10&#8239;kg&#44; with initial hyporexia&#44; which had resolved at the time of the first consultation&#46; Fever of up to 38&#8239;C&#44; predominantly in the evening&#44; which lasted 15 days at the onset&#46; He presented with a rash on his back&#44; already assessed by the Dermatology Department of the Hospital Universitario Virgen de las Nieves &#40;HUVN&#41; &#40;compatible with pityriasis rosea Gibert&#41;&#44; which appeared after symptoms compatible with COVID-19 &#40;nausea&#44; vomiting&#44; arthromyalgia and headache&#44; without associated respiratory symptoms&#41;&#46; Maxillary pain on chewing and difficulty opening the jaw&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the rest of the anamnesis by systems and apparatus&#58; dry cough predominantly at night&#44; no haemoptysis&#46; No chest or abdominal pain&#46; No diarrhoeal stools&#46; No dysphagia&#46; No dysuria&#46; No oral or genital aphthae&#44; no signs of uveitis&#44; no difficulty with mobility of the shoulder girdle or pelvis&#44; nor with flexion of the dorsal spine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Epidemiologically&#58; Denied foreign travel&#46; No consumption of toxic substances&#46; No risky sexual relations&#46; He has had a cat since February 2021&#46; He is originally from a rural area where there are ca-prino cattle&#44; but his family does not own or consume unprocessed dairy products&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On examination&#44; the vitals were stable&#44; with BP 115&#47;73&#8239;mmHg&#44; HR 94 bpm&#44; temperature 37&#46;1&#8239;C&#44; SaO2 96&#37; with FiO2 of 21&#37;&#46; Diuresis not quantified in the ED&#44; but maintained&#44; according to the patient&#46; Cardiorespiratory auscultation&#58; pure rhythmic tones&#44; with slightly elevated frequency&#44; without tachycardia&#46; Bilateral vesicular murmur was preserved&#44; with no extra sounds&#46; The abdomen was soft&#44; depressible&#44; with no palpable masses or megaliths&#46; There were no signs of peritonism and the hydro-aerial sounds were preserved and not increased&#46; At ENT level and in the head and neck&#44; the pharynx was non-erythematous&#44; with no alterations of interest&#46; There were no cervical&#44; retroauricular&#44; supraclavicular or axillary lymphadenopathies&#46; No palpable goitre&#46; There were no focal or neurological alterations&#46; No oedema or signs of venous thrombosis were observed in the lower limbs&#46; Examination of the locomotor system revealed distal symmetrical polyarthritis with four painful and swollen small joints &#40;PIJ&#41; and two painful large joints &#40;wrist and elbow&#41; in URL&#59; and four painful and swollen joints &#40;PIJ&#41; in ULL&#46; Both ankles were also affected&#46; The knees were unchanged&#46; The rest of the examination was unremarkable&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Among the complementary tests carried out&#44; the following stands out&#58; microcytic anaemia &#40;Hb 11&#46;6&#8239;g&#47;dL with MCV of 72&#46;4&#8239;fL&#41;&#44; without significant alterations in the white series &#40;11&#44;000 leukocytes&#47;L with 52&#37; neutrophils &#40;absolute count of 5&#44;730&#47;L&#41;&#44; 38&#46;9&#37; lymphocytes &#40;count of 4&#44;280&#47;L&#41; and 6&#46;8&#37; monocytes &#40;count of 690&#47;L&#41; and thrombocytosis with 930&#44;000 platelets&#47;mm3&#46; The CRP value was 66&#8239;mg&#47;L&#44; the ESR was 39&#8239;mm&#47;h&#46; Biochemistry&#44; lipid&#44; thyroid and ferric profile values were within normal ranges in our laboratory&#44; with uric acid at 3&#46;4&#8239;mg&#47;dL&#46; Urinalysis showed no findings of interest and haemostasia&#47;fibrinolysis parameters were normal except for hyperfibrinogenemia of 678&#46; Positive IgM and IgG class antibodies to SARS-CoV-2 were found&#46; Rose Bengal test was initially positive with a titre of 1&#58;8&#44; but later Brucella serology was negative&#46; All other serologies were negative &#40;HIV 1&#44; HIV 2&#44; HCV&#44; syphilis and R&#46; conorii&#41; or denoted past infections or correct vaccination patterns with positive IgG &#40;CMV&#44; EBV&#44; parvovirus B19&#44; HAV&#44; HBV&#44; rubella and VZV&#41;&#46; Molecular diagnostic techniques were performed for STI-causing germs such as C&#46; trachomatis&#44; M&#46; ge-nitalium&#44; M&#46; hominis&#44; U&#46; urealyticum and T&#46; vaginalis&#44; as well as urethral exudate cultures for bacteria&#44; fungi and gonococcus&#44; all of which were negative&#46; The IGRA test was also performed with negative results&#46; HLA-B27 and HLA-B51 were negative in both cases&#46; Rheumatoid factor was 6&#46;2 IU&#47;mL&#44; complement values were 139&#8239;mg&#47;dL for C3 and 23&#46;9&#8239;mg&#47;dL for C4&#46; The proteinogram showed a pattern with no abnormalities outside normality and the IgA value was 256&#8239;mg&#47;dL&#46; In the autoimmunity section&#44; the antinuclear antibodies were negative&#44; as well as the anti-extractable nuclear antigen&#44; anti-double-stranded DNA&#44; anti-myelopeptide oxidase&#44; anti-proteinase-3&#44; anti-cyclic citrullinated peptide and anti-transglutaminase antibodies were negative&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Radiographic series&#58; Chest X-ray shows no parenchymal condensation&#44; no signs of interstitial fibrosis&#44; no pleural effusion&#44; no calcifications&#44; no mediastinal masses and no thickening of the pleura&#46; The cardiothoracic index is less than &#46;5&#46; No bone alterations&#46; The radiograph of the hands and wrists shows slight soft tissue enlargement&#44; but no loss of alignment of the bony structures&#44; destructuring of the distal radioulnar&#44; carpal-radial or carpal-ulnar joints&#44; nor of the proximal or distal metacarpophalangeal or interphalangeal joints&#46; No osteopenia&#46; No bone erosions&#46; No fractures or dislocations&#46; The radiograph of the knees also shows a radiographic pattern within normality&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Using the anamnesis and PPCC described above&#44; we acceptably ruled out a wide variety of rheumatic diseases&#44; and given the history&#44; the compatible clinical features&#44; the positive serology for SARS-CoV-2 and the absence of other more plausible alternatives&#44; we established the diagnosis of reactive arthritis following SARS-CoV-2 viral infection&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Antibiotic treatment was initially prescribed with doxycycline plus gentamicin&#44; which did not improve the patient&#8217;s condition&#46; Prednisone 30&#8239;mg&#47;d was also prescribed in a tapering regimen&#44; which improved the clinical condition&#44; but the symptoms worsened when prednisone was reduced to 5&#8239;mg&#47;d&#44; and were controlled again at 10&#8239;mg&#47;d&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This is not the first case of SARS-CoV-2 reactive arthritis&#44; as there are other articles describing this phenomenon&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; to our knowledge&#44; it is the first to describe such an entity in a patient in the age range described&#44; as the others were over 50 years of age&#46; Reactive arthritis&#44; although typically described as oligoarticular involvement of large joints of the lower limbs following urogenital or gastrointestinal infections&#44; can also occur atypically for many other infections&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Some studies even link coronavirus infection with the development of RA&#44; although only in women over 60 years of age with no previous history of respiratory pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The limitations of this study include the lack of synovial fluid analysis&#44; which was not performed because there was no significant joint effusion to allow sample extraction&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">SARS-CoV-2 infection may be a mechanism of atypical reactive arthritis in patients of multiple age ranges&#44; which can be managed with low-dose oral corticosteroids&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Financing</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors of this article used the resources of the Andalusian Health System to carry out the complementary studies mentioned above&#46; The authors did not receive any additional funding from other entities or third parties&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest with respect to the information provided in the following case report&#46; For this purpose&#44; they have the express agreement of the patient to publicly disclose the clinical data and results of complementary tests provided&#46;</p></span></span>"
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Article information
ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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