Clinical spectrum of post‐streptococcal reactive arthritis (PSRA) revisited: Juvenile versus adult‐onset disease

Abstract

Dear Editor, The term post-streptococcal reactive arthritis (PSRA) refers to a form of reactive arthritis which is characterized by a streptococcal sore throat, a symptom-free interval of approximately 10 days followed by aseptic inflammation involving one or more joints. In the year 1959, post-streptococcal arthritis without cardiac involvement was first reported.1 The term PSRA was first suggested by Goldsmith and Long in 1982.2 The presentation may be like that of acute septic arthritis with sudden onset of fever and severe joint pain. The joint pain is usually out of proportion to the degree of physical findings. The pattern of joint involvement may be monoarticular or polyarticular, migratory, additive or chronic; arthritis is usually non-destructive and self-limiting, but the symptoms may last for months. The treatment response to aspirin is less dramatic than that with acute rheumatic fever. There may be no clear evidence of a preceding streptococcal infection and the throat culture can be sometimes negative.3 We tried to analyze the clinical profile of these patients (adult vs juvenile onset) in our tertiary level referral hospital during the period from 1998 to 2008. Retrospective case records of 25 cases of PSRA attending various outpatient services (Clinical Immunology and Rheumatology clinic, Early arthritis clinic and Pediatrics Rheumatology Clinic) of Christian Medical College and Hospital, Vellore, India were studied. The diagnosis of PSRA was based on criteria proposed by Ayoub et al in 1997.4 Out of 25 cases, 7 (28%) were female and 18 (72%) were male. Nine patients (36%) had juvenile-onset disease, whereas 16 (64%) had onset after the age of 16 years. The mean duration of disease at presentation was 3.6 ± 2.66 weeks. Ten patients (40%) had polyarticular onset and 15 patients (60%) had onset in large joints of the lower limbs. Concomitant axial joint involvement was seen in 4 patients (16%). Thirteen patients (52%) had fever and leucocytosis. Juvenile-onset patients had fever along with leucocytosis more frequently (78% vs 22%) as compared to those having disease onset after the age of 16 years (P = 0.058).The mean duration of persistent joint pain was longer in the later / adult age group patients as compared to juvenile-onset disease (29.25 ± 18.51 vs 16.78 ± 14.85 weeks; P = 0.049). None had any residual joint damage or deformity. No extra-articular feature such as carditis was seen, a findings similar to that described by Sato et al from Japan.5 As per decription in literature, PSRA is a rare but benign disease with varied clinical manifestations. In our study, we noted that the arthritis tends to persist for longer duration in later /adult onset PSRA as compared to juvenile-onset disease. PSRA should be considered in the differential diagnosis of a young adult with arthritis involving the lower limbs.6 Although substantial controversy still exists regarding the optimal therapy for patients with PSRA, there is concern about the risk of other non-suppurative complications upon recurrence.7 As streptococcal infections in the adult population are increasingly being reported, it is a timely opportunity to revisit PSRA and develop comprehensive treatment and antibiotic prophylaxis guidelines.8 In the adult-onset PSRA, it may be prudent to give antibiotic prophylaxis as the arthritis is prolonged; one such option include use of sulfasalazine as a disease-modifying agent, even though PSRA is classified by some as nonclassical reactive arthrits. None.