Post-streptococcal reactive arthritis: a clinical and serological description, revealing its distinction from acute rheumatic fever

Abstract

Objective: To follow-up prospectively patients with arthritis after infection with beta-haemolytic streptococci of Lancefield group A (beta HSA), with emphasis on clinical characteristics and serological features. We additionally investigated whether these patients, though often fulfilling the Jones' criteria for acute rheumatic fever (ARF), had a disease with clinical characteristics different from ARF.

Design: We performed a systematic prospective observational study of consecutive patients at a Dutch Outpatient Clinic and Department of Rheumatology, with arthritis after throat infection with beta HSA presenting to rheumatologist or internist from September 1992 until September 1996. Main outcome measures were clinical and biochemical characteristics with special reference to carditis.

Results: A total of 23 patients (21 Dutch, two Turkish; female/male ratio 15/8; mean (SD) age 42 (14) years) with predominantly non-migratory arthritis were included. A positive throat swab culture was obtained in 17%. All patients showed a significant rise of antistreptolysine-O (ASO; normal < 200 i.u. mL-1) and antideoxyribonuclease-B (anti-DNase-B; normal < 200 i.u. mL-1) titre. The mean (SEM) maximal ASO was 1305 (195) i.u. mL-1, and anti-DNase-B titre 980 (115) i.u. mL-1. Arthritis was present in mean (SEM) 5.4 (0.9) joints: 2.2 (0.7) small, 3.2 (0.4) larger joints. The arthritis was monarticular in 23% of the patients, oligoarticular in 35%, and polyarticular in 43%. Skin abnormalities were present in 12 patients: erythema nodosum in seven patients (30%), and erythema multiforme in five patients (22%). A transient cholestatic hepatitis was found in four patients (17%). In two patients a transient first-degree conduction block was found; however, neither echocardiography nor clinical course supported carditis. All patients were advised to receive monthly penicillin prophylaxis during a period of 2 years. Two patients refused to follow medical advice: in one a non-migratory arthritis recurred 15 months after the first episode of arthritis.

Conclusion: Commonly, arthritis secondary to beta HSA infection in the Netherlands, a prosperous West-European country with State Welfare, is not accompanied by carditis, contrary to literature on classical ARF. Other factors discriminating it from ARF are the age of onset, the non-migratory character of the arthritis, the high frequency of erythema nodosum and multiforme, as well as the presence of transient hepatitis. As arthritis is the hallmark of this syndrome, post-streptococcal reactive arthritis (PSRA) is the most proper name for this disease entity. Whether penicillin profylaxis is needed in PSRA, as it is in ARF, warrants further prospective investigation.