A novel approach with tofacitinib for the management of keratoderma blennorrhagicum in reactive arthritis: a case report.

Reactive arthritis(ReA), a form of arthritis occurring post-infection, manifests with antecedent infection symptoms, arthritis, and extra-articular manifestations, categorizing it as spondyloarthritis. "Keratoderma blennorrhagicum" (characterized by pustular hyperkeratosis on palms and soles, resembling pustular psoriasis) represents the most typical skin manifestation of ReA, occurring in acute or chronic phases. Severe lesions necessitate systemic disease modifying anti-rheumatic drugs (DMARDs) or biologic therapies. This article reports a case of ReA with sacroiliitis and widespread pustular eruptions following a urinary tract infection. Treatment with sulfasalazine and thalidomide significantly improved sacroiliitis, but the skin rash remained persistent and recurring. Subsequent use of adalimumab and secukinumab resulted in worsening skin rash, prompting a switch to tofacitinib, leading to a remarkable improvement in pustular eruptions after 20 days of treatment. This case demonstrates successful application of tofacitinib in treating severe keratoderma blennorrhagicum refractory to conventional DMARDs and biologics, offering insights into JAK inhibition for challenging rheumatic diseases with skin involvement.

Unexpected Adverse Events of Immune Checkpoint Inhibitors.

The introduction of immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment standards and significantly enhanced patient prognoses. However, the utilization of these groundbreaking therapies has led to the observation and reporting of various types of adverse events, commonly known as immune-related adverse events (irAEs). In the following article, we present four patients who encountered uncommon toxicities induced by ICIs. The first patient was a 59-year-old female diagnosed with stage 4 lung adenocarcinoma. She received immunotherapy (pembrolizumab) together with chemotherapy and subsequently developed autonomic neuropathy (AN). The next two patients also received chemo-immunotherapy (pembrolizumab) and were both 63-year-old males with stage 4 lung adenocarcinoma. One of the two experienced palmoplantar keratoderma, while the other presented with Reiter's syndrome (urethritis, conjunctivitis and arthritis). The 4th patient, an 80-year-old male with stage 4 squamous cell carcinoma of the lung, received chemo-immunotherapy (pembrolizumab) and developed myasthenia gravis.

A Case Report of Intratesticular Hematoma in a Patient with Reiter's Syndrome.

We present a case of a 28-year-old male patient with a spontaneous intratesticular hematoma. He had no history of trauma but experienced sudden onset of painful swelling in his right testis. Initially, testicular malignancy was suspected. The tumor marker of testis, including alfa-fetoprotein, lactic dehydrogenase, and ß-human chorionic gonadotropin, was within normal range. The patient had been diagnosed with Reiter's syndrome at the age of 20 and had been treated with sulfasalazine, non-steroidal anti-inflammatory drugs, and acetaminophen for eight years. Various imaging techniques before operation planning, including ultrasonography and computed tomography, revealed a hematoma that accounted for 32% of the testicular volume. During the waiting period before the operation, the patient was diagnosed with a hematoma and avoided a possible diagnosis of malignancy. Follow-up imaging with computed tomography and magnetic resonance imaging confirmed the presence of an intratesticular hematoma that had decreased in size. Since no other related factor contributed to this hematoma, and considering the possible hematological side effects of sulfasalazine, we suggest that this may be a rare side effect of sulfasalazine. Although the patient's testis was preserved, further fertility should be observed because animal studies have reported that testicular hematoma may cause fertility changes if the initial volume occupied is over 30% of the testis.

Reactive Arthritis Triggered by Adalimumab and Leflunomide in a Patient with Ankylosing Spondylitis.

Reactive arthritis (ReA) is uncommon. The present case is a Chinese man who has been treated with adalimumab and leflunomide to control ankylosing spondylitis (AS). During the treatment, the patient developed a range of symptoms, including fever, fatigue, pustular rash, suppurative urethritis, genital ulcers, oral ulcers, bilateral uveitis, heel pain and swelling and pain of the knee and ankle joints. The laboratory studies revealed the presence of HLA-B27, and urethral secretions were positive for Ureaplasma urealyticum. The patient was eventually diagnosed with ReA. The development of ReA may be related to the combination of adalimumab and leflunomide, which reduces immune function and triggers activation of potential U. urealyticum. The patient received 3 weeks of antibiotics, corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs), resulting in a significant improvement. The dose of corticosteroids was gradually reduced, and adalimumab was reintroduced. The patient was followed up for 3 months without recurrence.

Osteomyelitis infection disguised as Reiter's syndrome in a child: A case report.

Reiter's syndrome (reactive arthritis) should always prompt a thorough clinical investigation of a potentially more serious disease condition in every pediatric patient and adults. It should always be regarded as a warning sign and not a disease. This is a case of a 16-year-old African boy with osteomyelitis presenting with symptoms of reactive arthritis (Reiter's syndrome).

Case Report of a Rare Cause of Reactive Arthritis: Leptospirosis.

INTRODUCTION: Leptospirosis is a zoonosis caused by infection with pathogenic Leptospira species. Leptospirosis has protean manifestations and rare, unusual presentations should be kept in mind in relevant epidemiological scenario. Reactive arthritis refers to acute non-purulent arthritis complicating an infection elsewhere in the body. It is attributed to an immune activation following certain infections; it is, therefore considered as aseptic arthritis. Very few case reports are available attributing leptospirosis as an established cause of reactive arthritis. We present a case of reactive arthritis of the hip joint due to leptospirosis. CASE REPORT: Here, we present a case of a 12-years- old female child who was admitted to our hospital with complaints of fever, headache, and pain in the right hip joint since past 5 days from admission. Subsequent elaboration revealed a past history of fever, headache, and myalgia for around 5-7 days around a week before the present complaints. There was rat infestation near her house and her father was working as sewage cleaner. Routine investigations, Ultrasonography (USG), Magnetic Resonance Imaging (MRI) of both hips and subsequently, diagnostic hip aspiration was performed. USG revealed synovitis, MRI revealed hip joint arthritis of infective or inflammatory origin. Diagnostic hip aspiration was negative for any microorganism. On 10th day of admission, patient started developing icterus with yellowish discolouration of urine. Patient was evaluated for the cause of jaundice. Screening for Leptospira was positive. Synovial biopsy of hip was performed, which showed inflammation with no specific pathology and no growth of any microorganism. In addition, Leptospira IgM MAC ELISA was done which was positive. Patient was thus confirmed to be having leptospirosis and reactive arthritis as a consequence of it. CONCLUSION: The presentation of reactive arthritis secondary to leptospirosis is rare. Leptospirosis can be an etiological factor for reactive arthritis, especially if reactive arthritis is complicated with jaundice.

Reactive Arthritis following Bacillus Calmette-Guerin Therapy for Bladder Cancer: a Systematic Literature Review.

PURPOSE OF REVIEW: Intravesical BCG therapy (ivBCG) is a treatment for bladder cancer that complements surgery and prevents tumor progression. Reactive arthritis (ReA) is a rare osteoarticular manifestation that can complicate this treatment. An updated systematic literature review has been investigated to identify clinical, biological, and therapeutic data of this pathology. RECENT FINDINGS: A systematic literature was performed on October 2020 to identify papers published from 2000 to 2020. Study eligibility criteria included case reports, case series, cohort studies, systematic reviews, meta-analysis, and letters to the editor, in English and French. Independent extraction of articles was performed by two investigators. Thirteen studies met the search criteria for the systematic review with a good quality assessment. The total number of patients was 107, with an average age of 61.5 [24-80]. The symptoms of ReA appeared after a mean number of 5.71 instillations and 13.9 days. Arthritis was the most common symptom (98.13%) followed by fever (80.76%) and conjunctivitis (64.42%). Human leukocyte antigen (HLAB27) was positive in 28.97% of patients. Therapeutic modalities included non-steroidal anti-inflammatory drugs (NSAIDs) (51.4%), corticosteroids (27.1%), conventional synthetic disease-modifying antirheumatic drugs (3.84%), antitubercular drugs (14.42%), and tocilizumab (0.93%). BCG therapy was discontinued in 29.9% of patients. Remission was achieved in 92.3% of patients and one patient progressed to spondyloarthritis. ReA is a rare complication of BCG therapy. Clinical signs are similar to those of typical ReA and treatment is primarily based on NSAIDs and corticosteroids.

Evolving patterns of reactive arthritis.

OBJECTIVE: To characterize rheumatologists' perspectives on evolving trends of reactive arthritis (ReA). METHODS: After ethics approval, 548 members of the Canadian Rheumatology Association were surveyed with 37 questions covering their demographic information, subspecialty, level of experience, practice setting and opinions on prevalence, treatment, and causes of ReA. Results were analyzed with descriptive statistics. RESULTS: Ninety-seven responded to the survey (18% response rate); 66 fully completed it. Nearly half of respondents believed that the incidence of ReA is declining and causes of ReA may be changing. Physicians reported that most of the ReA cases in their practices were caused by an unknown organism, sexually transmitted, or gastrointestinal infection. Full triad ReA increased the chance of recurrence according to their impressions. Common investigations in ReA included inflammatory markers, HLA-B27, chlamydia and gonorrhea testing, stool cultures, synovial fluid analyses, SI joint imaging. ReA treatment included NSAIDs, intra-articular corticosteroid injections, and DMARDs. Two-thirds said they used TNF alpha inhibitors in chronic ReA occasionally or more frequently. CONCLUSION: ReA may be decreasing in frequency and severity in Canada. Changes could be due to less food borne illness, cleaner water, or more rapid treatment of sexually transmitted infections. The cause is often unknown in clinical practice.Key Points• Reactive arthritis (ReA) is likely decreasing in prevalence and severity.• Patients with classic trial of arthritis, urethritis, and conjunctivitis are more likely to have recurrent and/or chronic ReA.• The causal organisms are often not detected and seem to be changing over time.