Letter to the Editor
Reactive Arthritis Caused by Blastocistys hominis
Artritis reactiva por Blastocistys hominis
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This infection usually precedes arthritis by a month. The most frequent reactive arthritis due to <span class="elsevierStyleItalic">Salmonella</span>, <span class="elsevierStyleItalic">Shigella</span>, <span class="elsevierStyleItalic">Chlamydia</span>, <span class="elsevierStyleItalic">Yersinia</span> and <span class="elsevierStyleItalic">Campylobacter</span>. However, there are cases described in the literature of reactive arthritis caused by other microorganisms, such as protozoa.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently there are no validated criteria for the classification or for the diagnosis of reactive arthritis. According to the working definitions of the Third International Workshop on Reactive Arthritis, there are two clinical features that are considered very important<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0015" class="elsevierStylePara elsevierViewall">Acute inflammatory arthritis, inflammatory back pain or enthesitis.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Evidence of infection preceding the disease between 4 and 8 weeks.</p></li></ul></p><p id="par0025" class="elsevierStylePara elsevierViewall">Here we report a case of reactive arthritis due to <span class="elsevierStyleItalic">Blastocystis hominis</span> in immunocompetent patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A 45-year-old Spanish woman, with no toxic habits, who had made multiple trips to places like India, Nepal, Kenya, Tanzania and Burma was seen. Her last trip to Egypt was made a year ago. Among her medical history featured a recurring tapeworm infection and isolation of <span class="elsevierStyleItalic">Blastocystis hominis (B. hominis)</span> in a control stool. She consulted for malaise, and joint and back pain accompanied by mild fever of 2 days duration. The latency period from the isolation of <span class="elsevierStyleItalic">B. hominis</span> to the onset of symptoms was 10 days. Physical examination showed fever (38<span class="elsevierStyleHsp" style=""></span>°C), monoarthritis of the left knee, heel pain and pain with redness of the eye. The rest of the examination was normal, including oral and genital mucosa. The chest radiograph showed no abnormalities. Chest and hand X-rays were normal. Knee arthrocentesis was performed, resulting in inflammatory synovial fluid: 21<span class="elsevierStyleHsp" style=""></span>250/mm<span class="elsevierStyleSup">3</span> leukocytes (94% polymorphonuclear) and glucose: 143.4<span class="elsevierStyleHsp" style=""></span>mg/dl. The examination of joint fluid under a polarized optical microscope showed no birefringent crystals. Joint fluid and blood cultures, urine cultures, stool cultures were negative for bacteria and parasites. ESR was 67<span class="elsevierStyleHsp" style=""></span>mm at 1<span class="elsevierStyleHsp" style=""></span>h, she had 15.8×10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>leukocytes (88% neutrophils), hemoglobin 12.2<span class="elsevierStyleHsp" style=""></span>g/dl, hematocrit 35%, CRP: 56<span class="elsevierStyleHsp" style=""></span>mg/l and fibrinogen<span class="elsevierStyleHsp" style=""></span>601<span class="elsevierStyleHsp" style=""></span>mg/dl. Liver and kidney functions were normal. Serologic testing for hepatitis B and C, HIV, <span class="elsevierStyleItalic">Salmonella</span>, <span class="elsevierStyleItalic">Brucella</span>, and <span class="elsevierStyleItalic">Treponema pallidum</span> were negative. Antinuclear antibodies and rheumatoid factor were negative. HLA-B27 was positive. Ophthalmologic examination revealed bilateral anterior uveitis, predominantly on the right eye. Reactive arthritis due to <span class="elsevierStyleItalic">B. hominis</span> was diagnosed, and treatment with metronidazole 250<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleHsp" style=""></span>was continued, which she had begun beforehand. In addition, indomethacin was started 125<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h, with resolution of arthritis. The patient was intolerant to metronidazole and tinidazole and was changed to 1000<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h.<span class="elsevierStyleHsp" style=""></span>Upon discharge, the patient had resolution of arthritis and improvement of uveitis. He continued with indomethacin and tinidazole. Subsequently, the patient came for a control visit, with improvement of arthritis, which allowed her to gradually reduce the anti-inflammatory dose. Further episodes of uveitis was controlled with topical treatment. Stool cultures were repeated at three weeks until deworming was positive. Subsequently, the patient underwent another round of treatment, repeated cultures after a month, which were negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Protozoal reactive arthritis is rare. The microorganisms most frequently implicated are <span class="elsevierStyleItalic">Giardia lamblia</span>, <span class="elsevierStyleItalic">Entamoeba histolytica</span>, <span class="elsevierStyleItalic">Trichomonas vaginalis</span>, <span class="elsevierStyleItalic">Toxoplasma gondii</span>, and rarely, <span class="elsevierStyleItalic">B. hominis</span>. This is a protozoa that is transmitted between animals and humans by ingestion of cysts in water or food contaminated by a carrier. Its pathogenic role is not universally accepted,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but has been associated with episodes of diarrhea and extraintestinal<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> manifestations, and its relationship with reactive arthritis is less common. Different morphological and ameboid<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> vacuolar types have been described, which could be related to its pathogenic capacity.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The mechanisms by which different parasites can cause joint disease are multiple. For example, local invasion from neighboring bones or muscles, via the blood or lymphatic with the presence of adult individuals, larvae or eggs in the joint cavity. They could also trigger a reactive inflammatory reaction to the presence of the parasite in the surrounding tissue, without an actual joint invasion<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. In our case, we assume that the latter was the most likely mechanism of action of <span class="elsevierStyleItalic">B. hominis</span>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">On the other hand, some authors use the term “parasitic rheumatism” in the case of inflammatory conditions without the presence of the parasite in the joint or in its vicinity, probably triggered by an immune mechanism.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In a 1990–2010 PUBMED literature review (keywords: <span class="elsevierStyleItalic">Blastocystis hominis</span> and arthritis) we found 4 cases of arthritis associated with <span class="elsevierStyleItalic">B. hominis</span>, treated in 2 cases as infectious arthritis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The other 2 cases were reactive arthritis associated with <span class="elsevierStyleItalic">B. hominis</span>.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> This case would be the fifth related to this parasite and the third description of reactive arthritis due to this organism.</p><p id="par0055" class="elsevierStylePara elsevierViewall">As in other cases, this was a middle-aged, immunocompetent woman, who had traveled to risk countries. However, unlike the cases described above, this case provided had a positive HLA B-27.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please, cite this article as: Tejera B, et al. Artritis reactiva por <span class="elsevierStyleItalic">Blastocistys hominis</span>. Reumatol Clin. 2012;<span class="elsevierStyleBold">8(1)</span>:50–1.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Arthrites parasitaires, rhumatismes parasitaires et arthrites reactionnelles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. 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|---|---|---|---|
| 2024 November | 41 | 22 | 63 |
| 2024 October | 348 | 26 | 374 |
| 2024 September | 483 | 28 | 511 |
| 2024 August | 476 | 34 | 510 |
| 2024 July | 561 | 42 | 603 |
| 2024 June | 491 | 52 | 543 |
| 2024 May | 522 | 40 | 562 |
| 2024 April | 382 | 47 | 429 |
| 2024 March | 433 | 46 | 479 |
| 2024 February | 353 | 32 | 385 |
| 2024 January | 498 | 25 | 523 |
| 2023 December | 361 | 30 | 391 |
| 2023 November | 354 | 40 | 394 |
| 2023 October | 351 | 36 | 387 |
| 2023 September | 328 | 39 | 367 |
| 2023 August | 405 | 33 | 438 |
| 2023 July | 434 | 26 | 460 |
| 2023 June | 427 | 31 | 458 |
| 2023 May | 384 | 27 | 411 |
| 2023 April | 332 | 15 | 347 |
| 2023 March | 672 | 32 | 704 |
| 2023 February | 291 | 21 | 312 |
| 2023 January | 277 | 7 | 284 |
| 2022 December | 222 | 34 | 256 |
| 2022 November | 218 | 37 | 255 |
| 2022 October | 192 | 44 | 236 |
| 2022 September | 149 | 35 | 184 |
| 2022 August | 151 | 39 | 190 |
| 2022 July | 141 | 46 | 187 |
| 2022 June | 142 | 32 | 174 |
| 2022 May | 192 | 40 | 232 |
| 2022 April | 194 | 60 | 254 |
| 2022 March | 198 | 46 | 244 |
| 2022 February | 196 | 45 | 241 |
| 2022 January | 167 | 39 | 206 |
| 2021 December | 158 | 48 | 206 |
| 2021 November | 122 | 54 | 176 |
| 2021 October | 163 | 67 | 230 |
| 2021 September | 113 | 58 | 171 |
| 2021 August | 95 | 60 | 155 |
| 2021 July | 156 | 38 | 194 |
| 2021 June | 127 | 50 | 177 |
| 2021 May | 147 | 52 | 199 |
| 2021 April | 346 | 94 | 440 |
| 2021 March | 249 | 46 | 295 |
| 2021 February | 130 | 28 | 158 |
| 2021 January | 102 | 21 | 123 |
| 2020 December | 102 | 24 | 126 |
| 2020 November | 110 | 26 | 136 |
| 2020 October | 76 | 16 | 92 |
| 2020 September | 88 | 26 | 114 |
| 2020 August | 57 | 24 | 81 |
| 2020 July | 66 | 31 | 97 |
| 2020 June | 85 | 26 | 111 |
| 2020 May | 100 | 20 | 120 |
| 2020 April | 41 | 12 | 53 |
| 2020 March | 29 | 5 | 34 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 20 | 0 | 20 |
| 2018 April | 121 | 7 | 128 |
| 2018 March | 167 | 7 | 174 |
| 2018 February | 157 | 5 | 162 |
| 2018 January | 127 | 8 | 135 |
| 2017 December | 120 | 4 | 124 |
| 2017 November | 124 | 5 | 129 |
| 2017 October | 155 | 9 | 164 |
| 2017 September | 107 | 6 | 113 |
| 2017 August | 141 | 2 | 143 |
| 2017 July | 131 | 4 | 135 |
| 2017 June | 154 | 13 | 167 |
| 2017 May | 172 | 7 | 179 |
| 2017 April | 144 | 12 | 156 |
| 2017 March | 195 | 10 | 205 |
| 2017 February | 123 | 5 | 128 |
| 2017 January | 174 | 7 | 181 |
| 2016 December | 215 | 16 | 231 |
| 2016 November | 228 | 5 | 233 |
| 2016 October | 209 | 16 | 225 |
| 2016 September | 310 | 6 | 316 |
| 2016 August | 246 | 7 | 253 |
| 2016 July | 99 | 11 | 110 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 0 | 18 | 18 |
| 2016 March | 0 | 14 | 14 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 0 | 9 | 9 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 1 | 11 | 12 |
| 2015 July | 72 | 7 | 79 |
| 2015 June | 111 | 11 | 122 |
| 2015 May | 231 | 17 | 248 |
| 2015 April | 126 | 18 | 144 |
| 2015 March | 146 | 7 | 153 |
| 2015 February | 175 | 8 | 183 |
| 2015 January | 171 | 7 | 178 |
| 2014 December | 163 | 6 | 169 |
| 2014 November | 111 | 12 | 123 |
| 2014 October | 158 | 11 | 169 |
| 2014 September | 103 | 10 | 113 |
| 2014 August | 111 | 12 | 123 |
| 2014 July | 108 | 17 | 125 |
| 2014 June | 141 | 14 | 155 |
| 2014 May | 129 | 10 | 139 |
| 2014 April | 110 | 12 | 122 |
| 2014 March | 106 | 12 | 118 |
| 2014 February | 109 | 16 | 125 |
| 2014 January | 94 | 16 | 110 |
| 2013 December | 84 | 14 | 98 |
| 2013 November | 74 | 11 | 85 |
| 2013 October | 64 | 13 | 77 |
| 2013 September | 77 | 18 | 95 |
| 2013 August | 63 | 21 | 84 |
| 2013 July | 60 | 12 | 72 |
| 2013 June | 68 | 20 | 88 |
| 2013 May | 63 | 19 | 82 |
| 2013 April | 62 | 19 | 81 |
| 2013 March | 54 | 22 | 76 |
| 2013 February | 41 | 10 | 51 |
| 2013 January | 55 | 19 | 74 |
| 2012 December | 66 | 21 | 87 |
| 2012 November | 36 | 21 | 57 |
| 2012 October | 25 | 16 | 41 |
| 2012 September | 26 | 3 | 29 |
| 2012 July | 3 | 0 | 3 |
| 2012 June | 14 | 0 | 14 |
| 2012 May | 9 | 0 | 9 |
| 2012 April | 7 | 0 | 7 |
| 2012 March | 5 | 0 | 5 |
| 2012 February | 6 | 0 | 6 |
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