Chlamydia-induced Reactive Arthritis

Chlamydia-induced
Reactive Arthritis
Treatment Options and Remission
Camille Renee
January 26, 2015
Dr. F.M.
RHM2 4111

Outline
 Approach to Research
 P.I.C.O. Summary
 What is Reactive Arthritis?
 Current Treatment Plan
 Treatment-based Case Report
 Remission
 Remission-based Case Control Study
 Questions for Future Research

Approach to Research
Source: Duke Library
1
2

P.I.C.O.
 Patient Problem:
◦ Joint pain
◦ Conjunctivitis
◦ Symptoms occur weeks after treatment of
Chlamydia trachomatis
 Intervention:
◦ Serology (HLA-B27)
◦ Cytoplasmic inclusions on histology
◦ Antibiotics
◦ Methotrexate

P.I.C.O.
 Comparison:
◦ TNF-α inhibitors i.e. Etanercept
 Outcome:
◦ Pain relief
◦ Inflammation reduced
◦ Resolution

Reactive Arthritis
 ‘Reiter’s Syndrome’ (classic triad)
1) Urethritis/Cervicitis
2) Conjunctivitis
3) Arthritis
 Generally associated with HLA-B27 on
serology
 Post-venereal type is particularly associated
with Chlamydia trachomatis infections
‘Can’t See, Can’t Pee, Can’t Climb a Tree.’

Toronto Notes, 2014
Reactive Arthritis –
Post-enteric Type

Chlamydia Trachomatis
• Most prevalent sexually
transmitted bacterial pathogen
• May cause:
• Reactive arthritis (Reiter’s
syndrome)
• Follicular conjunctivitis
• Nongonococcal urethritis
(NGU)
• Pelvic inflammatory
disease (PID)
• 3 million new C. trachomatis
infections occur each year in the
United States
Source: Le, T. First aid 2014
Only 4% of these
cases lead to
inflammatory arthritis

C. Trachomatis - Replication
Source: Carter, J.D. Int J Clin Rheumtol. 2011

C. Trachomatis - Histology
Source: Carter, J.D. Int J Clin Rheumtol. 2011

Traditional Treatments
Toronto Notes, 2014

Etanercept – Case Report
 Successful use of Etanercept
for the treatment of Reiter’s
syndrome: a case report and
review of the literature
(Edrees, A., 2011)
 33 year old male with
Chlamydia-induced reactive
arthritis refractory to NSAIDs,
sulfasalazine, prednisone,
and methotrexate treatment
Source: Gc.kinesis.co.uk

 33 year old white male
 Positive for Chlamydia
trachomatis
 Treated with
azithromycin
 3 weeks later: returns
with joint pain, itching
of both eyes, and
keratoderma
blennorrhagicum Source: Worldstemcells.com
Source: Wikipedia.org

 Two months without improvement
◦ Ibuprofen (800 mg t.i.d)
◦ Sulfasalazine (3000 mg q.d.)
◦ Methotrexate (15 mg once a week)
◦ Prednisone (20-60 mg q.d.)
 Etanercept was started
(50 mg sc. once a week)
 After two months, skin and joint pain improved.
Etanercept and methotrexate were continued for
12 months with resolution and no recurrence.
Source: Sweetclipart.com

Conclusions
 Etanercept is a TNF-alpha inhibitor
that may be used for patients that do not
respond to other treatment options
Although…
 TNF-alpha has been shown to inhibit
growth of bacterial organisms, but
also causes an inflammatory response
 In some cases, the use of TNF-alpha
inhibitors may lead to worsening of
symptoms

Combination Therapy
Source: Lippincott, 2006
• Treatment with
etanercept
together with
methotrexate
has been shown
to cause
remission in
patients with
reactive arthritis

Remission
Definition: ‘a period of time during a
serious illness when the patient's
health improves’
 Approximately 15% of reactive
arthritis cases become chronic
and result in destructiveness of
the joints
Source: Merriam-Webster.com

Remission – Systematic Study
 C. trachomatis is present and
metabolically active during the
remitting phase in synovial tissues
from patients with chronic Chlamydia-
induced reactive arthritis (Gerard,
H.C., Carter, J.D., Hudson, A.P., 2013)
 4 patients in remission compared to 10
patients with active reactive arthritis…

Remission – Systematic Study
 Synovial biopsies analyzed
using qPCR and RT-PCR
 Bacterial load of patients in
remission was 20% of the load
in active patients
 Heat shock protein 60
(hsp60), monocyte
chemotactic protein (MCP1),
RANTES (regulated on
activation, normal T cell
expressed and secreted)
mRNA levels were equal to or
higher in remitted patients
compared to active patients
Source: Aespecialists.com

Gene Expression
Source: Gerard,
H. Am J Med
Sci. Jul 2013

Conclusion
 Bacterial load in synovium of patients
in remission are low; proinflammatory
proteins are equal to or higher than
patients with active reactive arthritis
 Organism is present and metabolically
active in synovium during remission
 Genetic patterns of patients in
remission are complex

Future Research
 How exactly does
chlamydia replicate and
how can we create
therapeutic agents that
target every component
of these replication
patterns (transcription,
translation, etc.)?
 How can we develop
nanotechnology that
introduces bactericidal
agents directly into target
sites in the synovium?
Source: Mynamesnotmommy.com

Future Research
 Why do patients with reactive arthritis
relapse into active symptoms at low
bacterial loads?
 What are the effects of
immunosuppressive drugs that
specifically target heat shock protein
60, monocyte chemotactic protein,
RANTES on patients with chronic
reactive arthritis?

Acknowledgements
 Dr. FM, M.D.

Works Cited
1. Carter, J.D., Gerard, H.C., Whittum-Hudson, J.A. Hudson, A.P. Combination
antibiotics for the treatment of Chlamydia-induced reactive arthritis: is a cure in sight?
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case report and review of the literature. Rheumatol. Int. 2011. DOI 10.1003/600296-
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Chlamydia-induced Reactive Arthritis

Chlamydia-induced Reactive Arthritis

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