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Rheumatology 2001; 40: 945-947
© 2001 British Society for Rheumatology
Letters to the Editor |
Effective control of incomplete reactive arthritis with cyclosporin
University Department of Medicine, Royal Perth Hospital, Department of Rheumatology, Level 1, Q Block, 6 Selby Street, Shenton Park, WA 6008, Australia
SIR, In some studies 10–20% of patients with Reiter's syndrome (RS) and reactive arthritis (ReA) were found to have persistent disease 2 yr after the onset of symptoms [1]. In these cases various agents were used to stem progression, including sulphasalazine (SAS), methotrexate (MTX) and azathioprine (AZA). Combination therapies with or without corticosteroids have also been tried [2].
Cyclosporin A (CyA) is an established disease-modifying agent in rheumatoid arthritis [3]. There have been case reports of successful treatment of RS and psoriatic skin lesions as well as arthritis with this agent [4, 5]. We report a patient with features of incomplete RS who responded to CyA.
A 44-yr-old Caucasian male presented in August 1995 with a 2-yr history of polyarthralgia, bilateral buttock pain and left heel pain. He had lost 7 kg over the preceding 5 months. Apart from two episodes of painless urethral discharge, he had no other symptoms compatible with RS. There was no history of psoriasis, pustules, mouth ulcers, ocular inflammation, abdominal pain or passage of mucus or blood per rectum. He had undergone a Billroth II gastrectomy for duodenal ulceration at the age of 15 yr. Treatment at presentation included high-dose indomethacin (250 mg daily in divided doses), MTX 20 mg intramuscular injection each week, SAS 1 g twice daily, prednisolone 10 mg daily and slow-release morphine sulphate 60 mg twice daily. He was also taking oxycodone 20 mg daily, famotidine 40 mg daily and cisapride 30 mg daily.
Examination revealed cachexia, reactive lymphadenopathy in both axillae and polysynovitis involving the left ring-finger proximal interphalangeal joint, both wrists, the left elbow, the left ankle and left hindfoot joints. The heart rate was 96 beats/min and blood pressure 130/70 mmHg. Examination of the cardiovascular and respiratory system was unremarkable. There were no skin lesions. He had no evidence of mouth or genital ulcers and no conjunctivitis or iritis. There was no urethral discharge at presentation.
Investigations revealed anaemia (haemoglobin 91 g/l), an elevated white cell count (11.0x109/l) with neutrophilia (79%), a raised platelet count (619x109/l) and a high erythrocyte sedimentation rate (ESR) (111 mm/h). Albumin was reduced at 32 g/l. He was positive for the HLA B27 antigen. X-rays of the involved joints, the sacroiliac joints and the thoracic and lumbar spine were normal. No antinuclear antibodies were detected. He was negative for rheumatoid factor. Examination of early morning urine with the polymerase chain reaction disclosed no evidence of chlamydial infection.
Treatment with prednisolone, MTX and SAS was ceased. AZA was introduced. The patient could not tolerate more than 125 mg of AZA per day in divided doses. There was no clinical improvement, but the ESR decreased to 60 mm/h during treatment with AZA. In February 1996, treatment with AZA was stopped because of nausea and abdominal pain. The patient remained severely ill. He continued to lose weight and was unable to work as a mechanic. CyA 50 mg twice daily was commenced. The dose was increased progressively over 2 months to 100 mg twice daily (3.1 mg/kg/day) and was well tolerated. There was no significant increase in blood pressure or serum creatinine concentration. Clinical improvement followed. The synovitis regressed. He gained weight and the laboratory indices all improved. A progressive reduction in the ESR was observed (Fig. 1
). He returned to work.
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Eighteen months later he developed circinate balanitis despite continuing CyA. This resolved within 2 months with application of a topical corticosteroid. Two years after presentation, repeat X-rays revealed right sacroiliitis. After 4 yr of therapy with CyA he remains free of symptoms and signs of arthritis. Reduction in the dose of CyA to less than 50 mg twice daily resulted in unacceptable polyarthralgia.
RS represents one end of a spectrum of clinical phenomena that occur in ReA [6]. In the absence of a microbiological diagnosis or a clear history of preceding infection, it was difficult to establish a diagnosis of RS or ReA. However, the asymmetrical pattern of joint involvement, the presence of bilateral buttock pain and the ultimate development of radiologically convincing unilateral sacroiliitis (24 months after initial presentation) and the development of circinate balanitis (18 months after initial presentation) were considered to be supportive of incomplete RS. His human immunodeficiency virus (HIV) status was not ascertained, but the lack of HIV-AIDS manifestations more than 6 yr after the onset of illness weighs against this diagnosis. The patient did not satisfy the ACR (American College of Rheumatology) criteria for rheumatoid arthritis or EULAR (European League against Rheumatism) criteria for ankylosing spondylitis.
ReA is usually self-limiting [7]. Chronic disease occurs in a small minority of patients with community-acquired disease but in as many as 52% in hospital practice [8, 9]. The natural course of ReA is variable. Among those patients who qualify for trials of potential disease-modifying agents in ReA, remission is observed after 1 yr in approximately 80% of placebo recipients [10]! Our patient was severely ill and refractory to aggressive therapy. However, it is conceded that spontaneous improvement unrelated to AZA or CyA therapy may have occurred. Additional studies are required to confirm the efficacy of CyA and elucidate its mechanism of action in ReA.
Notes
Correspondence to: G. J. Carroll. 
References
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[Abstract/Free Full Text] - Glennas A, Kvien T, Melby K, Overboo A, Andrup O, Karstensen B et al. Reactive arthritis: a favorable 2 year course and outcome, independent of triggering agent and HLA-B27. J Rheumatol1994;21:2274–80.[Medline]
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