COVID-19 can act as trigger for development of reactive arthritis

The investigators found that COVID-19 can act as a trigger or as a causative agent for the development of reactive arthritis, even with the absence of rheumatological disorders. They suggest that treating physicians should have a high index of suspicion while treating post-infectious COVID-19 patients with arthralgia.

Previous studies have shown an association between COVID-19 and immune-mediated conditions, including lupus, myositis, antiphospholipid antibody syndrome, and vasculitis. Emerging evidence has shown the potential occurrence of reactive arthritis in patients infected previously with COVID-19.

"There is a need to investigate further the underlying immune mechanisms behind the immune-mediated manifestations occurrence after COVID-19," the authors wrote. "COVID-19 could induce transient immunosuppression, which may lead to an immune-mediated innate response, with a marked increase in TNF-α, MIP1A, IP10, IL-10, IL-8, IL-7, IL-6, IL-2R, and IL-2. Hence, increased Interleukin-17 levels in serum have also been observed in patients with Middle East respiratory syndrome, whereas patients with COVID-19 showed elevated circulating Th17 cells. These interleukins are critical in the pathogenesis of psoriatic arthritis and psoriasis.

The systematic review by Filippo Migliorini, RWTH University Hospital, Aachen, Germany, and colleagues summarised the current evidence on reactive arthritis occurrence in patients previously infected by COVID-19.

The study was performed according to the PRISMA 2020 guidelines. All the clinical investigations describing reactive arthritis following COVID-19 were accessed. Online databases were accessed in September 2022.

The investigators retrieved the following data on COVID-19 management and severity:

• Hospitalization regimes (outpatient or inpatient)
• Type of treatment
• The need for mechanical ventilation
• Admission to the ICU (intensive care unit)
• Pharmacological management

Data on reactive arthritis were also collected.

The study led to the following findings:

· The authors retrieved data from 27 case reports, including 54 patients, with a mean age of 49.8 ± 14.5 years. 54% were women.

· The mean time between COVID-19 infection and the occurrence of reactive arthritis symptoms was 22.3 ± 10.7 days.

· Between studies, diagnosis and management of reactive arthritis were heterogeneous. Symptoms resolved within a few days in all studies considered.

· At the last follow-up, all patients were minimally symptomatic or asymptomatic, and any patient required no additional therapy or attention.

To sum up, low-quality evidence suggests that COVID-19 infection can be a trigger or causative agent for developing reactive arthritis, even in patients who did not show the antibodies of rheumatological disorders.

The diagnosis was made by exclusion: all patients shared a previous COVID-19 infection about 22 days before the symptoms. The length is similar to what is described in other reactive arthritis, which is about a few days to 4 weeks following an infection.

The researchers concluded, "within a few days, all cases were resolved in all studies considered. At the last follow-up, all patients were minimally symptomatic or asymptomatic and did not require additional therapy or attention."

Dr Raju Vaisyhya at Department of Orthopaedics, Indraprastha Apollo Hospitals Institutes of Orthopaedics, New Delhi, India one of authors told Medical Dialogues "Cases have been reported on the occurrence of reactive arthritis in patients previously infected with COVID-19. We did a systematic review of the literature and found 27 case reports (of 54 patients). The mean time span between COVID-19 infection and the occurrence of reactive arthritis symptoms was 22.3 ± 10.7 days. Symptoms resolved within few days in all cases. At last follow-up, all patients were minimally symptomatic or asymptomatic, and no additional therapy or attentions were required by any patient.

We found a poor evidence to suggests that COVID-19 could target the musculoskeletal system causing reactive arthritis at its post infectious stage. However, COVID-19 can act as a causative agent or as a trigger for development of reactive arthritis even without presence of antibodies of rheumatological disorders. Treating physicians should have a high index of suspicion while treating post infectious COVID-19 patient with arthralgia".

Reference:

Migliorini, F., Bell, A., Vaishya, R. et al. Reactive arthritis following COVID-19 current evidence, diagnosis, and management strategies. J Orthop Surg Res 18, 205 (2023). https://doi.org/10.1186/s13018-023-03651-6