I have become aware of two cases of chronic pain following a Stretococcal infection. This could be a flavour of an Ankylosing Spondylitis with sacroiliits being a prime factor. As a matter of fact in those patients with persistently elevated Antistretolysin titers (ASO titers) suggestive of chronic strep infection, “Most of the subjects with high ASO titer had unclassified or undifferentiated arthritis.”
Evidence-based correlation between anti-streptolysin O serum titer and sacroiliac joint disorder
Chang ST (Chang, Shin-Tsu), Ku CH (Ku, Chih-Hung), Cherng SC (Cherng, Shiou-Chi)
JOURNAL OF RHEUMATOLOGY 34(8): 1746-1752; AUG 2007 abstract
Acute Post- Streptococcus Reactive Arthritis:
1) Post – Streptococcus infection – strep throat, streptococcus septicemia, strep skin infection.
2) In adults, peak age is 21- 37 for onset.
3) Initially in adults, 46% had multiple joint involvement, 35% a few joints, and 19% had one joint affected. 81% of time condition was “non-migratory” – ie not jumping from joint to joint. Acutely, joints often affected included knee, ankle, hip, and wrist.
4) 66% had frank reactive arthritis lasting over 6 weeks, while arthralgias could persist after that.
5) While spinal arthritis was seen in only 2% of cases, if subject was HLA-B27 positive (known to be related to Ankylosing spondylitis as well), then incidence was 24%
6) Flare condition with recurrent infections and persistent Penicillin use can help prevent these flares.
Chronic Post Streptococcus Reactive Arthritis
1) Persistent sensitization indication – persistently elevated ASO titers with “Most of the subjects with high ASO titer had unclassified or undifferentiated arthritis”
2) Arthrtis responds poorly to NSAID’s “arthritis with poor responsiveness to salicylates/non-steroidals”
Rheumatology 2005 44(1):136
Poststreptococcal reactive arthritis (PSRA): a plea for diagnostic criteria
T. L. T. A. Jansen, M. Efde and A. Spoorenberg free article
3) Spinal involvement especially SI joints (as per #1 above). Pain is deep, dull, maximal over SI joint areas – ie parasagittal sacrum
4) If radiation, to thigh only
5) Patrick’s test was always positive!
6) Signs of inflammation – ESR, CRP – most often normal
7) Poor response to NSAID’s
8) Rare cases of soft tissue inflammation noted – supraspinatus or achilles tendonitis, dorsum foot tenosynovitis, adductor enthesitis (sore groin to knee area), dactylitis (sore swollen fingers)
9) Rare rashes – leukocytoclastic or necrotizing vasculitis rash – non blanching red spots, perhaps a bit lumpy, rarely forming ulcers.
10) MRI or SI joint scintigraphy might be positive in a research setting but I have not been convinced radiologists have had enough experience (and the equipment is advanced enough) to make a diagnosis here.
11) In all cases that were HLA-B27 positive (a marker used in kidney etc transplants) – all had spondylitis after early episode of post strep reactive arthritis
12) Fatigue is common in Ankylosing spondylitis so expect would be here too : Turan Y, Duruöz MT, Bal S, Guvenc A, Cerrahoglu L, Gurgan A.Assessment of fatigue in patients with ankylosing spondylitis.Rheumatol Int. 2007 Jul;27(9):847-52. Epub 2007 Jan 25.PMID: 17252263
TNF inhibitors like Etanercept (Enbrel) are now licenced for use in ankylosing spondylitis(AK) and found useful in AK with mixed connective tissue disease:
Yonsei Med J. 2008 Feb 29;49(1):159-62. Successful etanercept therapy for refractory sacroiliitis in a patient with ankylosing spondylitis and mixed connective tissue disease. Lee JY, Chang HK, Kim SK.
With Post Streptococcal reactive arthritis, it would seem prudent to keep on Penicillin while taking Enbrel.
Comment: This has a low potential for being diagnosed because:
1) Can’t see it – spinal
2) Poor response to arthritis pills – even I would have trouble diagnosing without a response to therapy
3) Normal ESR and CRP – blood work is no help
4) Xrays are normal and more involved imaging requires machinery and expertice I am not convinced is available here.
5) Women with the disorder will be confused with sacroiliac disease, a condition aggravated by the ligamentous loosening in pregnancy.
6) In women, I see this being confused with Fibromyalgia. I would only diagnose FM after treatment with Enbrel failed.
7) The major finding, though obviously not very specific, was a Positive patrick’s test:
Push knee down and brace opposite anterior pelvic brim – Look for pain IN THE BACK.
8) That finding, along with a positive blood test for ASO titer would be highly suspicious.
9) A short course of Prednisone (with a statin to help prevent osteonecrosis), or a Kenalog 60 mg IM shot (with statin coverage) could potentially unmask the inflammatory nature.
Anyone had experience with or have this condition?