Thanks to Tim for presenting the interesting case of a middle-aged man with h/o inadequately treated syphilis who presented with neck stiffness worse in the mornings, back pain, and blurry vision, admitted for presumed neurosyphilis.  Exam revealed inflammation of T2/T3 joints, L SI joint tenderness, and an inflamed R foot with dactylitis of the 3rd and 4th digits.  Further history revealed a recent gonorrhea/chlamydia for which he was treated and HLA B27 positivity consistent with reactive arthritis!  He was started on NSAIDs with significant improvement of symptoms.

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Clinical Pearls:

• Neurosyphilis is most commonly seen in HIV positive patients and can present at any time after infection.
• Early neurosyphilis occurs within the first year after infection and involves the CNS, meninges, and vasculature
  • Neurosyphilis presents with posterior uveitis or pan-uveitis whereas reactive arthritis presents with anterior uveitis
• Late neurosyphilis occurs >10 years after infection and involves the brain and spinal cord parenchyma
• The four main spondyloarthropathies are ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and IBD-related arthritis.
• The genital pathogen most commonly associated with reactive arthritis is chlamydia trachomatis.
  • HLA B27 is positive in 30-50% of patients
  • Mainstay of treatment is NSAIDs
  • Disease typically lasts 3-5 months.

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Syphilis

Neurosyphilis manifestations

• Refer to this prior post
• Early (w/n first year of infection)
  • CSF, meninges, vasculature
  • Symptomatic meningitis
  • Ocular syphilis (posterior uveitis, panuveitis)
  • Meningovascular syphilis
    • Arteritis of any sized vessel which can lead tostroke or spinal cord infarction
• Late
  • Brain and spinal cord parenchyma
    • General paresis (10-25 years after initialinfection)
      • Progressive dementia
      • Psychiatric symptoms
    • Tabes dorsalis (>20 years after initialinfection)
      • CSF may be completely normal
      • Affects dorsal columns
      • Symptoms
        • Sensory ataxia
        • Argyll-Robertson pupil
        • Lancinating pains
• Diagnosis
  • Non-treponemal tests (poor sensitivity but highspecificity)
    • VDRL
    • RPR
  • Treponemal tests
    • FTA-ABS
    • Syphilis EIA
  • In an HIV negative patient with suspectedneurosyphilis and a non-reactive CSF-VDRL, one can establish the diagnosis with
    • CSF lymphocytes >5 cells/microL
    • CSF protein concentration >45

Reactive Arthritis

• Epimiology
  • Young adults, M:F equal
• Typically follows GI or urogenital infections (several days to weeks after infection)
  • Chlamydia trachomatis (most common genital infection associated)
  • Yersinia
  • Salmonella
  • Shigella
  • Campylobacter
  • E coli
  • C diff
  • Chlamydia pneumoniae
• Manifestations
  • Mono- or oligoarticular pattern of arthritis,often involving the lower extremities, sometimes associated with dactylitis and enthesitis
  • The triad of arthritis, urethritis, andconjunctivitis is only present in a subset of patients (formerly called Reiter’s syndrome)
  • Ocular manifestions: conjunctivitis, less frequently anterior uveitis, episcleritis, and keratitis.
  • Other: 
    • Skin: keratoderma blennorhagica, erythema nodosum
    • Circinate balanitis 
    • Nail changes resembling psoriatic arthritis
• Lab
  • E/o of antecedent or concomitant infection
  • Elevated acute phase reactants
  • Positive HLA-B27 (present in 30-50% of patients)
  • Inflammatory synovitis
  • Imaging consistent with enthesitis or arthritis
• Treatment
  1. Treat any ongoing concurrent infection
  2. NSAIDs (first line)
  3. Steroids (if refractory to NSAIDs)
  4. DMARDS (for chronic reactive arthritis)
  5. Anti-TNF (last resort)
• Prognosis
  • Duration is typically 3-5 months
  • >6 months duration is considered chronic reactive arthritis
  • Most remit completely or have little active disease w/n 6-12 months after presentation
  • 15-20% may experience more chronic persistent arthritis