Concurrence of Sjögren's Syndrome in a Patient with Chlamydia-induced Reactive Arthritis; An Unusual Finding
A 40-year-old man presented with a history of swelling and pain of both ankle joints and plantar surfaces, and inflammatory back pain for 5 years. He also had dry mouth and eyes, and fatigue. The patient had a medical history of urethritis with a recurrent dysuria and pyuria, which was intermittently treated with systemic antibiotics.\nA physical examination revealed significant swelling of both ankle joints and severe tenderness around the bony insertion portions of the Achilles tendon. Tenderness was also noted in the: iliac crest (bilaterally), tibial tuberosities, and calcaneus. Bilateral keratoconjunctivitis sicca was confirmed by an ophthalmologic examination which included the Schimer's test (3 mm left eye and 2 mm right eye). However characteristic manifestations of ReA including keratoderma blennorrhagica, circinate balanitis, and painless oral ulcer were absent.\nLaboratory analyses on admission demonstrated a C-reactive protein of 2.0 mg/dL (normal: < 0.3 mg/dL) and a erythrocyte sedimentation rate of 36 mm/hr (normal: 0-20 mm/hr). Complete blood count and blood biochemistry produced normal findings. Routine analysis and culture of urine showed pyruia (WBC 10-19/high power field) without identification of any bacterial organisms. HLA-B27 was positive. ANA was detected at a titer of 1:320. RF and anti-Ro antibody were elevated to 56 IU/mL (normal: < 15 IU/mL) and 460 AAU (normal: < 150 AAU), respectively. However, anti-neutrophil cytoplasmic antibody, double-strand DNA antibody, anti-Sm antibody, anti-RNP antibody, and anti-La antibody were all negative. IgG titer for Chlamydia trochomonas was 4.0 (normal: <0.9); this value is almost four fold elevated compared to the cut-off value using the ELISA method.\nThe radiological finding of the sacroiliac joints revealed mild marginal irregularity and subchondral sclerosis at the left joint surface (). In addition to periostitis, soft tissue thickening, and subchondral sclerosis along the inferior and posterior aspects of the calcaneus, bony erosion was also present at the bony insertion site of the Achilles tendon (). A whole body bone scan using Tc99m-MDP showed more increased uptake at the left sacroiliac joint compared to the right joint; in addition, increased uptake of the left foot compared to the right was observed (). A reduced excretion or abnormal uptake of the salivary glands was not noted in the evaluation by salivary scan.\nOn the basis of: inflammatory back pain, asymmetrical sacroiliitis, evidence of urethritis by Chlamydia infection, recurrent pyuria, peripheral arthritis dominant in lower extremities, and enthesitis of Achilles tendon with radiological changes, a diagnosis of ReA combined with SS was assigned to the patient. The criteria were fulfilled for the diagnosis of ReA based ib the European Spondylarthropathy Study Group (ESSG) and SS of European-American Consensus Group, respectively, . For the enthesitis and arthritis, we administered low dose corticosteroid (prednisolone 5 mg/day), sulfasalazine (1,000 mg bid/day), and non-inflammatory anti-inflammatory drugs (NSAIDs). Intra-articular injection or intra-lesional infiltration of steroid was also performed for swollen joints and tender lesions of enthesopathy. Only 1 gram of oral azithromycine for urethritis was needed. Dry eyes were controlled by replacement with an artificial tear solution. The use of pilocarpine for dry mouth was withdrawn because of an erosive gastric lesion confirmed by endoscopy. After discharge from the hospital, inflammatory back pain, swollen joints, and enthesitis subsided. Laboratory findings indicating disease activity were also gradually improved. Pyuria resolved on repeat urine analysis.