HSS Journal

, Volume 7, Issue 2, pp 187–189 | Cite as

Aortic Insufficiency in a Patient with Reactive Arthritis: Case Report and Review of the Literature

Case Report

Abstract

Background

Reactive arthritis (ReA) consists of the classic clinical triad of arthritis, urethritis, and conjunctivitis generally occurring within 6 weeks of an infection, typically of the gastrointestinal or genitourinary systems. Cardiovascular manifestations of ReA and other members of the spondyloarthritis family have long been recognized.

Case Report

A 43-year-old male who was human leukocyte antigen-27 (HLA-B27)-positive and who had ReA for 19 years developed severe aortic insufficiency requiring aortic valve replacement. Typically, the onset of musculoskeletal symptoms precedes development of aortic insufficiency by many years. The average calculated from reported cases was 13 years, with a range from 4 days to 61 years. The mechanism by which the aortic valve leaflets become targets in HLA-B27-associated disease is unclear. At one point, interest developed as to whether the HLA-B27 allele was independently associated with lone aortic insufficiency, in the absence of clinical spondylitis. The preponderance of cardiac abnormalities in patients with HLA-B27-positive ReA has led to the suggestion that a genetic syndrome of the heart consisting of aortic insufficiency and conduction-system abnormalities exists, and has been dubbed the “HLA-B27-associated cardiac syndrome”. This case highlights the importance of recognizing the association between HLA-B27-associated spondyloarthritis and serious aortic valvular complications.

Conclusion

Clinicians should maintain a high suspicion for aortic insufficiency in patients with ReA, including a low threshold for echocardiographic evaluation. A heightened awareness can lead to earlier identification and potential avoidance of fatal events in these patients.

Keywords

reactive arthritis aortic insufficiency 

References

  1. 1.
    Colmegna I, Cuchacovic R, Espinoza LR. HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations. Clin Microbiol Rev 2004; 17(2):348–69.PubMedCrossRefGoogle Scholar
  2. 2.
    Qaiyumi S, Hassan ZU, Toone E. Seronegative spondyloarthropathies in lone aortic insufficiency. Arch Intern Med 1985; 145(5):822–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Rodnan GP, Benedek TG, Shaver JA, Fennell RH Jr. Reiter’s syndrome and aortic insufficiency. JAMA 1964; 182:889–94.Google Scholar
  4. 4.
    Paulus HE, Pearson CM, Pitts W Jr. Aortic insufficiency in five patients with Reiter’s syndrome. A detailed clinical and pathologic study. Am J Med 1972; 53(4):464–72.Google Scholar
  5. 5.
    Machado H, Befeler B, Morales AR, Vargas A, Aranda J. Aortic insufficiency in Reiter’s syndrome. South Med J 1976; 69(7):955–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Cosh JA, Barritt DW, Jayson MI. Cardiac lesions of Reiter’s syndrome and ankylosing spondylitis. Br Heart J 1973; 35(5):553.PubMedGoogle Scholar
  7. 7.
    Collins P. Aortic incompetence and active myocarditis in Reiter’s disease. Br J Vener Dis 1972;48(4):300–3.PubMedGoogle Scholar
  8. 8.
    Good AE. Reiter’s disease: a review with special attention to cardiovascular and neurologic sequellae. Semin Arthritis Rheum 1974; 3(3):253–86.PubMedCrossRefGoogle Scholar
  9. 9.
    Zvaifler, NJ, and Weintraub, AM. Aortitis and aortic insufficiency in the chronic rheumatic disorders—a reappraisal. Arthritis Rheum 1963; 6: 241–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Misukiewicz P, Carlson RW, Rowan L, Levitt N, Rudnick C, Desai T. Acute aortic insufficiency in a patient with presumed Reiter’s syndrome. Ann Rheum Dis 1992; 51(5):686PubMedCrossRefGoogle Scholar
  11. 11.
    Bergfeldt L. HLA-B27-associated cardiac disease. Ann Intern Med 1997; 127(8Pt1):621–9.PubMedGoogle Scholar
  12. 12.
    Yates DB and Scott JT. Cardiac valvular disease in chronic inflammatory disorders of connective tissue: factors influencing survival after surgery. Ann Rheum Dis 1975; 34: 321–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Baron JH in Heberden Society, clinical meeting. Ann Rheum Dis 26 Feb 1960; 19: 183–5.Google Scholar
  14. 14.
    Bergfeldt L, Edhag O, Rajs J. HLA-B27-associated heart disease. Clinicopathologic study of three cases. Am J Med 1984; 77(5):961–7.Google Scholar
  15. 15.
    Block, SR. Reiter’s Syndrome and Acute Aortic Insufficiency. Arthritis Rheum. 1972; 15(2): 218–20.PubMedCrossRefGoogle Scholar
  16. 16.
    Cliff, JM. Spinal bony bridging and carditis in Reiter’s disease. Ann Rheum Dis 1971; 30(2): 171–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Dixon, AJ. “Rheumatoid arthritis” with negative serological reaction. Ann Rheum Dis 1960; 19:209–28.PubMedCrossRefGoogle Scholar
  18. 18.
    Du Bois RM, Freedman S. Rheumatoid factor in a patient with Reiter’s disease and aortic incompetence. Br Med J 1977; 41(6):451–5.Google Scholar
  19. 19.
    Hubscher, O, and Graci y Susini, J. Aortic insufficiency in Reiter’s syndrome of juvenile onset. J Rheum 1984; 11(1): 94–5.PubMedGoogle Scholar
  20. 20.
    Huppertz, HI and Sandhage, K. Reactive arthritis due to Salmonella enteritidis complicated by carditis. Acta Paediatr 1994; 83 (11): 1230–1.PubMedGoogle Scholar
  21. 21.
    Kean, WF, Anastassiades, TP, and Ford, PM. Aortic incompetence in HLA B27-positive juvenile arthritis. Ann Rheum Dis 1980; 39(3); 294–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Podell, TE, Wallace DJ, Fishbein, MC, Bransford, K, Klinenberg, JR, and Levine S. Severe giant cell valvulitis in a patient with Reiter’s syndrome. Arth Rheum 1982; 25(2): 232–4.CrossRefGoogle Scholar
  23. 23.
    Ruppert GB, Lindsay J, Barth WF. Cardiac conduction abnormalities in Reiter’s syndrome. Am J Med 1982; 73(3):335–40.PubMedCrossRefGoogle Scholar
  24. 24.
    Toone, EC, Pierce, EL, and Hennigar, GR. Aortitis and aortic regurgitation associated with rheumatoid spondylitis. Am J Med 1959; 26(2): 255–63.PubMedCrossRefGoogle Scholar
  25. 25.
    Unverferth, DV, Beman, FM, Ryan JM, and Whisler RL. Reiter’s aortitis with pericardial fluid, heart block and neurologic manifestations. J Rheumatol 1979; 6(2): 232–6.PubMedGoogle Scholar
  26. 26.
    Vazquez de Corral, L, Mejas, E, and Rivera, JV. Reiter’s syndrome: skeletal and cardiac scans. Bol Assoc Med P R May 1981; 73(5): 241–4.Google Scholar
  27. 27.
    von Leitner, ER, Kotter, V., and Schroder, R. Kardiale spatmanifestationen des morbus Reiter. Dtsch Med Wochenschr 1981;106(29–30): 939–41.CrossRefGoogle Scholar
  28. 28.
    Yates, DB, and Scott, JT. Cardiac valvular disease in chronic inflammatory disorders of connective tissue. Ann Rheum Disc 1975; 34(4): 321–5.CrossRefGoogle Scholar
  29. 29.
    Csonka, GW, Litchfield, JW, Oates, JK, Wilcox, RR. Cardiac lesions in reiter’s disease. Brit Med J 1961; Jan 28: 243–7.CrossRefGoogle Scholar
  30. 30.
    Howard JH, Litovsky SH, Tallaj JA, Liu X, Holman WL. Xenograft calcification in Reiter’s syndrome. J Heart Valv Dis Mar 2007; 16(2): 159–61.Google Scholar
  31. 31.
    Bergfeldt L, Insulander P, Lindbolm D, Moller E, Edhag O. HLA-B27: an important genetic risk factor for lone aortic regurgitation and severe conduction system abnormalities. Am J Med 1988; 85(1):12–18.PubMedCrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2011

Authors and Affiliations

  1. 1.Johns Hopkins University School of Medicine, Johns Hopkins Outpatient CenterBaltimoreUSA
  2. 2.Hospital of the University of Pennsylvania, Heart and Vascular CenterPhiladelphiaUSA

Personalised recommendations