AN UNCOMMON CAUSE OF PERSISTENT DIARRHEA

Persistent Diarrhea (duration > 14 days) can have an etiology different than those seen in acute illness. We present the case of a 36-year-old female with no significant medical history. She had traveled 4 weeks prior to Marrakech, Morocco presenting during the trip acute initially non-bloody diarrhea with a low-grade fever then the presence of mucus and bright red blood. On arrival to Spain, she was reviewed by her GP with stool culture and study for parasite done that were negative. A week afterward she presented bilateral conjunctivitis that resolved with symptomatic therapy and 3 days prior to admission presented with pain in her left knee with swelling and lower back pain. She presented to the emergency department where orthopedic surgeon reviewed her knee and performed arthrodesis with the extraction of inflammatory culture and gram-negative fluid without birefringent crystal under the polarized microscope. Laboratory test showed a slight leukocytosis with normal x rays of the lumbosacral region and knee.

Colonoscopy showed multiple erosions of < 5 mm, some with an erythematous halo and general mucosal erythema of the left colon. Biopsy showed a chronic colitis suggestive of an infectious process. Stool cultures were positive for Shigella Flexneri and antibiotic therapy was started with ciprofloxacin. A lumbosacral MRI performed with arthritis of the right inter-joint articulations of L4-S1. The right knee was infiltrated with corticoids and NSAIDs started for pain control of lower back pain. She was diagnosed with enterocolitis due to Shigella with reactive arthritis. The patient presented clinical improvement and was discharged home.

Reiter's syndrome is a triad of arthritis, conjunctivitis/iritis and urethritis. Extra-articular infections that cause Reiter's syndrome have been identified, sexually transmitted diseases, found primarily in males and a post-dysentery form that often affects women, children, and the elderly as seen in our patients.