Key words
COVID19 - reactive arthritis - dactylitis - chilblain-like acral lesions
Schlüsselwörter
COVID-19 - reaktive Arthritis - Daktylitis - chilblain-ähnliche Läsionen der Akren
Introduction
Autoimmune and rheumatic diseases in patients after COVID-19 represent an urgent
public health problem. COVID-19 may unmask previously undiagnosed rheumatic
conditions or trigger and provoke the disease de novo. Several cases of acute
COVID-19-associated arthritis have been reported and classified as reactive
arthritis [1]. Clinical and laboratory
manifestations of arthritis observed after SARS-CoV-2 infections are similar to
reactive arthritis caused by other pathogens. However, post-virus arthritis remains
a diagnosis of exception, which highlights the importance of completing laboratory
and instrumental research for qualitative differential diagnostics. Complications
of
COVID-19 can manifest as joint pain in 31.4% of cases, but the occurrence of
dactylitis combined with acral lesions has not been studied yet [2].
Case Report
A 32 year old female patient was admitted to the Rheumatology department, with
clinical presentation of pain in the small joints of feet, redness, and swelling
of toes.
One month erlier, there appeared pain and swelling of the 1st
–5th toes on both feet. The patient was taking
over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) for a month,
without improvement.
Two months erlier hospital admission the patient was diagnosed with COVID-19,
with complaints of low-grade fever, weakness, fatigue, sore throat, and loss of
smell, that lasted for five days; and positive polymerase chain reaction (PCR)
of SARS-CoV-2 RNA confirmed the diagnosis. The patient was treated as an
outpatient due to a mild course of the disease.
The patient denied previous chronic diseases, and unhealthy behaviours, including
smoking. There was no evidence of psoriasis, uveitis, conjunctivitis,
inflammatory bowel disease, back pain, or burning sensation when urinating.
Family medical history was also unremarkable.
The clinical examination showed symmetric swelling of the 2nd
–5th proximal interphalangeal (PIP) joints and the
1st interphalangeal joint (IP) of both feet with obvious signs of
skin redness, decreased range of movement, and positive squeeze test ([Fig. 1]). No clinical signs of
sacroiliitis were revealed, and the Achilles’ tendons were not inflamed
as well. There range of the spinal motion did not show any limitations (BASMI
score 0), and other joints were unaffected.
Fig. 1 Pronounced dactylitis of both feet with chilblain-like
acral lesions.
The laboratory examination showed normal complete blood count, erythrocyte
sedimentation rate of 14 mm/h (Westergren assessment), C-reactive
protein of 4 mg/l (reference values 0–5 mg/l), uric acid
of 0.2 mmol/l (reference values 0.24–0.51 mmol/l),
coagulation parameters and D-dimer within limits, rheumatoid factor (RF) of 7.0
IU/ml (reference values 0–14 IU/ml) and anti-cyclic citrullinated
peptide antibodies (ACCP) of 0.5 IU/ml (reference values 0–15 IU/ml).
HLA-B27, HBsAg, HCV and HIV were negative, complement fractions C3, C4 within
normal limits, screening for antinuclear antibodies (ANA) normal (1:80). The
Chlamydia trachomatis DNA was not revealed in the PCR of the urogenital
sample.
The hands and feet X-ray did not show any pathologic findings. The MRI of the
sacroiliac joints showed no signs of sacroiliitis.
To exclude vascular abnormalities, nail fold capillaroscopy was conducted. The
examination showed U-shaped loops of capillaries, approximately the same width
and length, evenly distributed, with single dark mass that resembles hemosiderin
deposits due to micro-thrombosis and vasospasm with a normal number of
capillaries. The ultrasound of the small joints of the feet revealed synovitis
with increased vascularization of the 2nd– 5th of
the PIP joints and the 1st IP joint of both feet, tendovaginitis of
the flexors of the fingers, and tendinitis of the extensor of the first finger.
Based on the above-mentioned, the patient was diagnosed with COVID-19-related
undifferentiated dactylitis, combined with chilblain-like acral lesions,
HLA-B27-negative.
A single injection of betamethasone 0,3 ml into the 3rd-
5th PIP joints, and NSAIDs was recommended. Taking into account
the acral skin lesions and the results of nailfold capillaroscopy with the signs
of micro-thrombosis and vasospasm, aspirin 75 mg per day was added to
the therapy.
During the second examination , one month after hospital admission, the patient
noticed reduction in swelling and redness of the skin, but complained of
recurrent pain in the small joints of the feet. The manifestations of dactylitis
still persisted ([Fig. 2]). There were no
deviations from normal values in laboratory examination. Repeated ultrasound of
the feet showed persistent tendovaginitis of the flexors of the fingers and
decreasing intensity of synovitis of the 2nd- 5th PIP
joints and the 1st IP joints on both sides.
Fig. 2 Residual manifestation of dactylitis.
Due to polyarticular synovitis and tendinitis persisting over 6 weeks despite
therapy, we started treatment with sulfasalazine (2 g per day), and
NSAIDs (etoricoxib 90 mg daily for 4 weeks). After 6 weeks, regression
of exudative changes, pain, and swelling of the small joints of the feet was
detected.
Discussion and conclusions
The variety of joint and skin symptoms after a coronavirus infection is a major
challenge for the rheumatologist.
We used several clinical cases of COVID-associated dactylitis to understand possible
approaches to treatment. A similar case of dactylitis associated with COVID-19
resolved after taking naproxen and, unlike our case, did not require additional
therapy [3]. The first described clinical case
of COVID-19-induced polyarthritis of the small joints of the foot started 8 days
after infection and also disappeared after administration of NSAIDs [4].
Another interesting case series was published, which presented seven clinical cases
including the authors’ data. Thus, the authors noted that in two cases, the
“typically” affected joints were the knees, in the third one
– the ankles, and in the fourth – the small joints (left
1st MTP, PIP, DIP, and right 2nd PIP, and DIP), and in the
authors’ described clinical case – the knee and ankle, and only in
one case – tendinitis of the 2nd, 3rd and
4th extensor of the right hand was noted [5]. Notably, patients in six out of seven cases
were treated with NSAIDs, two of them with intra-articular glucocorticoids, and one
case resolved spontaneously without any therapy.
The uniqueness of our clinical case is in the fact that the patient had not only
dactylitis, but also the obvious chill-blain acral lesion, signs of vasospasm, and
micro-thrombosis by nailfold capillaroscopy. For this reason, we insist that this
case should be considered not only as an articular involvement but also as a
skin-vasculopathy one. Therefore, we drew attention to the experience of our
colleagues-dermatologists. Thus, Spanish dermatologists presented their experience
of treating the skin lesions associated with COVID-19 [6]. The present article investigates the
connection between different patterns of skin involvement and COVID-19. They
described twenty patients, six of them with acral erythema, seven patients with
purpuric maculopapular, four patients with dactylitis patterns, and three patients
with mixed patterns. All these clinical presentations in children and adolescents
were not characterized by any hematologic and serologic changes as well.
The most common skin manifestation is a chilblain-like acral lesion, which is often
associated with milder disease course of COVID, and is typical for children and
young adults [7]. The COVID-19-associated
cutaneous changes are not defined by a unified term, and are called “COVID
toes'', or “chill-blain acral lesions”, or
“red fingers” in different reviews and case reports. The mechanism
of development is still unclear, and an evidence-based approach to treatment has not
been developed yet [8].
There are still many clinical questions that need to be answered:
-
When should the COVID-related dactylitis therapy be started?
-
How long should NSAIDs be prescribed before starting the DMARDs?
-
Is it relevant to use the same approach as for post-viral reactive
arthritis?
-
What approaches should be used in the mixed cases of dactylitis and
microangiopathy?
-
What are the long-term outcomes of this condition that should be
expected?
Further observations should clarify whether these cases are to be interpreted as
manifestations of reactive arthritis or represent the beginning of a chronic
inflammatory process, the onset of which was merely provoked by the viral
infection.
The article describes the clinical observation of the onset of dactylitis and acral
lesions after COVID-19. Our clinical case demonstrates the complexity of diagnosis
after COVID-19, and the difficulty in choosing therapy for patients with dactylitis,
acral lesions, and chronic duration of the disease. Finally, this clinical case
formulates a series of questions and seeks to understand what approach will be most
beneficial for the patient.
