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.
