Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : OR01 - OR03 Full Version

Joint Manifestations Following COVID-19 Infection- A Case Series of Six Patients


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51552.16192
Jyothi Visalakshy, Thomas George, Sekhar V Easwar

1. Associate Professor, Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita Nagar, Edappally, Ponekkara, Kochi, Kerala, India. 2. Senior Resident, Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita Nagar, Edappally, Ponekkara, Kochi, Kerala, India. 3. Physician Assistant, Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita Nagar, Edappally, Ponekkara, Kochi, Kerala, India.

Correspondence Address :
Thomas George,
Amrita Nagar, Edappally, Kochi, Kerala, India.
E-mail: thomasg@aims.amrita.edu

Abstract

A rare subset of Coronavirus Disease-2019 (COVID-19) positive patients has musculoskeletal manifestations including arthritis, arthralgia, myalgia and non specific bodyaches. Moreover, postviral Reactive Arthritis (ReA) has been reported following COVID-19 infection. This article reports the characteristic joint manifestations of Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) infection in 6 out of 211 consecutive patients with laboratory-confirmed diagnosis of COVID-19 and treated at dedicated hospital. One 49-year-old female patient developed arthritis while having active COVID-19 infection, one 54-year-old male had post COVID-19 ReA, and one 48-year-old female was found to have undifferentiated arthritis. One 58-year-old female patient was initially thought to have ReA the diagnosis was reconsidered later when her symptoms resolved without any disease modifying agents. Two patients 37-year-old male and 63-year-old female, developed arthralgia following COVID-19 infection. Non Steroidal Anti-Inflammatory Drugs (NSAIDs) and steroids were found to be beneficial in the series of patients. The key point to be noted is that not all arthritis or arthralgia following COVID-19 is ReA.

Keywords

Coronavirus disease-2019, Postviral arthritis, Severe acute respiratory syndrome-coronavirus-2

The ongoing pandemic of COVID-19 caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has affected more than thirty two crore cases across the world till mid-January 2022. Most common symptoms include fever, cough, fatigue, breathing difficulties, and loss of smell and taste (1). At least a third of the patients remain asymptomatic.

The ReA belongs to a group of diseases called spondyloarthropathies typically causing monoarthritis or oligoarthritis that usually involves the lower limbs (ankles and knees). It is commonly preceded by a gastrointestinal (Campylobacter, Salmonella and Shigella) or urogenital (Chlamydia) infection (2),(3). A rare subset of COVID-19 patients has musculoskeletal manifestations including arthritis, arthralgia and non specific bodyache (3). Moreover, few case reports of postviral ReA have been reported following COVID-19 infection (4),(5),(7). This article compiles a series of six patients with muskuloskeletal manifestations following COVID-19 infection.

Case Report

All the patients reported between September 1, 2020 to December 31, 2020 at a tertiary centre in Kerala, India. Overall, 211 consecutive patients with a history of COVID-19 infection were analysed for musculoskeletal manifestations during active infection and following it. Only those cases confirmed by a positive result to real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) assay for COVID-19 from throat swab specimens were included in the series (8). All patients with history of rheumatological diseases or joint disorders were excluded. Out of 211, 6 patients had muskulosteletal manifestations. The clinico biochemical parameters of the patients in present study are mentioned in (Table/Fig 1).

Case 1

A 49-year-old female had oligoarthritis with early morning stiffness involving left knee and left ankle on the second day of admission for COVID-19 infection. Inflammatory markers were high (ESR-92 mm/hr, CRP-204 mg/dL). Rheumatoid Factor (RF), Anti Cyclic Citrullinated Peptide (anti-CCP) and antinuclear antibody by Immunofluorescence-ANA (IFA) were negative. X-rays of ankles and knees were normal. A possibility of acute viral arthritis was made. Along with the ongoing Dexamethasone i.v. 6 mg once daily for active COVID-19 infection, colchicine was also added. Steroids were later converted to oral on discharge after he turned seronegative (14th day) and tapered and stopped over two weeks. Oral colchicine was continued for a total of three weeks, following which patient became completely asymptomatic, and the drug was stopped.

Case 2

A 54-year-old male with background history of hypertension developed right knee pain and swelling with early morning stiffness lasting more than 30 minutes, 3 weeks following detection of COVID-19 infection (patient was in isolation at home). Laboratory parameters showed raised Erythrocytes Sedimentation Rate (ESR) (64 mm/hr) and CRP (146 mg/dL). X-rays of knees, RF, Anti CCP and ANA were normal. A provisional diagnosis of post COVID-19 ReA was made. Synovial fluid aspiration and local steroid injection was not attempted, as patient didn’t gave consent. Stat dose of i.v. Dexamethasone 4 mg was given and patient was advised to take oral etoricoxib 60 mg twice daily, daily calcium and weekly Vitamin D 60000 units. The symptoms improved significantly on a two week follow-up and was advised to continue etoricoxib 90 mg once daily. On review after four weeks he was asymptomatic and inflammatory markers normalised (ESR 22 mm/hr, CRP- 0.9 mg/dL).

Case 3

A 58-year-old female presented with mild left knee arthritis with early morning stiffness lasting less than 30 minutes for three days duration, two weeks after recovery from COVID-19. Patient was admitted at the present facility during COVID-19 infection. Knee radiographic examinations were normal. Inflammatory markers were mildly raised (ESR - 32 mm/hr, CRP-12 mg/dL). Possibility of ReA was considered. RF and CCP were normal. Synovial fluid study couldn’t be done as patient did not consent. She was given stat oral etorcoxib 60 mg and topical preparations thereafter in view of five year history of type 2 Diabetes Mellitus and high normal creatinine values (0.9 mg/dL). Two weeks later on her review visit, she was completely asymptomatic. As she became completely asymptomatic without any active intervention, the possibility of ReA was considered unlikely at this stage.

Case 4

A 48-year-old female presented a week after recov-ering from COVID-19 infection with arthralgia involving bilateral elbows and knees with generalised bodyache. Laboratory parameters showed normal inflammatory markers (ESR-13 mm/hr, CRP 4.5 mg/dL). X-rays showed early osteoarthritic changes in bilateral knees. She was reassured and was sent home on oral calcium and vitamin supplements. She was asymptomatic on her 1-month revisit.

Case 5

A 37-year-old male, known diabetic with nephropathy, developed bilateral knee and right ankle arthritis three months after COVID-19 infection. He had high ESR of 67 mm/hr with normal CRP, normal knee and ankle X-rays. The Computed Tomography (CT) Chest showing bilateral ground glass opacities probably sequela of
COVID-19, ANA 2+ speckled pattern with normal complements. The RF (8 IU/mL) and anti CCP (5 U/mL) were normal and coombs test was negative. A provisional diagnosis of undifferentiated arthritis, probably triggered by COVID-19 was made and was initiated on oral prednisolone (0.5 mg/kg/day) and hydroxychloroquine 300 mg. He is assumed to return for his follow-up visit before long and is yet to be reviewed.

Case 6

A 63-old-year female, had non specific generalised joint pains involving small and large joints with no objective evidence of arthritis, 2two weeks following COVID-19 infection. Her inflammatory markers and X-rays were normal. She was reassured and was asked to review in case of persistent symptoms. She remained asymptomatic on follow-up after a month.

Discussion

Molecular mimicry is one among the proposed mechanisms of pathogenesis of viral associated arthritis (9). Examples of molecular mimicry concerning SARS-CoV-2 are reported and this mechanism is hypothetically involved in the pathogenesis of both the acute systemic infection and the postinfective viral related immunological consequences (10),(11),(12). Studies demonstrate that coronaviruses share molecular epitopes with human proteins (e.g., spike glycoprotein S) (13).

Out of 211 patients with history of SARS-CoV-2 infection, six patients developed joint manifestations. Out of six, only one patient developed ReA. One patient had arthritis during active COVID-19 infection. Two developed arthralgia following COVID-19 infection. One was diagnosed with undifferentiated connective tissue disease. Lower limb predominant oligoarticular involvement was observed to be the most common pattern of disease. None of them developed any extra-articular manifestations of ReA.

The most frequent presentation of ReA is oligoarthritis (14). It can affect any peripheral joint, but the knee is considered to be the most involved. Axial manifestations may go under-recognised (15). The diagnosis of ReA is established on the association of clinical and microbiological criteria (16). Since, the emergence of COVID-19, only a few cases of post COVID-19 ReA has been published. Honge BL et al., describes about post COVID-19 reactive monoarthritis involving right knee in a 53-year-old male (4). He was hospitalised for 12 days due to COVID-19. Few days following discharge, he developed severe right knee monoarthritis restricting his mobility. Synovial fluid analysis revealed numerous polymorphonuclear cells with sterile cultures with elevated CRP (279 mg/L). His RF, Anti CCP, HLA B-27 was negative. He was treated with NSAIDs (Ibuprufen 400 mg thrice daily) and short course of steroids (prednisolone 25 mg) for 10 days following which he became asymptomatic.

Mukarram IG et al., describes about post COVID-19 ReA involving right knee in a 34-year-old male patient 10 days after testing positive for COVID-19 (5). The MRI of knees showed mild joint effusion and had elevated levels of CRP and ferritin. Treatment with intra-articular steroids and 10 days with NSAIDs made him asymptomatic.

Ono K et al., reports on a 50-year-old male patient who was admitted for COVID-19 pneumonia and developed bilateral ankle arthritis and right achilles tendinitis (6). Synovial fluid was inflammatory in nature with no growth of any organism. The RF, Anti CCP, HLA B-27 all were negative. He was diagnosed with ReA; NSAIDs and intraarticular corticosteroid injection resulted in moderate improvement.

A 73-year-old man with diabetes mellitus, hypertension, and coronary heart disease as reported by Saricaoglu EM et al., developed swelling, redness, pain, and tenderness in the left first metatarsophalangeal, proximal and distal interphalangeal joints and right second proximal and distal interphalangeal joints two weeks following onset of symptoms of COVID-19 (7). The CRP and ferritin were markedly elevated. The RF, Anti CCP and serum uric acid levels were normal. Arthritis symptoms resolved completely with one week NSAIDs.

In the current study group and previous published case reports, post COVID-19 ReA was reported in males. The ReA patient had right knee monoarthritis as in the other two reports (4),(5). Lower limb predominant oligo or monoarthritis involving large joints was the common pattern observed except in Saricaoglu EM et al., case (7). Inflammatory markers were elevated in all cases like in present case (CRP -146 mg/dL, ESR- 64 mm/hr). Synovial fluid study revealed inflammatory picture with negative culture in the published case reports and the authors couldn’t attempt the same due to lack of consent. The RF, Anti CCP and X-rays of affected joints were normal in all the cases as in present case.

The treatment of choice for ReA caused by other pathogens is NSAIDs and glucocorticoids. In present case series, and previously reported cases (4),(5),(6),(7), NSAIDs were employed and patients became clinically better although Mukarram IG et al., and Ono K et al., employed intra-articular steroids while Honge BL et al., used oral steroids in addition to NSAIDs (4),(5),(6). As in present case, all patients became asymptomatic or clinically better within one to two weeks following treatment.

The course of ReA varies considerably, probably depending upon the triggering pathogen and the genetic background of the host (17). The typical disease duration is three to five months. Most patients either remit completely or have little active disease within 6-12 months after presentation, but 15-20% may experience more chronic persistent arthritis (18). All of our patients improved clinically and biochemical parameters also improved during our follow-up after one month. One of our patients is yet to follow-up. Currently, five out of the six patients described above are asymptomatic and not on any medications now. Considering the current scenario, the prognosis of these patients is expected to be good. This series is limited by the lack of synovial fluid analysis and HLAB27 gene testing as the patients did not consent for the same.

Conclusion

All joint pains following COVID-19 may not be due to ReA. Out of six patients having muskuloskeletal manifestations from our 211 post COVID-19 patients, only one had ReA. He was successfully treated with parenteral steroids and oral NSAIDs. As increasing number of COVID-19 related arthritis reports are coming, further study is warranted.

References

1.
Wei M, Yang N, Wang F, Zhao G, Gao H, Li Y. Epidemiology of Coronavirus Disease 2019 (COVID-19) Caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Disaster Medicine and Public Health Preparedness. 2020;14(6):796-804. [crossref] [PubMed]
2.
Selmi C, Gershwin ME. Diagnosis and classification of reactive arthritis. Autoimmunity Reviews. 2014;13 (4-5):546-49. [crossref] [PubMed]
3.
Schenker HM, Hagen M, Simon D, Schett G, Manger B. reactive arthritis and cutaneous vasculitis after SARS-CoV-2 infection. Rheumatology. 2021;60(1):479-80. [crossref] [PubMed]
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Hønge BL, Hermansen ML, Storgaard M. reactive arthritis after COVID-19. BMJ Case Reports CP. 2021;14 (3):e241375. [crossref] [PubMed]
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Mukarram IG, Mukarram MS, Ishaq K, Riaz SU. Post-COVID-19 reactive arthritis: An Emerging Existence in the Spectrum of Musculoskeletal Complications of SARS-CoV-2 Infection. J Clin Stud Med Case Rep. 2020;7(101):2. [crossref]
6.
Ono K, Kishimoto M, Shimasaki T, Uchida H, Kurai D, Deshpande GA, et al. Reactive arthritis after COVID-19 infection. RMD Open. 2020;6(2):e001350. [crossref] [PubMed]
7.
Saricaoglu EM, Hasanoglu I, Guner R. The first reactive arthritis case associated with COVID-19. J Med Virol. 2020:jmv.26296. [crossref] [PubMed]
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Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y. Clinical features of patients with 2019 novel coro-navirus in Wuhan, China. Lancet. 2020;395(10223):497-506. [crossref]
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Gasparotto M, Framba V, Piovella C, Doria A, Iaccarino L. Post-COVID-19 arthritis: A case report and literature review. Clinical Rheumatology. 2021;40(8):3357-62. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2022/51552.16192

Date of Submission: Jul 24, 2021
Date of Peer Review: Sep 14, 2021
Date of Acceptance: Feb 07, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 11, 2021
• Manual Googling: Jan 28, 2022
• iThenticate Software: Feb 05, 2022 (15%)

ETYMOLOGY: Author Origin

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