Clostridium difficile is a well‐known cause of pseudomembranous colitis but is seldom thought of in the differential diagnosis of reactive arthritis. Here, we present a case to highlight this uncommon entity.

Case Presentation:

A 40 year old male was treated with clindamycin for a dental abscess six weeks prior to admission. He then developed profuse watery diarrhea with abdominal cramps and an outside hospital treated him empirically with metronidazole for C. diff colitis. Three weeks later his symptoms progressed to fever, myalgia, joint pain, weight loss and anorexia. He presented to our clinic and was admitted.

He worked in a steel mill but had no significant medical, travel, occupational, or exposure history. He denied tobacco, alcohol, or drug use and denied sick contacts, unusual food or insect exposure, or high risk sexual behavior.

On exam, he was in moderate discomfort, febrile and had orthostatic hypotension. Oral mucosa was dry. There was no lymphadenopathy or rash. Multiple joints were warm and swollen and mobility was limited due to pain. He had diffuse abdominal pain, but no guarding, rebound, or organomegaly. Stool was hemoccult negative. The remainder of the exam was normal.

Laboratory was significant for normal CBC, PT/PTT, chemistries and urinalysis. His ESR was 36 mm/hr but rheumatoid factor and ANA were negative. Blood and urine cultures, hepatitis panel, HIV, monospot testing, and CMV, Lyme and Parvovirus serologies were negative. Abdominal X‐rays were normal. Knee films showed minimal osteoarthritis. Stool for Giardia, Salmonella, Shigella, and Campylobacter were negative.

The patient's stool was positive for C. diff and he was started on metronidazole. Colonoscopy was consistent with C. diff colitis and revealed a 4mm sigmoid polyp. Colonic and polyp biopsies were negative for malignancy. Arthrocentesis for continued knee pain and swelling revealed a clear yellow aspirate negative for crystals, or infection, but WBC count was 8400/cc with 78% PMNs and 11% lymphocytes.

This patient's presentation was consistent with reactive arthritis due to C. diff colitis. He was started on indomethacin and prednisone in addition to the metronidazole. By discharge, his diarrhea had resolved and his arthritis was improving. Within a month, his symptoms had resolved.

Discussion:

Reactive arthritis is associated with many infectious etiologies. It is uncommon with C. diff colitis and in young patients with diarrhea and arthritis, inflammatory bowel disease is much more likely. Nonetheless, its rare association with C. difficile is known. This patient had prolonged diarrhea and had been on antibiotics so a gastroenterology consult was warranted. Arthrocentesis of joint effusion was indicated to help delineate therapeutic options. Joint aspirate consistent with reactive arthritis allowed initiation of therapy, NSAIDS, and helped avoid an expensive work‐up and shorten hospital stay.

Author Disclosure Block:

H. Singh, None; M.R. Janosko, None.