Patient re-presents to the clinic with reactive arthritis in the right hip after covid-19 infection: A case report


 Background: SARS-COV-2, first reported in December 2019, usually presents with respiratory symptoms but can have various other manifestations and sequelae. One of the rare complications of COVID-19 infection is Reactive Arthritis. This complication is more likely to occur following sexually transmitted or gastrointestinal infection.Case presentation: Herein, we report a 58 years old woman hospitalized following COVID-19 infection and was discharged after a week. She consequently presented to the clinic ten days after her discharge, complaining of walking difficulties and radiating pain in her right hip. After ultrasound and MRI, she was diagnosed with reactive arthritis inflammation in the hip’s neck. Other known microorganisms responsible for reactive arthritis were ruled out before attributing it to the earlier COVID-19 infection. She reached remission after being treated using a combination of indomethacin and depot methyl-prednisolone for 14 days. Conclusion: To our knowledge, this is the first case of reactive arthritis caused by SARS-COV-2 in the hip. Further attention should be paid to symptoms occurring after an episode of infection with COVID-19 in order to expand our understanding of the disease and the symptoms with which it can manifest.


Background
Autoimmune reactions to viral and bacterial infections are a known phenomenon, which occurs 2-4 weeks after infection and affects joints in the lower extremities. [1,2] SARS-COV-2 infection, rst reported in December 2020, was previously thought to display respiratory symptoms as part of the coronaviridae family; [3,4] The rapid spread of this virus, however, revealed various sequelae and symptoms, with the autoimmune system as the primary perpetrator of most of these reactions. [5,6] Herein we report a case of Reactive Arthritis (ReA) after COVID-19 infection. This case report was prepared following the CARE Guidelines [7].

Case Presentation
A 58 years old Iranian woman with a previous history of hypertension, coronary heart disease, and type 2 diabetes was admitted to the emergency room complaining of unproductive coughs, shortness of breath, and extreme fatigue. RT-PCR test using nasopharyngeal swab yielded positive results for the SARC-COV-2 virus; additionally, CT images showed ground-glass opacity typical of viral pneumonia. Upon hospitalization with an SPO 2 of 88%, a complete blood workup was performed. She was started on interferon β1, dexamethasone, ceftriaxone, enoxaparin, and nortriptyline and was discharged after ve days with oxygen levels of 92%. A summary of her laboratory results and her vital information is available in Table 1. Ten days after her discharge, she represented to the clinic complaining of radiating pain in her right hip, which had caused her walking di culties. Physical examination revealed movement di culties as well as pain in her right sacroiliac. Color doppler sonography of right lower extremities found no signs of either stenosis in the arteries and thromboses in deep and super cial veins. However, ultrasound images of the soft tissues around the hip revealed an increase in the thickness of synovium and articular effusion in the hip's neck with a 7 mm diameter (Fig. 1). Additionally, MRI revealed a uid rim around the pelvic area, suggesting in ammation in the right hip (Fig. 2). High CRP (6.5 mg/L) and ESR (45 mmol/h) suggested the presence of reactive arthritis in the right hip. Since reactive arthritis typically happens due to an infection, the patient was tested for Brucellosis (Using Wright, Combs Wright, and 2ME tests) and Tuberculosis (Using PPD skin test) as two of the primary organisms causing ReA. Enteric infections were also ruled out since no gastrointestinal symptoms were present. IgM and IgG tests of COVID-19 con rmed that the patient had antibodies from her infection with the SARS-COV-2 virus. A diagnosis of ReA after COVID-19 was established based on the lab results and the images.
The patient was started on 100 mg indomethacin twice a day and 80 mg IM depot prednisolone based on this diagnosis. She showed dramatic improvement starting ve days after her visit and reached remission after 14 days.

Discussion And Conclusions
Reactive arthritis is a form of spondyloarthritis that typically manifests with the involvement of one or a few joints asymmetrically following an infection episode, classically with genitourinary or gastrointestinal microorganisms [8,9]. These microorganisms, however, are not the only ones to which ReA can be attributed. Previous studies have reported ReA following HIV infection as well as with dengue and chikungunya viruses [10][11][12]. In theory, reactive arthritis can be caused by SARS-COV-2, since by now, it has been shown to cause multi-organ involvement, presenting with respiratory and neurologic, and gastrointestinal symptoms.
Only a few cases of arthritis caused by COVID-19 have been reported until now. Lopez-Gonzales reported 4 cases of acute arthritis during COVID-19 admission, all of which had rheumatologic background diseases [13]. Two other reactive arthritis cases following infection with SARS-COV-2 were reported, one of a 57 years old man in Japan and the other of a 73 years old man in Turkey [14,15]. In both cases and our case, arthritis symptoms appeared 2-3 weeks after being diagnosed with COVID-19. However, none of these two patients had any symptoms in their hip since their ReA had mainly affected smaller joints, particularly in the hands. To our knowledge, this is the rst case of ReA symptoms in the hip after COVID-

19.
Despite our effort to exclude the primary infections responsible for ReA, our ability to perform tests on the patients was heavily limited due to the high amount of resources allocated to COVID-19 patients during the current pandemic. Accordingly, we could not entirely rule out genitourinary infections or obtain a sample of the patient's synovial uid. Further investigation is required to establish the probability of ReA after infection with the SARS-COV-2 and to nd the most appropriate treatment for this condition. Informed consent was obtained from the patient for publication of this case report and any accompanying images.

List Of Abbreviations
Availability of data and materials: All data of this study are included in this published article.
Competing interests: All of the authors have no con ict of interest to declare. Funding: All of the authors have no funding sources to declare relevant to this report.

Authors' contributions:
Maryam Masoumi conceived and planned the visit. Maryam Masoumi, Tahereh Eftekhari and Rasoul Shajari carried out the physical examinations. Maryam Masoumi, Kamyar Shokraee and Soroush Moradi planned and carried out the laboratory tests. Kamyar Shokraee, Maryam Masoumi, Soroush Moradi, Tahereh Eftekhari and Rasoul Shajari took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research.