Joint Symptoms and Reactive Arthritis After a Waterborne Gastroenteritis Outbreak in Pirkanmaa ...

137 Pages·2014·1.47 MB·English

TERHI UOTILA
Joint Symptoms and Reactive Arthritis After
a Waterborne Gastroenteritis Outbreak
in Pirkanmaa, Finland, 2007
ACADEMIC DISSERTATION
To be presented, with the permission of
the Board of the School of Medicine of the University of Tampere,
for public discussion in the Small Auditorium of Building M,
Pirkanmaa Hospital District, Teiskontie 35,
Tampere, on November 7th, 2014, at 12 o’clock.
UNIVERSITY OF TAMPERE
TERHI UOTILA
Joint Symptoms and Reactive Arthritis After
a Waterborne Gastroenteritis Outbreak
in Pirkanmaa, Finland, 2007
Acta Universitatis Tamperensis 1989
Tampere University Press
Tampere 2014
ACADEMIC DISSERTATION
University of Tampere, School of Medicine
Tampere University Hospital, Department of Internal Medicine
Finland
Supervised by Reviewed by
Docent Markku Korpela Docent Anneli Lauhio
University of Tampere University of Helsinki
Finland Finland
Docent Jaakko Antonen Professor Tom Pettersson
University of Tampere University of Helsinki
Finland Finland
The originality of this thesis has been checked using the Turnitin OriginalityCheck service
in accordance with the quality management system of the University of Tampere.
Copyright ©2014 Tampere University Press and the author
Cover design by
Mikko Reinikka
Distributor:
[email protected]
http://granum.uta.fi
Acta Universitatis Tamperensis 1989 Acta Electronica Universitatis Tamperensis 1476
ISBN 978-951-44-9610-3 (print) ISBN 978-951-44-9611-0 (pdf)
ISSN-L 1455-1616 ISSN 1456-954X
ISSN 1455-1616 http://tampub.uta.fi
Suomen Yliopistopaino Oy – Juvenes Print
Tampere 2014
P4a4i1n o t7u2o9te
To my Family
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CONTENTS ……………………………………………………………….5

LIST OF ORIGINAL PUBLICATIONS …………………………………....7

ABBREVIATIONS …………………………………………………….....8

ABSTRACT………………………………………………..........................10

TIIVISTELMÄ……………………………………………………………..12

1. INTRODUCTION……………………………………………………….14

2. REVIEW OF THE LITERATURE……………………………………...15
2.1 Waterborne gastroenteritis outbreaks………………………15
2.1.1. Epidemiology………………………………………15
2.1.2. Microbiology………………………………….……16
2.1.2.1. Campylobacter……………………..………17

2.2. Joint symptoms and reactive arthritis ……………….……..22
2.2.1 Definition of reactive arthritis……….……………..22
2.2.2 Epidemiology of enteroarthritis…………………….26
2.2.3 Triggering infections in reactive arthritis…………..31
2.2.4 Pathogenesis of reactive enteroarthritis…………….33
2.2.5 Outcome of reactive enteroarthritis………………...36
2.2.6 Treatment of reactive arthritis……………...………40
2.2.6.1. Chlamydia-induced arthritis……………….40
2.2.6.2 Enteroarthritis……………………………..41

3. AIMS OF THE STUDY…………………………………………………43

4. POPULATION AND METHODS………………………………………44

4.1 Setting and study population……………………………….44
4.1.1 Setting……………………………………………....44
4.1.2 Study population…………………………………....46
4.2 Methods…………………………………………………….50
4.2.1 Clinical studies (Studies I-II)……………………………….50
4.2.1.1 Rheumatological examination……………………...50
4.2.1.2 Laboratory tests…………………………………….51

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4.2.1.3 Radiographic examination……………………….....52
4.2.1.4 One-year follow-up…………………………………52
4.2.2 Questionnaire studies (Studies III-IV)……………………...53
4.2.2.1 Population-based questionnaire study 8 weeks after
the outbreak (Study III)…………………………………….53
4.2.2.2 Population based questionnaire study of
Campylobacter-positive and -negative respondents 21 months
after the outbreak (Study IV)……………………………….54
4.2.2.3 Telephone survey 5 years after the outbreak…….…55
4.2.3 Statistics…………………………………………………….56
4.2.4 Ethical consideration……………………………………….56

5. RESULTS…………………………………………………………..……58
5.1 Patients referred for rheumatological examination ………...58
(Study I)
5.2 One-year follow-up of reactive arthritis patients …………..63
(Study II)
5.3 Questionnaire study 8 weeks after the outbreak…………....68
(Study III)
5.4 Questionnaire study of joint symptoms in
Campylobacter positive and negative subjects……………..72
(Study IV)

6. DISCUSSION……………………………………………………………80
6.1 Study methods………………………………………..…….80
6.2 Incidence and outcome of joint symptoms…………………83
6.3 Limitations of the study…………………………………….91
6.4 Open questions……………………………………………...92

7. SUMMARY AND CONCLUSIONS……………………………………93

8. ACKNOWLEDGEMENTS……………………………………………...94

9. REFERENCES…………………………………………………………..96

10. APPENDIX……………………………………………………………110

ORIGINAL PUBLICATIONS
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LIST OF ORIGINAL PUBLICATIONS

I. Uotila T, Antonen J, Laine J, Kujansuu E, Antonen J, Haapala
A-M, Lumio J, Vuento R, Oksa H, Herrala J, Kuusi M,
Mustonen J, Korpela M for the Pirkanmaa Waterborne Out-
break Study Group (2011): Reactive arthritis in a population
exposed to an extensive waterborne gastroenteritis outbreak
after sewage contamination in Pirkanmaa, Finland. Scand J
Rheumatol 40:358-62.

II. Uotila TM, Antonen JA, Paakkala AS, Mustonen JT, Korpela
MM for the Pirkanmaa Waterborne Outbreak Study Group
(2013): Outcome of reactive arthritis after an extensive Finn-
ish waterborne gastroenteritis outbreak: a 1-year prospective
follow-up study. Clin Rheumatol 32:1139-45.

III. Laine J, Uotila T, Antonen J, Korpela M, Kujansuu E, Lumio
J, Huovinen E, Mustonen J, Ruutu P, Virtanen MJ, Kuusi M
and the Pirkanmaa Waterborne Study Group (2012): Joint
symptoms after a large waterborne gastroenteritis outbreak - a
controlled, population-based questionnaire study. Rheumatol-
ogy 51:513-8.

IV. Uotila T, Korpela M, Vuento R, Laine J, Lumio J, Kuusi M,
Virtanen MJ, Mustonen J, Antonen J for the Pirkanmaa Wa-
terborne Outbreak Study Group (2014): Joint symptoms after
a faecal culture positive Campylobacter infection associated
with waterborne gastroenteritis outbreak: a questionnaire
study. Scand J Rheumatol. Sep 10, Epub ahead of print.
DOI:10.3109/03009742.2014.920916.

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ABBREVIATIONS

ACPA Anti-citrullinated protein antibody
ANA Anti-nuclear antibody
AS Ankylosing spondylitis
BASDAI Bath Ankylosing Spondylitis Disease Activity Index
BASFI Bath Ankylosing Spondylitis Functional Index
CARD Caspase recruitment domain
CB+ Campylobacter-positive
CB- Campylobacter-negative
CI Confidence interval
CD Cluster of Differentiation (surface antigen in cell)
CRP C-reactive protein
CRPS Complex regional pain syndrome
DMARD Disease-modifying anti-rheumatic drug
ECG Electrocardiogram
EIA Enzyme immunoassay
ESR Erythrocyte sedimentation rate
GC Glucocorticoid
GE Gastroenteritis
GI Gastrointestinal
GH Global health
HAQ Health Assessment Questionnaire
HLA Human leukocyte antigen
IBD Inflammatory bowel disease
IBS Irritable bowel syndrome
ICD-10 International classification of diseases
Ig Immunoglobulin
IL Interleukin
LPS Lipopolysaccharide
MMP-8 Matrix metalloproteinase-8
MRI Magnetic resonance imaging
NA Not analyzed
NOD Nucleotide-binding oligomerization domain
NSAID Non-steroidal anti-inflammatory drug
OR Odds ratio
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OTC drug “Over the counter” drug
PCR Polymerase chain reaction
PI-IBS Postinfectious irritable bowel syndrome
PsA Psoriatic arthritis
ReA Reactive arthritis
ReTEB Reactive tendinitis, enthesopathy or bursitis
RF Rheumatoid factor
SD Standard deviation
SIR Standardized incidence ratio
SpA Spondyloarthritis
SLE Systemic lupus erythematosus
STEC Shiga toxin-producing E. coli
Th1 T-helper type 1
Th2 T-helper type 2
TLR Toll-like receptor
TNF Tumor necrosis factor
uSpA Undifferentiated spondyloarthropathy
VAS Visual analogue scale
WHS Walkerton Health Study

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