From the Guidelines
Migratory arthritis is most commonly caused by rheumatic fever, which is triggered by a Group A Streptococcal infection, but other causes such as gonococcal infection, Lyme disease, and inflammatory bowel diseases should also be considered. The etiology of migratory arthritis is complex and multifactorial, involving various underlying conditions that trigger an autoimmune response or direct invasion of the joint by infectious agents. According to the Jones criteria revision of 1992, as described in the study by 1, the arthritis of acute rheumatic fever (ARF) is a migratory polyarthritis, typically affecting large joints like knees, ankles, elbows, and wrists. Other important causes of migratory arthritis include gonococcal infection, which often presents with migratory polyarthralgia before settling into a septic monoarthritis; Lyme disease, caused by Borrelia burgdorferi transmitted through tick bites; inflammatory bowel diseases like Crohn's disease and ulcerative colitis; viral infections such as hepatitis B, parvovirus B19, and rubella; reactive arthritis following gastrointestinal or genitourinary infections; and systemic lupus erythematosus. The pathophysiology typically involves either direct invasion of the joint by infectious agents or immune complex formation and deposition in the synovium, triggering inflammation that can migrate between joints, as seen in adult-onset Still's disease, where arthritis and arthralgia are found in the majority of patients, with incidences ranging from 64% to 100%, as reported in the study by 1. Proper diagnosis requires consideration of the patient's complete clinical picture, including recent infections, travel history, and systemic symptoms, and management should be guided by the latest recommendations, such as those provided by the European League Against Rheumatism (EULAR), as outlined in the studies by 1 and 1. In terms of management, the goal is to achieve clinical remission, and treatment strategies should be guided by regular monitoring of disease activity, adverse events, and comorbidities, with methotrexate considered the anchor drug, unless contraindicated, as recommended by 1. Overall, a comprehensive approach to diagnosis and management is essential to improve outcomes in patients with migratory arthritis.
From the Research
Etiology of Migratory Arthritis
The etiology of migratory arthritis can be attributed to various factors, including:
- Infection with Borrelia burgdorferi, the tick-transmitted spirochaete that causes Lyme disease 2, 3, 4
- Autoimmune responses triggered by infectious agents, such as Lyme disease 4, 5
- Complex interplay between microbes and host immunity, leading to prolonged inflammation and unique microbial and host interaction 3, 4
Lyme Arthritis as a Cause of Migratory Arthritis
Lyme arthritis is a common manifestation of late-stage Lyme disease, typically presenting as a monoarthritis or oligoarthritis in large joints such as the knee 2, 3
- Accompanying positive 2-tier Lyme serologies or polymerase chain reaction from synovial fluid/tissue is considered diagnostic for patients from an endemic area 2
- The mainstay of initial treatment is a prolonged course of oral antibiotics, with doxycycline recommended for late Lyme arthritis 3
Post-Infectious Lyme Arthritis
Post-infectious Lyme arthritis is a subset of patients who develop persistent arthritis despite antimicrobial therapy, thought to be related to prolonged inflammation and unique microbial and host interaction 3, 4
- This condition is characterized by an excessive, dysregulated pro-inflammatory immune response during the infection phase that persists into the post-infectious period 4
- Therapy at this stage relies on immunosuppression and/or synovectomy 3
Autoimmune Arthritides Following Lyme Disease
Systemic autoimmune joint diseases, such as rheumatoid arthritis, psoriatic arthritis, or peripheral spondyloarthritis, may follow Lyme disease 5
- These conditions typically present with polyarthritis, and patients with psoriatic arthritis or peripheral spondyloarthritis often have previous psoriasis, axial involvement, or enthesitis 5
- Treatment with anti-inflammatory agents, such as disease-modifying antirheumatic drugs, can result in improvement 5