Relapsing Clostridium difficile colitis and Reiter's syndrome

We describe a patient with recurrent Clostridium difficile-associated colitis who suffered severe arthritis and urethritis with each of three episodes of diarrhea. Although immune complex formation was demonstrated in synovial fluid, neutralizing antibodies to C. difficile cytotoxin A and B were not found in either serum or synovial fluid. Cholestyramine did not prevent a third episode of colitis which followed the use of amikacin. This patient was HLA-B27 positive; she developed sacroiliitis, tenosynovitis, oligoarthritis, culture negative urethritis, and cervicitis. With the successful treatment of each episode of diarrhea, these additional symptoms resolved. The close temporal correlation between recurrences of C. difficile-associated colitis and these other symptoms strengthens evidence from other reports which suggests that colonic infections with C. difficile may precipitate the Reiter's syndrome. Evidence from this case does not support the contention that antibodies to C. difficile toxins are implicated in producing joint inflammation.