Reactive arthritis is a member of the spondyloarthropathy family, the family of conditions which includes AS. Giardia is an intestinal parasite which is common in certain areas of the world. It is usually spread through contact with contaminated water. Giardia-induced reactive arthritis is a treatable form of spondyloarthropathy- eradication of the parasite results in remission of the associated arthritis.
Giardia-induced reactive arthritis is probably underdiagnosed, since it is not often considered. Metronidazole (Flagyl ) is often used as the treatment for giardia, and in many cases only a short course is needed . Metronidazole is generally viewed as a safe medication (more on metronidazole in the pharmacy forum).
My son, now 17, developed joint pain after travel/exposure to an "uncertain" water source at the age of eight. At his worst (age 12-14), he was unable to stand, let alone walk, due to pain in the hip/groin area of both legs. The longest flare lasted five weeks, resulted in hospitalization and required steroid treatment to resolve. He suffered two more years of these strong flares, occurring every few months and requiring steroid treatment for resolution. Through reading on the internet and through reading in the medical school library, I came to be aware of the existence of the condition of parasite-induced reactive arthritis. Based on the history of travel and exposure to possibly contaminated water just prior to the start of pain, we asked the rheumatologist to prescribe a course of Flagyl (10 days of treatment, 3 tablets a day) as a "therapeutic trial" for possible giardia infection. My son has been in remission since the Flagyl, for a little more than three years now (knock on wood!). In retrospect it is likely that my son had suffered from giardia-induced reactive arthritis with remission induced by Flagyl treatment. The child who could not walk before has joined both the varsity track and cross country teams at school, running 13 mile in practice last fall!.
Here are titles of articles from medline on giardia-induced (or parasite-induced) reactive arthritis: The first listed is the article we brought in to share with our rheumatologist:
Layton MA, Dziedzic K, Dawes PT. Sacroiliitis in an HLA B27-negative patient following giardiasis. Br J Rheumatol. 1998 May;37(5):581-3.
"…From a clinical viewpoint, we feel that this case highlights the necessity of taking a detailed history. In the specific case of giardiasis, the intestinal infection may be asymptomatic and the diagnosis may be overlooked in a patient presenting with ReA. This is important as antimicrobial chemotherapy appears to be curative… We conclude that chronic giardiasis needs to be excluded in patients presenting with a spondyloarthritis, abdominal symptoms and a suspicious travel history."
(PDF file of the letter can be downloaded-click on link at the top of the abstract in Medline-the letter starts on page 5 of the PDF file)
Letts M, Davidson D, Lalonde F. Synovitis secondary to giardiasis in children. Am J Orthop. 1998 Jun;27(6):451-4. PMID: 9652890; UI: 98314998
"Giardia lamblia, a gastrointestinal protozoan, is one of the most common disease-causing parasites in the world. Giardiasis is primarily encountered in areas with poor sanitation, but it is also seen in more developed countries. A possible sequela of Giardia infections of the bowel is reactive arthritis or synovitis. Arthropathy secondary to giardiasis is uncommon, but may be underdiagnosed."
Tupchong M, Simor A, Dewar C. Beaver fever--a rare cause of reactive arthritis. J Rheumatol. 1999
Dec;26(12):2701-2. PMID: 10606388; UI: 20072404
"…Antimicrobial treatment is essential to eradicate the parasite and control the arthritis."
4. LeBlanc CM, Birdi N Giardia lamblia associated arthritis in a 19-month-old child J Rheumatol. 1999
Sep;26(9):2066-7. PMID: 10493698; UI: 99421441
5. Gato Morais R, Banez Sanchez F, Pascual Garcia J, Fernandez Crisostomo C, Garcia Jimenez C. [Reactive arthritis due to Giardia lamblia in a patient with IgA deficiency}. An Med Interna. 1998 Jul;15(7):398-9. Spanish. PMID: 9711002; UI: 98376861
6. Susano RC, de Quiros JF, Caminal L, Ferro J, Busono C, Gomez C [Reactive arthritis caused by Giardia lamblia in a patient with secretory IgA deficiency]. Acta Med Port. 1993 Dec;6(12):593-7. Portugese. PMID:8165930; UI: 94219244
7. Gonzalez-Gay MA, Cereijo MJ, Aguero JJ, Sanchez-Andrade A. [Arthritis reactive to Giardia lamblia]. Med Clin (Barc). 1992 Sep 26;99(9):359. Spanish. PMID: 1435014; UI: 93061484
8. Lorente T, Rosello R, Martinez B. [Reactive arthritis from Giardia intestinalis]. Med Clin (Barc). 1991 Nov 9;97(16):635-6. Spanish. PMID: 1766288; UI: 92114556
9. Gonzalez-Gay MA, Cereijo MJ, Aguero JJ, Sanchez-Andrade A, Lopez Roses L [Reactive arthritis and
infestation by Giardia lamblia]. Rev Esp Enferm Dig. 1991 Oct;80(4):269-70. Spanish. PMID: 1805894; UI:92215603
10. Arman MI. [Arthritis in lambliasis intestinalis (giardiasis) in the adult]. Z Rheumatol. 1991
Jul-Aug;50(4):216-8. German. PMID: 1746171; UI: 92081263
11. Brouqui P, Richard P. [Articular manifestations of Giardia lamblia infections]. Bull Soc Pathol Exot.
1990;83(5):688-9. French. PMID: 2085916; UI: 91199351
12. Shaw RA, Stevens MB. The reactive arthritis of giardiasis. A case report. JAMA. 1987 Nov
20;258(19):2734-5. PMID: 3312667; UI: 88036375
13. Barton JJ, Burke JP, Casey EB. Reactive arthritis--Giardia lamblia, another new pathogen? Ir Med J.
1986 Aug;79(8):223. PMID: 3759385; UI: 87007463
14. Woo P, Panayi GS. Reactive arthritis due to infestation with Giardia lamblia. J Rheumatol. 1984
Oct;11(5):719. PMID: 6512798; UI: 85082902
15. Di Pietro A, Proverbio MR, Coletta M, Siani P, Zeoli L, Tammaro V [Parasitic arthritis: a case report].Pediatr Med Chir. 1996 Mar-Apr;18(2):211-2. Italian. PMID: 8767588; UI: 96331028
16. Bocanegra TS, Vasey FB. Musculoskeletal syndromes in parasitic diseases Rheum Dis Clin North Am.1993 May;19(2):505-13. Review. PMID: 8502785; UI: 93276020
17. Doury P. [Is there a role for parasites in the etiology of inflammatory rheumatism?] Bull Acad Natl Med.1990 Jun-Jul;174(6):743-51; discussion 751-4. French. PMID: 2271983; UI: 91105559
18. Doury P, Pattin S, Dienot B, Roue R, Delahaye RP. [Parasitic rheumatism]. Sem Hop. 1977 Jun
9-16;53(22-23):1359-63. French. PMID: 197621; UI: 77258995
19. McGill PE. Rheumatic syndromes associated with parasites. Baillieres Clin Rheumatol. 1995
Feb;9(1):201-13 PMID: 7728882; UI: 95246156
20. Meza-Ortiz F. Giardiasis-associated arthralgia in children. Arch Med Res. 2001 May-Jun;32(3):248-50.PMID: 11471528