[Question #3122] Difficult case

40 months ago

Dr.Handsfield/Hook,I’m a 37 yo m/w.My problem started in 2004.October 2004  I remember masturbating and rubbery ejaculate came out and hung out the end of penis. The last day of October 2004 I developed a sore throat with fever and body aches with white spots in throat. I went to my doctor and received a Zpack. Neg rapid strep test. I took 4 of the 250mg pills over the next three days and didn’t improve so i went back to Doc and received Amoxicillin 875mg 2 xDay for 6 days. My fever went away and throat improved. On day 6 of Amoxicillin my testicles began to ache severely and i went to my doctor. He asked about my sexual history.I had 2 new partners in the last year.Aug 2004 - i had unprotected vaginal sex for a few minutes with a woman i knew well. Didn’t ejaculate or urinate and went to bed.Early September 04-  i received oral sex from another woman and performed oral on her vagina unprotected. I spit on my hand after the oral and masturbated.My doctor stated i couldn’t have an STD and prescribed me Cipro 500 for 10 days for a UTI or prostatitis. He didn’t test me for any STDs.That week i started having urinary problems and difficulty emptying my bladder and a split stream/spraying. Prostate exam was very painful. IMy prostatitis didn’t improve so i was prescribed a month of Levaquin after the 10 days of Cipro and a  after the Levaquin a month of Doxycycline. My prostatitis didn’t improve. I became very depressed due to the testicular and back pain and urinary problems. In 2006 i developered finger and toe joint pain. In 2012 both my heels started hurting. I currently have chronic prostatitis, neck pain, plantar Fasciitis and Arthritis in my fingers and toes. I’ve been diagnosed with Reactive Arthritis. Was this triggered by Chlamydia after one unprotected intercourse? After my problems started both women told me they were tested negative forall STDs..
I had a negative Antibody test for Igg Chlamydia antibodies and neg. IGG/IGM C.Trach Antibodies.
Thanks for any help






H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
40 months ago
Welcome to the forum and thanks for your question. I happened to log in a few minutes after you posted it; most users should not expect nearly real-time replies.

I'm not sure why your question appeared in an atypical window, requiring scrolling to see all of it. I have copied it in this window, for my (and perhaps your and other users') convenience in reading and assimilating it. My reply appears in the window that follows.

HHH, MD

Dr.Handsfield/Hook,I’m a 37 yo m/w.My problem started in 2004.October 2004  I remember masturbating and rubbery ejaculate came out and hung out the end of penis. The last day of October 2004 I developed a sore throat with fever and body aches with white spots in throat. I went to my doctor and received a Zpack. Neg rapid strep test. I took 4 of the 250mg pills over the next three days and didn’t improve so i went back to Doc and received Amoxicillin 875mg 2 xDay for 6 days. My fever went away and throat improved. On day 6 of Amoxicillin my testicles began to ache severely and i went to my doctor. He asked about my sexual history.I had 2 new partners in the last year.Aug 2004 - i had unprotected vaginal sex for a few minutes with a woman i knew well. Didn’t ejaculate or urinate and went to bed.Early September 04-  i received oral sex from another woman and performed oral on her vagina unprotected. I spit on my hand after the oral and masturbated.My doctor stated i couldn’t have an STD and prescribed me Cipro 500 for 10 days for a UTI or prostatitis. He didn’t test me for any STDs.That week i started having urinary problems and difficulty emptying my bladder and a split stream/spraying. Prostate exam was very painful. IMy prostatitis didn’t improve so i was prescribed a month of Levaquin after the 10 days of Cipro and a  after the Levaquin a month of Doxycycline. My prostatitis didn’t improve. I became very depressed due to the testicular and back pain and urinary problems. In 2006 i developered finger and toe joint pain. In 2012 both my heels started hurting. I currently have chronic prostatitis, neck pain, plantar Fasciitis and Arthritis in my fingers and toes. I’ve been diagnosed with Reactive Arthritis. Was this triggered by Chlamydia after one unprotected intercourse? After my problems started both women told me they were tested negative forall STDs.

I had a negative Antibody test for Igg Chlamydia antibodies and neg. IGG/IGM C.Trach Antibodies. Thanks for any help

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
40 months ago
So basically the question is the origin of your reactive arthritis. For purposes of this reply, I'll assume the diagnosis is accurate. There is no single test for reactive arthritis and the diagnosis is based on a combination of findings and expert judgment, preferably by an experienced rheumatologist (arthritis/immunology specialist). But your symptome are consistent with ReA, and for purposes of this reply I will assume the diagnosis is accurate and you indeed have it.

You may have the impression that chlamydia is the only trigger of ReA. It is not; chlamydia accounts for a sizeable proportion of cases, but by no means all, maybe not even half. Several inflammatory conditions of the intestinal tract and genital tract can trigger it. The trigger in your case is not apparent to me, but all evidence is against chlamydia. It's pretty unlikely after only 2 episodes of unprotected vaginal sex, and oral sex carries little or no risk. Altered appearance of semen or testicular aching, without evidence of urethritis (urethral discharge), are not likely due to chlamydia. The negative blood test is against it, but the chlamydia blood tests are not very accurate, so we can't put too much weight on that result. Your partners' negative tests for chlamydia are additional evidence you also didn't have it.

It seems clear you had prostatitis, but chlamydia was not the cause. Chlamydia rarely if ever causes prostatitis, and its failure to improve with levofloxacin or doxycycline shows it was not chlamydial. Indeed, it probably was not due to any bacteria at all, which is why all three antibiotics made no difference. Most prostatitis is probably due to non-infectious inflammation.

As you probably know, genitourinary inflammation -- nongonococcal urethritis in men, cervicitis in women -- can be a manifestation of ReA. Indeed, it is often difficult to know whether NGU was the trigger of ReA or a manifestation of it. Prostatitis may also be possible, either as a trigger or as a manifestation of ReA.

In summary, it is clear you didn't have chlamydia and it wasn't the trigger of your ReA. Whether your prostatitis is part of your ReA syndrome or a trigger of it remains unclear. The most common other triggers are various gastrointestinal infections. If you had any illness associated with diarrhea in the months before onset of ReA symptoms, that's a much better bet for the origin than chlamydia is.

My final comment is to urge you to entirely cease wondering and worrying about the trigger of your arthritis. You'll probably never know, and at this point it makes no difference in your treatment or prognosis. I'm afraid you'll have to chalk it up as unknown, which in fact is the usual situation:  the exact trigger is not known for most ReA cases.

As implied above, presumably you are in the care of a rheumatologist, or at least have consulted with one. You might discuss this reply with him or her (you could print out this thread as a framework for discussion). My bet is s/he will agree with all I have said.

I hope this information is useful. Let me know if anything isn't clear.

HHH, MD
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40 months ago
HHH,
I am being treated by a rheumatologist and an ID doctor. It’s been difficult for me to NOT think my ONE unprotected encounter didn’t cause my ReA. I’m not sure I can believe my partner had negative results. The timing (2.5 to 3 months) prior to the encounter and being single/sexually active at that age makes it seem to be more than a coincidence. I realize Chlamydia was unlikely, but so is having ReA as a young healthy athlete. :( I also never really had acute swelling of joints. The joint pain developed over the course of 5 to 10 years.
As you’ve said the origin of my ReA shouldn’t be my focus now, but I’m sure you can imagine the guilt i associate with that one time i put my penis in a vagina without a condom and a chronic pain condition. 
There is also a new 6 month combo antibiotic treatment that’s showing promise for CT ReA.  My ID doc thinks it’s worth a try. 
I also don’t think it’s a coincidence that the throat infection and fever preceded my health problems by a few days. Post strep ReA? Throat Chlamydia?
I didn’t have dysentery prior to it, but i have had IBS (frequent loose stools and stomach pain) since i can remember.  And still do... No IBD on colonoscopy.
I realize the prostatitis could have been the first manifestation of ReA. 
I know you don’t value the CT IFA,Elisa tests to diagnose a Chlamydia infection but do the negative results contribute to your opinion? 
Would a Chlamydia IGG response still register 13 years later if i was exposed? I’ve read that Men with SARA often have elevated Titers.
If there’s any chance I had Chlamydia I would want to try the 6 months of Rifampin/Azithromycin.  
Any more thoughts? Thanks!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
40 months ago
Hmmm....   You apparently came to the forum convinced your problem is related to chlamydia. So why did you ask about it if you weren't going to be persuaded by reasoned, common sense, science based reassurance? Your problem is inherently psychological. Yes, I can "imagine" the guilt you associate with a regretted sexual exposure and your later health problems. But I'm doing my best to reassure your ReA probably is not connected with the sexual events described, despite the coincidence in timing.

I don't understand your comment about ReA being unlikely in a "healthy young athlete". No data link physical conditioning or age with onset of ReA, and I have cared for a at least two buff young guys who had it.

"do the negative results contribute to your opinion?" I already said that your blood test results argue against a past chlamydial infection. They're not definitive, but yes, they contribute to my conclusion you never had chlamydia and that it wasn't the trigger of your ReA.

Chlamydia is not known to cause pharyngitis. There have been no reported oral chlamydial infections with symptoms. I don't know if strep or other pharyngitis can trigger ReA. It makes sense that it might, but I am unaware of any data on it. 

The potential efficacy of long-term antibiotics against ReA is not necessarily because of chlamydia. Azithromycin  is active against a wide range of bacteria other than chlamydia, and it has fairly potent anti-inflammatory effects, independent of its antibiotic activity. I'm not intimately familiar with the data on such treatment, but I'm inclined to believe it's worth a try. It isn't likely to be harmful, so why not? But this issue is independent of the potential triggering infectious or inflammatory event.

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40 months ago
I appreciate you frankness. I realize that there is a psychological aspect to my condition that can contribute to the suffering and surely anyone might feel it. I know I’ll never know what kicked this off. That being said
I did seek your world class expertise out to discuss the exposures I mentioned. 
Now that you’ve put my Chlamydia questions to rest could you reflect on the oral/vaginal sex i had with the 2nd woman approximately a couple weeks to a month before my sore throat, fever, body aches (elevated WBC) that preceded the prostatitis.  
I know you say gonorrhea of the throat is rare but could i have contracted it from licking her vagina and then it festered into a bad tonsillitis a few weeks to a month later? The woman was a middle class Caucasian who was  21 and I’m assuming quite sexually active since she jumped into the sack quite quickly with me.  She also said she would get tested and was clean but I didn’t trust her word.

1)How easily is Gon transferred this way?
2)If i had Gon in my throat and spit on my hand and masturbated could it get into my urethra?
3)would drinking beer and liquor daily help curtail a gon throat infection?
4)what demographic generally carries this?
 You now this bug and I’m quite tired of reading all the information on the web including govt./health sites.
Thanks for your no BS advice on this.






 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
40 months ago
Gonorrhea is not likely to have either occurred or, if it did, to contribute to your ReA. Vaginal to oral gonorrhea transmission is rare (it's quite common penis to mouth, but not vaginal to oral). Over 90% of oral gonorrhea is entirely asymptomatic. Pharyngitis and tonsillitis can occur, but I've never heard of a case that didn't develop symptoms immediately, i.e. within a few days of exposure; there are bno reports of onset delayed by 2 weeks or more. And it seems likely she wasn't infected. (You seem to have doubts about your partners' testing histories. Most people don't lie in situations like that. When people are told a partner has an STD and may have caught it from them, most people get it checked out pretty quickly. You would have done that, right? So why not your partners?) In any case, if you had gonorrhea at that time, the azithromycin and/or amoxicicllin would have cured, and so would the follow-up treatments you had for prostatitis.

To these specific questions:

1) Gonorrhea transmission by cunnilingus:  very rare but happens from time to time. But probably only with more prolonged oral sex, not a few licks.
2) Auto-infection of new body sites doesn't occur with gonorrhea -- at least no cases ever reported. The only known exception is eye infection in persons with genital gonorrhea.
3) Alcohol has no known effect either in helping clear pharyngeal gonorrhea or making it worse.
4) The frequency of oral gonorrhea is directly correlated with frequency of performing oral sex on men (fellatio):  highest rates in men who have sex with men, lower rates in women who perform oral on their male partners, and very rare in men whose only oral exposure is cunnilingus on women (and in lesbian women). Most STD clinics don't even test for oral gonorrhea if their only oral exposure was cunnilingus.

In any case, all this is irrelevant to your ReA. As noted previously, I cannot exclude the possibility that your pharyngitis/tonsillitis contributed to it, but I think it unlikely -- and I imainge your ID and rheumatologist agree. Although you'll never know for sure what triggered it, in my view it was not the result of any of the sexual exposure or symptoms you had back in 2004.

Good luck going forward, including best wishes for a good outcome if you try the azithro/rifampin regimen.

That concludes the two follow-up comments and replies included with each thread, and so concludes this discussion. I hope it has been helpful.

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