Q: My 30 years old brother was asymptomatic 16 years back when he developed pain in his right ankle joint after a fall from a bike. His pain gradually increased in severity and in a few days he developed pain in knee, sacroiliac, shoulder, metacarpo phalangeal, proximal inter phalangeal and wrist joints. The involvement was bilateral. He also complained of body stiffness and fever. He was treated conservatively with medicines, steroids for 3-4 months and fluid from knee joint was aspirated. He had a similar episode after a gap of 2-3 years but now the frequency has increased and currently he has such episodes (sometimes milder) 1-2 times in a year. For first 10-12 years he was on continuous oral analgesics mainly NSAIDs (indomethacin 75 mg). For the last two years, he stopped indomethacin as he was diagnosed with chronic persistent reactive arthritis and started on DMARDs (sulfasalazine and methotrexate) with folate supplementation and selective cox 2 inhibitor (etorcoxib 90 mg). Upper gastrointestinal endoscopy came normal. ESR came down to 10 mm first hour. After a year, methotrexate was stopped as he wanted to father a child. But he had another episode and for the last four months his symptoms are not resolving. He had to take steroid injection (prednisolone 40 mg once weekly for 2 weeks). His haemoglobin level also has dropped from 8.6 g/dl to 7.9 g/dl in the last 15 days despite iron supplementation. How can chronic persistent reactive arthritis be treated?

A:You have described the symptoms in enough details. Your brother seems to be having Seronegative spondylarthropathy of reactive arthritis type. However, the status of following various other essential tests is not known by your description: Mantoux test, HLA B-27, CRP level, Rheumatoid factor, radiological evidence of sacroiliitis. If he wants to father a child, it is advisable to stop Salazopyrine and methotrexate. If you can afford it, switch to anti-TNF alpha antibodies biologic therapy, although it will be quite expensive. Once disease becomes inactive, and after he fathers the child, he can switch again to the DMARDs in case you can not afford expensive therapy. All this is to be done under guidance of a rheumatologist (Joint physician). If you have not consulted a rheumatologist so far, please get the diagnosis confirmed by him.