Hi everyone,  Over the past month or so, I've had very watery and horribly putrid smelling stool. My fingers, especially the knuckles are very painful and I've had 3 bouts of conjunctivitis (I've never had it before).  Labs show a 45 ESR, normal CRP, and an elevated calprotectin level.  My colorectal doc put me on Xifaxin 550mg twice a day.  He also scheduled a scope for 9/25.  I see my new GI on the 13th.  Any thoughts?

Thanks so much.

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This sounds like reactive arthritis. The diarrhea/conjunctivitis/arthritis combination used to be called Reiter’s Syndrome. The most common gastrointestinal bacteria involved are Salmonella, Campylobacter, Yersinia, Shigella, E. coli, and Vibrio. Did your doc happen to collect a stool sample for testing before starting the antibiotic?

Bacterial GI infections are usually contracted from contaminated food handled by someone who ignored the “Employees must wash hands...” sign in the bathroom. Some, like Shigella, are also infectious enough to be transmitted from person to person.

Calprotectin doesn’t give very useful information in most cases. It’s usually a good idea to try to identify the specific bacteria before treating with antibiotics. In any case these can run the gamut from clearing up by themselves to killing you (fortunately that’s unusual). It’s generally best to find an antibiotic that the specific bug is sensitive to, and treat with that.

Mostly it’s done by stool culture, which works best before antibiotics are started. C. diff is diagnosed with a different kind of test, but still best without antibiotics. You could try something like the following:

1) I have a combination of symptoms (diarrhea/arthritis/conjunctivitis) that sounds like Reiter’s syndrome/reactive arthritis.

2) It hasn’t responded to Xifaxan (if that’s still true)

3) Can we try a stool culture to look for a specific bacterial cause?

J-pouchers probably have a different bacterial risk profile than folks with colons, but I don’t know if anyone has studied it in detail. Since most of these infections are thought of as occurring in the colon, doctors sometimes assume that J-pouchers can’t get them. This is certainly false for C. diff, and probably false for the others, too.

Phun phact: One of the reasons the term “Reiter’s syndrome” has fallen out of use is that Reiter was a dreadful Nazi.

Here’s more than you probably wanted to know about diagnosis of bacteria in stool: https://cmr.asm.org/content/28/1/3

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