Reactive arthritis

Reactive arthritis, (formerly known as Reiter syndrome), is an autoimmune condition that occurs after a bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondyloarthritis because of its association with HLA-B27. Reactive arthritis primarily affects young men and usually presents with musculoskeletal or extra‑articular symptoms. The characteristic triad consists of arthritis, conjunctivitis, and urethritis. The diagnosis is based on clinical features such as patient history and physical examination; there are no specific tests for reactive arthritis. Treatment is primarily symptomatic and consists of the administration of NSAIDs, as most patients recover spontaneously.

• Genetic predisposition and association with HLA-B27 (see “Seronegative spondyloarthritis”)
• Commonly affects young men
• HIV infection is associated with a higher risk of reactive arthritis. ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Postinfectious autoimmune disorder
  • Posturethritis: after infection with Chlamydia (common) or Ureaplasma urealyticum
  • Postenteritis: after infection with Shigella, Yersinia, Salmonella, or Campylobacter ^[1]
  • In rare cases: after infection with Bartonella henselae ^[2]

She Cherishes Cooking Yummy Salmon: Shigella, Chlamydia, Campylobacter, Yersinia, and Salmonella are the most common causes for reactive arthritis.

• Latency period: 1–4 weeks
• Musculoskeletal symptoms
  • Oligoarthritis (sometimes polyarthritis) ^[3]
    • Acute onset
    • Often asymmetrical with a migratory character
    • Occurs predominantly in the lower extremities
  • Sacroiliitis
  • Enthesitis
  • Dactylitis
• Extra‑articular symptoms
  • Conjunctivitis or iritis
  • Dermatologic manifestations
    • Balanitis circinata: skin lesions of the glans resembling psoriasis
    • Keratoderma blenorrhagicum: hyperkeratinization of the palms and soles
  • Oral ulcers
• Symptoms from preceding infection
  • Diarrhea
  • Urogenital tract symptoms (dysuria, pelvic pain, urethritis, prostatitis) ^[1][4]

The classic triad of reactive arthritis consists of urethritis, conjunctivitis, and arthritis, but it manifests in only about a third of affected individuals.

Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis).

Reactive arthritis is a clinical diagnosis that may be supported by diagnostic steps, but there is no confirmatory test. ^[1][5]

• Laboratory tests
  • ↑ ESR and CRP
  • Test for potentially positive HLA-B27
  • Consider performing additional tests to confirm a preceding infection
    • Microscopy and culture of synovial fluid
    • Imaging
    • Stool and urine cultures
    • Urethral swab
    • HIV testing in patients with persistent symptoms
• Arthrocentesis
  • May be performed to rule out differentials
  • Findings from synovial fluid analysis include:
    • ↑ WBC count: 10,000–40,000/μL
    • Mostly polymorphonuclear leukocytes predominate
    • Gram stain and cultures are negative

Most common infection-associated differentials

Other

• Rheumatoid arthritis
• Seronegative spondyloarthritis
• Crystal-induced arthritis (i.e., gout, pseudogout)
• Systemic lupus erythematosus

The differential diagnoses listed here are not exhaustive.

There is no curative treatment. The goal of treatment is to primarily control symptoms as the disease is usually selflimiting. Extraintestinal manifestations should be treated as necessary.

• Arthritis
  • First-line: NSAIDs
  • Local treatment: cryotherapy and physiotherapy
  • If NSAIDs are not effective: glucocorticoids (intraarticular or oral)
  • In chronic cases : DMARDs, e.g., sulfasalazine or MTX
• Ongoing infection: See ”Bacterial gastroenteritis” and “Urethritis.”

• Resolves spontaneously within a year
• High rate of recurrence

1. Hu L. Clinical Manifestations of Lyme Disease in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-lyme-disease-in-adults.Last updated: August 17, 2016. Accessed: March 13, 2017.
2. Yu DT. Reactive Arthritis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/reactive-arthritis.Last updated: July 21, 2016. Accessed: March 16, 2017.
3. Diagnostic approach to polyarticular joint pain. http://www.aafp.org/afp/2003/0915/p1151.html. Updated: September 15, 2003. Accessed: March 16, 2017.
4. Lyme disease and the orthopaedic implications of Lyme arthritis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3656475/. Updated: February 1, 2011. Accessed: March 16, 2017.
5. Ruan XC, Lim JH, Tey HL. Acute Inflammatory Polyarthritis: A Rare Presentation of Secondary Syphilis.. Ann Acad Med Singapore. 2017; 46 (2): p.72-73.
6. Ghanem KG. Chapter 46: Disseminated Gonococcal Infection. In: Imboden JB, Hellmann DB, Stone JH, eds. Current Diagnosis & Treatment in Rheumatology, Third Edition. Third Edition, ed. McGraw-Hill Education / Medical ; 2013.
7. Li R, Hatcher JD. Gonococcal Arthritis. StatPearls. 2019 .
8. Barth WF, Segal K. Reactive arthritis (Reiter's syndrome). Am Fam Physician. 1999; 60 (2): p.499-503.
9. Maman E, Bickels J, Ephros M, et al. Musculoskeletal Manifestations of Cat Scratch Disease. Clinical Infectious Diseases. 2007; 45 (12): p.1535-1540. doi: 10.1086/523587 . | Open in Read by QxMD
10. Apoorva Cheeti; Rebanta K. Chakraborty; Kamleshun Ramphul.. Reactive Arthritis (Reiter Syndrome). StatPearls. 2020 .
11. Arthritis associated with enteric infection. http://europepmc.org/abstract/MED/12787523. Updated: April 1, 2003. Accessed: March 16, 2017.