Reactive arthritis

Last updated: May 18, 2022

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Reactive arthritis (formerly known as Reiter syndrome) is a postinfectious autoimmune condition that is most commonly preceded by bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondyloarthropathy and is associated with HLA-B27. Reactive arthritis often affects young adults and manifests with musculoskeletal and/or extraarticular symptoms. The classic triad of arthritis, conjunctivitis, and urethritis is only seen in about one-third of patients. The diagnosis is based on clinical features such as patient history and physical examination and may be supported by laboratory or imaging findings, although there are no specific confirmatory tests for reactive arthritis. Reactive arthritis usually resolves spontaneously within 6–12 months; treatment during this acute phase is primarily supportive (e.g., NSAIDs for arthritis). Underlying infections should be identified and treated. A small proportion of patients develop severe or chronic arthritis; for these individuals, systemic corticosteroids or disease-modifying antirheumatic drugs (DMARDs) may be required.

Epidemiological data refers to the US, unless otherwise specified.

Postinfectious autoimmune disorder [4]

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

Classic triad of reactive arthritis (seen in approximately one-third of affected individuals): “can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)”. [8]

Overview

Laboratory studies [1][6]

As with other seronegative arthropathies, there is an association between reactive arthritis and HLA-B27 (approximately 50–80% of HLA-B27 tests are positive in patients with reactive arthritis); however, HLA-B27 testing is not required to diagnose reactive arthritis and does not change the management of the condition. [1][6]

Genitourinary chlamydia infection is frequently asymptomatic; have a low threshold for testing for chlamydia in patients with reactive arthritis. [1]

Imaging [1][10]

Additional studies

Aortic regurgitation can be fatal if missed; request an echocardiogram if there are any concerning clinical features. [7]

Overview

Supportive therapy

Arthritis

Extraarticular manifestations [6][15]

Treatment should be overseen by the relevant specialist.

Management of underlying infections [6][11]

Infection-associated arthritis [20]

Differential diagnoses of infection-associated arthritis [9][21]
Condition Reactive arthritis Septic arthritis Lyme disease [22] Syphilitic arthritis
Nongonococcal Gonococcal (disseminated gonococcal infection) [23]
Causative pathogen
Risk factors
  • Frequent outdoor activities (e.g., hunters, farmers, hikers)
Onset
  • Acute
  • Acute
  • Variable [25]
  • Progressive
  • Progressive
Clinical features
Distribution pattern
  • Oligoarthritis
    • Asymmetrical
    • Migratory
    • Lower body (especially knee)
Treatment

Non-infectious arthritis [20]

The differential diagnoses listed here are not exhaustive.

  • Resolves spontaneously within a year
  • High rate of recurrence
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  3. Diagnostic approach to polyarticular joint pain. http://www.aafp.org/afp/2003/0915/p1151.html. Updated: September 15, 2003. Accessed: March 16, 2017.
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  10. Adizie T, Moots RJ, Hodkinson B, French N, Adebajo AO. Inflammatory arthritis in HIV positive patients: A practical guide. BMC Infect Dis. 2016; 16 (1). doi: 10.1186/s12879-016-1389-2 . | Open in Read by QxMD
  11. Fox C, Walker-Bone K. Evolving spectrum of HIV-associated rheumatic syndromes. Best Pract Res Clin Rheumatol. 2015; 29 (2): p.244-58. doi: 10.1016/j.berh.2015.04.019 . | Open in Read by QxMD
  12. Cusick MF, Libbey JE, Fujinami RS. Molecular mimicry as a mechanism of autoimmune disease. Clin Rev Allergy Immunol. 2012; 42 (1): p.102-11. doi: 10.1007/s12016-011-8294-7 . | Open in Read by QxMD
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  16. Sonia Szamocki, Clarissa Martyn-Hemphill, James S.A. Green. Reactive arthritis: can't see, can't pee, can't climb a tree. Trends Urol Men's Health. 2016; 7 (1): p.17-20. doi: 10.1002/tre.501 . | Open in Read by QxMD
  17. Jacobson JA, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria ® Chronic Extremity Joint Pain—Suspected Inflammatory Arthritis. J Am Coll Radiol. 2017; 14 (5): p.S81-S89. doi: 10.1016/j.jacr.2017.02.006 . | Open in Read by QxMD
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  22. Carlin E, Ziza J, Keat A, Janier M. 2014 European Guideline on the management of sexually acquired reactive arthritis. Int J STD AIDS. 2014; 25 (13): p.901-912. doi: 10.1177/0956462414540617 . | Open in Read by QxMD
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