Reactive Arthritis

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Original Editors - Jennifer Colgan from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Reiter’s Syndrome is an autoimmune condition that develops in response to infection. It is marked by inflammatory synovitis and erosion at the insertion sites of ligaments and tendons. It is often referred to as reactive arthritis that follows an infection elsewhere in the body primarily in HLA-B27-positive individuals. 

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Prevalence

Prevalence is difficult to establish due to lack of consensus regarding diagnostic criteria, the nomadic nature of the young target population, the underreporting of venereal disease, and the asymptomatic or milder course in affected women. 

Two forms of RS are recognized:  sexually transmitted and dysenteric.  Sexually transmitted usually occurs in young men ages 20-40.  RS is less common in women, children, and the elderly, who usually acquire the dysenteric form after a bacterial infection.

Individuals with the HLA-B27 genetic marker have a predisposition and increased risk for developing RS following sexual contact or exposure to a bacterial infection.

Clinical Characteristics/ Clinical Presentation

Peak onset occurs in the third decade of life and more commonly affects males. In a mojority of cases history will elicit Sx of genitourinary or enteric infection 1-4 weeks prior to onset of other features. Urethritis, conjunctivitis, and arthritis are the three symptoms classically associated with Reiter’s Syndrome. Urethritis discharge is intermittent and may be asymptomatic.  Conjuctivits is usually minimal. The arthritis is usually asymmetrical and pulyarticular, occuring in the large joints of the lower extremities. Musculoskeletal manifestation are acute inflammatory arthritis, inflammatory back pain (in severe cases), and enthesitis.  Enthesitis is inflammation at the insertion of tendons and ligaments into bones.  Dactylitis or "sausage digit", plantar fasciitits, and achilles tendinitis are the most common sites. Skin lesions are very similar to those of psoriasis.  Constitutional symptoms include fatigue, malaise, fever, and weight loss.  Cardiovascular involvement with aortitis, aortic insufficiency, and conduction defects occur rarely.

The initial illness typically resolves in 3-4 months, however 50% of patients experience reoccurence of symptoms and components of the syndrome over a period of years. Joint deformity and ankylosis as well as sacroiliitis and spondylititis may occur with chronic or recurrent RS. 

Associated Co-morbidities

Reactive Arthritis is associated with and may be the presenting Sx of HIV.

Medications

There is no evidence that antibiotic therapy changes the course of the disorder. NSAIDS are the primary intervention.

Diagnostic Tests/Lab Tests/Lab Values

Due to various manifestations of the disease occurring at different times, a diagnosis may take months to establish. The combination of peripheral arthritis with urethritis lasting longer than 1 month is necessary before the diagnosis can be confirmed. Laboratory tests typically reveal an aggressive inflammatory process. Elevated ESR and C-reactive protein are detected, and thrombocytosis and leukocytes are common findings. Urine samples, genital swabs, and stool cultures are useful laboratory tests for identifying the triggering infection. Positive gonococcal cultures and a rapid response to penicillin therapy differentiate acute gonococcal arthritis from RS in sexually active young patients. Radiographic abnormalities may include asymmetric involvement of the lower extremity diarthroses, amphiarthroses, symphyses, and enthuses. Also, ill defined bony erosions with adjacent bony proliferation or paravertebral ossiciation may show.

Causes

Reiter’s syndrom usually follows venereal disease or an episode of bacillary dysentery (enteric infection).  Up to 85% of people with Reiter's possess the HLA-B27 alloantigen.  Individuals with the appropriate genetic background can develop reactive arthritis by an enteric infectipon.

Systemic Involvement

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Medical Management (current best evidence)

Tetracyclin or erythromycin 500 mg orally qid for 10 days is recommended in treatment of pt's with RS due to sexual exposure, because it is often associated with C trachmomatis infection.  No tx is necessary for conjunctivitis and mucocutaneous lesions, although topical opthalmic glucocorticosteroidsiritis may be required to treat iritis . Arthritis is treated with NSAIDs in doses similar to those used for RA. Enthesopathy may need to be treated with local injection of corticosteroids. 

Physical Therapy Management (current best evidence)

Physical Therapy is helpful during the recovery phase

Alternative/Holistic Management (current best evidence)

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Differential Diagnosis 

• Psoriasis
• Pityriasis rubra pilaris
• Lichen planus
• Lupus Erythematosus
• Dermatomyositis
• Behcet's disease
• Arthritis associated with gonococcal disease
• Rheumatoid arthritis
• Septic Arthritis
• Mycosis fungoides
• Subcorneal pustulosis of Sneddon-Wilkinson
• Atopic dermatitis
• Acute exanthematous pustulosis
• other causes of erythroderma  

Case Reports

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2141619/
2. http://web.ebscohost.com.libproxy.bellarmine.edu/ehost/pdfviewer/pdfviewer?vid=6&hid=6&sid=8f6576b8-d7f9-47a7-b612-599db37689f6%40sessionmgr12
3. http://proquest.umi.com.libproxy.bellarmine.edu/pqdweb?index=3&sid=1&srchmode=2&vinst=PROD&fmt=6&startpage=-1&clientid=1870&vname=PQD&RQT=309&did=50867742&scaling=FULL&ts=1270843747&vtype=PQD&rqt=309&TS=1270843769&clientId=1870

Recent Related Research (from Pubmed)

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