Reactive Arthritis

Original Editors - [[User:|Jennifer Colgan]] from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors  

Definition/Description

Reiter’s Syndrome is a reactive arthritis that develops in response to an infection and characterized by a triad of arthritis, conjunctivits, and nonspecific urethritis.  It is considered an autoimmune disease marked by inflammatory synovitis and erosion at the insertion sites of ligaments and tendons. It commonly occurs after the presence of venereal disease process or enteric infection.  

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. 

Literature suggests that Reiter's Syndrome is more commonly seen in males, but recently studies suggest that the incidence in women is potentially underestimated.  Women's symptoms tend to be less severe than men and women are prone to genitourinary diseases often causing a misdiagnosis. (pathology book)

Individuals with the HLA-B27 genetic marker have an increased risk for developing Reiter's Syndrome following sexual contact or exposure to a bacterial infection. This history of infection (enteric or venereal) further increases the risk of developing Reiter's Syndrome.  There is a strong prevalence of Reiter's Syndrome in individuals with HIV.  The literature states that in patient's who are HIV positive, Reiter's Syndrome is more strongly correlated with male homosexuality than it is with people who have a history of injection drug use or other risky behaviors. (pathology book)

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.

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.

Reiter's Syndrome is also associated with or triggered by Shigella, Salmonella, Yersinia, Campylobacter, and Chlamydia.

Medications

There is no evidence that antibiotic therapy changes the course of the disorder. NSAIDS are the primary intervention.  Below is a list of several more options.

Non-steroidal anti-inflammatory drugs (NSAIDs)

• Non-selective cyclo-oxygenase (COX) inhibitors - Ibuprofen, Naproxen, Diclofenac, Nabumetone, and many others
• Selective COX-2 inhibitor: Celecoxib

Corticosteroids

• Systemic steroids seldom used except in more severe cases, and only in low doses (5-10 mg/day)
• Intra-articular steroids for individual joints (e.g., triamcionlone acetonide) - may be useful in almost any inflamed joint

Antibiotics

• Antibiotics probably not useful in patients with reactive arthritis following enteric infection (salmonella, shigella, etc.)
• Antibiotics for non-gonococcal urethritis in patients with previous episodes will decrease risk of recurrence from 37% to 10%.
• Longer course of antibiotics (i.e., 3 months) may reduce duration of acute illness following urogenital chlamydia infection; choices include:

                     – Doxycycline 100 mg qd
                     – Minocycline 100 mg bid
                     – Tetracycline 250 mg qid

Disease-modifying anti-rheumatic drugs (DMARDs)

• Used in more severe reactive arthritis, but not needed nearly as often as in rheumatoid arthritis

                     – Sulfasalazine 500-1,500 mg bid
                     – Methotrexate 7.5-25 mg weekly in single dose

DMARDs used rarely - all anecdotally, none well studied

• Hydroxychloroquine 200 mg bid
• Cyclosporine A 2.5 mg/kg/day
• Auranofin 3 mg bid
• Injectable gold (Solganol 50 mg q1-4 weeks)
• Azathioprine 50 mg bid-tid
• Leflunomide 10-20 mg qd (with or without loading of 100 mg for 3 days)

Biological therapies - all anecdotally - reserved for rare severe cases

• Etanercept 25 mg sq twice weekly; may be given alone, but usually used as addition to Methotrexate
• Infliximab 3 mg/kg IV - at weeks 0, 2, 6, and then every 8 weeks; dose can be increased up to 10 mg/kg; almost always given in conjunction with Methotrexate
• Adalimumab 40 mg sq every 2 weeks; may be given alone, but usually added to Methotrexate
• Golimumab 50 mg sq every 4 weeks; may be given alone, but usually added to Methotrexate
• Other biologics (certolizumab, abatacept, rituximab) have potential benefit, but not as extensively studied as others
  

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.

Bacteria that most often cause infections and Reiter's syndrome are Chlamydia, Salmonella, Shigella, Yersinia, and Campylobacter.  These can be developed through sexually transmitted diseases or contaminated food.  

You cannot devlop Reiter's sydrome from another person. However, the bacteria that trigger it can be passed on from one person to another.

Systemic Involvement 

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.

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. 

Very rarely surgery will be recommended such as a synovectomy, fusion, or tendon repair.  Total joint replacements usually for the hip are rarely needed.

Physical Therapy Management (current best evidence)

Physical Therapy is helpful during the recovery phase.  Physical Therapy should follow a program similar for any person who has arthritis. Pt. education is very important as well as well as regular exercise to increase ROM and conditioning. Strengthening of the muscles around the effected joints should be targeted to increase the overall joints support.  ROM is also important to prevent contractures, increase joint flexibility, and reduce stiffness. Goals of treatment should include: pain relief, improved activities of daily living, reduce joint swelling, prevention of joint damage and disability.  The Physical Therapist should provide exercise that helps maintain the person's strength while they are recuperating.    

Preferred Practice Patterns for Physical Therapy:
4E: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with Localized Inflammation.
6B: Impaired Aerobic Capacity/Endurance Associated with Deconditioning.

Alternative/Holistic Management (current best evidence)

• Bed Rest and decreased activity recommended during the day to decrease inflammation and pain caused by body's pressure on the joints with standing and other activities.  
• Ultraviolet Light Therapy can be performed by the PT
• Plant sterols and sterolins incorporated into the diet as well as hemp oil and barley grass root vitamin to help with inflammation
• colloidal silver and leaf capsules to wipe out the infection

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

Resources

Tools for the Physical Therapist:

1. Reactive Arthritis Checklist
2. Clinical References
3. Treatment Strategies

Support/additional Information to offer to your patient with Reiter's Syndrom:

1. http://risg.org/blog/
2. http://www.experienceproject.com/groups/Have-Reiters-Syndrome/92021

 

Recent Related Research (from Pubmed)

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