Reactive Arthritis

By admin Last updated Feb 26, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Reactive Arthritis

Reactive Arthritis

Chris Hutchins MD

Derek F. Papp MD

Basics

Description

Reactive arthritis (previously called
Reiter syndrome) is a form of reactive, inflammatory arthritis
classically associated with urogenital, ocular, mucocutaneous, and
musculoskeletal involvement.
This syndrome is categorized with the
group of seronegative arthritides, along with AS, psoriatic arthritis,
and enteropathic arthritis.
Diagnosis often is overlooked because of
its variable presentation and the similarities with other seronegative
arthritides and with gonococcal arthritis.
At examination, the classic triad of
symptoms—urethritis (or cervicitis in females), conjunctivitis, and
arthritis—often is not present or the symptoms of the urethritis or
conjunctivitis are mild and not recognized or described by the patient.
Moreover, cervicitis often is asymptomatic, thus making the probability of missing the diagnosis in females even greater.

General Prevention

Barrier methods of contraception to prevent transmission of venereal disease
Proper food handling and preparation to prevent food-borne infection

Epidemiology

Mean age of onset in 1 study was 38 years (1).

Incidence

The incidence of reactive arthritis is unknown and appears to depend on the population studied.
Affects whites more than other racial groups because of the former’s higher frequency of the HLA-B27 gene.
In Rochester, MN, the incidence in males <50 years old was 3.5 per 100,000 (2).

Risk Factors

HIV
HLA-B27 haplotype
Poor hygiene with associated exposure to enteric pathogens
Increased sexual activity and thus wider exposure to sexually transmitted pathogens
Geographic location, although this may be related to hygienic conditions and sexual behavior of the population

Genetics

HLA-B27 gene: 60% of patients (3):
- Persons with this gene are thought to be more susceptible to the disease.
- 80% of affected individuals have this haplotype (4).

Etiology

The cause of the disease is thought to be
an immune response to a sexually transmitted bacterial infection or to
bacterial gastroenteritis.
Most cases are transmitted sexually, as opposed to enterically.
Organisms that have been associated with the disease include the following:
- Chlamydia:
  - Chlamydia trachomatis and Chlamydia psittaci
  - Recent evidence shows that Chlamydia pneumoniae may be implicated (5).
- Campylobacter fetus or Campylobacter fetus jejuni
- Salmonella enteritidis, Salmonella heidelberg, or Salmonella paratyphi
- Shigella flexneri
- Ureaplasma urealyticum
- Yersinia enterocolitica or Yersinia pseudotuberculosis
- Giardia lamblia
- Cryptosporidium

Associated Conditions

HIV syndromes

Diagnosis

Signs and Symptoms

The onset of the disease process generally occurs 2–4 weeks after enteric or sexually transmitted infection.
Urethritis (classic presentation):
- Often the initial feature of the disease
- Males experience mild dysuria and/or a mucopurulent urethral discharge.
- Females may have dysuria, vaginal discharge, with or without purulent cervicitis/vaginitis.
- Genitourinary symptoms may evolve after sexual or enteric exposure.
Conjunctivitis in 30–50% of patients (4):
- Usually bilateral and can be as mild as onset of crusting of the eyelids each morning
- As such, often unnoticed by patient and physician
- Ocular involvement occurs along with urethral involvement, or within a few days of onset.
- Less commonly seen but much more serious is unilateral, acute uveitis with associated severe ocular erythema and photophobia (6).
Articular involvement:
- Most commonly includes acute
  oligoarticular arthritis with effusion, marked tenderness, and
  overlying erythema; a marked blue discoloration also appears sometimes.
- Pain on active and passive ROM
- The average number of joints involved is 4:
  - 1 or 2 joints have more severe involvement than do the others.
- Typically involves lower extremities (knees, ankles, feet) asymmetrically, although upper extremity involvement may be present.
- Axial involvement, with spondylitis or sacroiliitis:
  - Much more common in the chronic form
- Rarely involves hip
- Back pain and buttock pain are common.
Enthesopathies:
- An enthesis is an insertion of a tendon or ligament into bone.
- Very commonly involves the insertion of
  the Achilles tendon into the calcaneus or the plantar aponeurosis,
  causing characteristic heel pain
- Involvement of the extensor hallucis
  longus or extensor digitorum longus tendons gives rise to “sausage
  toes,” a characteristic of reactive or psoriatic arthritis.
- Although severe, the condition usually lasts only days to weeks before resolving.
Skin and mucous membrane involvement occur weeks after the inciting infection in 1 of several typical lesions.
- In keratoderma blennorrhagica, clear
  vesicles erupt on the palms and soles, then crust, forming
  hyperkeratotic lesions that look similar to psoriasis.
- Circinate balanitis is marked by small vesicles about the margins of the glans penis that are painless and self-limited.
- Small, painless, shallow erosions occur in the buccal mucosa.
- Fingernails and toenails are opaque and thickened, and can crumble and resemble mycotic infection.

History

The triad of urethritis, conjunctivitis, and arthritis is present in <1/3 of affected persons on examination.
Therefore, emphasis on the history—especially sexual history—is crucial!

Physical Exam

Given the often mild presentation, a thorough urogenital examination is important, especially in females.
All involved joints should be examined
for the presence of effusion, surrounding erythema, and pain on passive
and/or active ROM.
ROM of the lumbar spine

P.357

Tests

Lab

Positive HLA-B27 haplotype
Elevated ESR
Elevated C-reactive protein
Elevated C3 and C4 complement levels
Moderate leukocytosis with left shift
Mild anemia
Negative antinuclear antibody and rheumatoid factor
Joint fluid aspirate generally reveals an
elevated white blood cell count with values from 500–50,000 with
predominantly neutrophils.
Normal glucose and negative cultures, despite increased protein levels in the synovial fluid
Urethral swabs, cervical brushings, or fecal samples may be analyzed for chlamydial ribonucleic acid.
Sterile pyuria can be seen on 1st-voided morning urine sample.

Imaging

Radiographs are essential for documenting joint destruction: Obtain AP and lateral films.
Look for joint destruction, which may manifest as degenerative changes on either side of the involved joint and deformity.
Periosteal reactions indicating enthesitis can be seen at tendon insertions.

Differential Diagnosis

The differential diagnosis must include
the other seronegative spondyloarthropathies: Psoriatic arthritis; AS;
enteropathic arthritis
Psoriatic arthritis often presents with
sausage digits, and enteropathic arthritis may be associated with
gastrointestinal symptoms.
The differential diagnosis also must
include gonococcal arthritis, which may present with urethritis and is
associated with a positive sexual history.

Treatment

General Measures

Treatment is 2-fold, aimed at relieving the symptoms and eradicating the infection to prevent chronic reactive arthritis.

Activity

To prevent muscle atrophy or contractures, prolonged bed rest should be avoided.
Activity should be advanced as tolerated.

Special Therapy

Physical Therapy

A physical therapy program aimed at maintaining ROM should be instituted gradually.

Medication

First Line

NSAIDs:
- Indomethacin (25–50 mg orally 4 times daily)
- Sulfasalazine (2 g/day)
Steroids:
- Intra-articular injection of steroids may be helpful.
- Cutaneous lesions can be controlled with topical corticosteroids.
- Limited scientific evidence suggests that
  long-term treatment with antibiotics is effective in shortening the
  acute course of the disease or in preventing chronic disease.
Antibiotics: Treatment of bacterial infections such as Chlamydia may help lessen chronic sequelae (7).

Second Line

Immunosuppressive agents:
- Drugs such as methotrexate should be reserved for patients with severe, unremitting symptoms.
- Disease-modifying agents such as TNF inhibitors may offer hope in the future for those affected with chronic disease.

Surgery

Occasionally, arthroplasty is necessary.

Follow-up

Patients are followed-up at 3–6-month intervals, depending on the severity of their symptoms.

Disposition

Issues for Referral

Joint destruction

Prognosis

The arthritis typically resolves over several months to a year and leaves no disability.
15% of patients have chronic disease,
typically marked by chronic joint discomfort with occasional
exacerbations that are less severe than the initial presentation (8).
- Chronic arthritis may lead to permanent joint destruction and deformity.

Complications

Chronic arthritis may occur.

References

1. Savolainen
E, Kaipiainen-Seppanen O, Kroger L, et al. Total incidence and
distribution of inflammatory joint diseases in a defined population:
results from the Kuopio 2000 arthritis survey. J Rheumatol 2003;30:2460–2468.

2. Michet CJ, Machado EBV, Ballard DJ, et al. Epidemiology of Reiter’s syndrome in Rochester, Minnesota: 1950–1980. Arthritis Rheum 1988;31:428–431.

3. Ozgul A, Dede I, Taskaynatan MA, et al. Clinical presentations of chlamydial and non-chlamydial reactive arthritis. Rheumatol Int 2006;24:1–7.

4. Kataria RK, Brent LH. Spondyloarthropathies. Am Fam Physician 2004;69:2853–2860.

5. Reveille
JD, Arnett FC, Keat A, et al. Seronegative spondyloarthropathies. In:
Klippel JH, ed. Primer on the Rheumatic Diseases,12th ed. Atlanta:
Arthritis Foundation, 2001:239–258.

6. Kiss
S, Letko E, Qamruddin S, et al. Long-term progression, prognosis, and
treatment of patients with recurrent ocular manifestations of Reiter’s
syndrome. Ophthalmology 2003;110:1764–1769.

7. Carter
JD, Valeriano J, Vasey FB. Doxycycline versus doxycycline and rifampin
in undifferentiated spondyloarthropathy, with special reference to
chlamydia-induced arthritis. A prospective, randomized 9-month
comparison. J Rheumatol 2004;31:1973–1980.

8. Colmegna I, Espinoza LR. Recent advances in reactive arthritis. Curr Rheumatol Rep 2005;7:201–207.

Additional Reading

Petersel DL, Sigal LH. Reactive arthritis. Infect Dis Clin North Am 2005;19:863–883.

Miscellaneous

Codes

ICD9-CM

099.3 Reiter syndrome

Patient Teaching

Prevention

Prevent sexually acquired disease by using condoms.
Prevent food-borne infection by following proper food-preparation techniques.

FAQ

Q: How often does reactive arthritis lead to chronic problems?

A: ~15% of people develop chronic disease; only 20% of those develop chronic arthritis.