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INTRODUCTION

DEFINITION

Reactive arthritis refers to acute nonpurulent arthritis complicating an infection elsewhere in the body. The term has been used primarily to refer to spondyloarthritides following enteric or urogenital infections occurring predominantly in HLA-B27-positive individuals.

PATHOGENESIS

Up to 85% of pts possess the HLA-B27 alloantigen. It is thought that in individuals with appropriate genetic background, reactive arthritis may be triggered by an enteric infection with any of several Shigella, Salmonella, Yersinia, and Campylobacter species; by genitourinary infection with Chlamydia trachomatis; and possibly by other agents.

CLINICAL MANIFESTATIONS

The male:female ratio following enteric infection is 1:1; however, genito -urinary-acquired reactive arthritis is predominantly seen in young males. In a majority of cases, Hx will elicit Sx of genitourinary or enteric infection 1–4 weeks prior to onset of other features.

  • Constitutional—fatigue, malaise, fever, weight loss.

  • Arthritis—usually acute, asymmetric, oligoarticular, involving predominantly lower extremities; sacroiliitis may occur.

  • Enthesitis—inflammation at insertion of tendons and ligaments into bone; dactylitis or "sausage digit," plantar fasciitis, and Achilles tendinitis are common.

  • Ocular features—conjunctivitis, usually minimal; uveitis, keratitis, and optic neuritis rarely present.

  • Urethritis—discharge intermittent and may be asymptomatic.

  • Other urogenital manifestations—prostatitis, cervicitis, salpingitis.

  • Mucocutaneous lesions—painless lesions on glans penis (circinate balanitis) and oral mucosa in approximately a third of pts; keratoderma blennorrhagica: cutaneous vesicles that become hyperkeratotic, most common on soles and palms.

  • Uncommon manifestations—pleuropericarditis, aortic regurgitation, neurologic manifestations, secondary amyloidosis.

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

EVALUATION

  • Pursuit of triggering infection by culture, serology, or molecular methods as clinically suggested.

  • Rheumatoid factor and ANA negative.

  • Mild anemia, leukocytosis, elevated ESR may be seen.

  • HLA-B27 may be helpful in atypical cases.

  • HIV screening should be performed in all pts.

  • Synovial fluid analysis—often very inflammatory; negative for crystals or infection.

  • Radiographs—erosions may be seen with new periosteal bone formation, ossification of entheses, sacroiliitis (often unilateral).

DIFFERENTIAL DIAGNOSIS

Includes septic arthritis (gram +/−), gonococcal arthritis, crystalline arthritis, psoriatic arthritis.

TREATMENT Reactive Arthritis

  • Controlled trials have failed to demonstrate any benefit of antibiotics in reactive arthritis. Prompt antibiotic treatment of acute chlamydial urethritis may prevent subsequent reactive arthritis.

  • NSAIDs (e.g., indomethacin 25–50 mg PO tid) benefit most pts.

  • Intra-articular glucocorticoids.

  • Sulfasalazine up to 3 g/d in divided doses may help some pts with persistent arthritis.

  • Cytotoxic therapy, such as azathioprine [1–2 (mg/kg)/d] or methotrexate (7.5–15 mg/week) may be considered for debilitating disease refractory to other modalities; contraindicated in HIV disease.

  • Anti-TNF agents can be considered in severe chronic cases.

  • Uveitis may require therapy with ocular or systemic glucocorticoids.

OUTCOME

Prognosis is variable; 30–60% will have recurrent or sustained disease, with 15–25% developing permanent ...

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