Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ For further information, see CMDT Part 20-33: Reactive Arthritis + Key Features Print Section ++ ++ Essentials of Diagnosis ++ Oligoarthritis, conjunctivitis, urethritis, and mouth ulcers most common features Usually follows dysentery or a sexually transmitted infection Fifty to 80% of patients are HLA-B27 positive ++ General Considerations ++ Reactive arthritis Precipitated by antecedent gastrointestinal and genitourinary infections Manifests as an asymmetric sterile oligoarthritis, typically of the lower extremities Frequently associated with enthesitis Extra-articular manifestations are common and include Urethritis Conjunctivitis Uveitis Mucocutaneous lesions ++ Demographics ++ Most common in young men The gender ratio: 1:1 after enteric infections but 9:1 with male predominance after sexually transmitted infections Associated with HLA-B27 in 80% of white patients and 50–60% of blacks + Clinical Findings Print Section ++ ++ Symptoms and Signs ++ Most cases develop within 1–4 weeks after either a gastrointestinal infection (usually with Shigella, Salmonella, Yersinia, or Campylobacter) or a sexually transmitted infection (with Chlamydia trachomatis or perhaps Ureaplasma urealyticum) The arthritis is most commonly asymmetric and frequently involves the large weight-bearing joints (chiefly the knee and ankle) Sacroiliitis or ankylosing spondylitis is observed in at least 20% of patients Systemic symptoms including fever and weight loss are common at the onset of disease Mucocutaneous lesions may include Balanitis Stomatitis Keratoderma blenorrhagicum (indistinguishable from pustular psoriasis) When present, conjunctivitis is mild and occurs early in disease course Anterior uveitis, which can develop at any time in HLA-B27-positive patients, is a more clinically significant ocular complication Carditis and aortic regurgitation may occur ++ Differential Diagnosis ++ Gonococcal arthritis Psoriatic arthritis Ankylosing spondylitis Rheumatoid arthritis Behçet disease Arthritis associated with inflammatory bowel disease + Diagnosis Print Section ++ ++ Laboratory Tests ++ HLA B-27 test is useful in the diagnosis ++ Imaging Studies ++ Radiographic signs of permanent or progressive joint disease may be seen in the sacroiliac as well as the peripheral joints + Treatment Print Section ++ ++ Medications ++ Nonsteroidal anti-inflammatory drugs (NSAIDs) have been the mainstay of therapy Patients who do not respond to NSAIDs may respond to sulfasalazine, 1000 mg twice daily orally or methotrexate 7.5–20 mg per week orally Antitumor necrosing factor agents, which are effective in other spondyloarthropathies, may have efficacy in recent-onset disease refractory to NSAIDs, sulfasalazine, and methotrexate For chronic reactive arthritis associated with chlamydial infection, combination antibiotics taken for 6 months is more effective than placebo + Outcome Print Section ++ ++ Prognosis ++ While most signs of the disease disappear within days or weeks, the arthritis may persist for several months or become chronic Recurrences involving any combination of the clinical manifestations are common and are sometimes followed by permanent sequelae, especially in the joints (eg, articular destruction) ++ Prevention ++ Antibiotics given at the time of a nongonococcal sexually transmitted infection reduce the chance that reactive arthritis will develop ++ When to Refer ++ Refer to a rheumatologist for progressive symptoms despite therapy + References Print Section ++ + +Courcoul A et al. A bicentre retrospective study of features and outcomes of patients with reactive arthritis. Joint Bone Spine. 2018 Mar;85(2):201–5. [PubMed: 28238883] + +García-Kutzbach A et al. Reactive arthritis: update 2018. Clin Rheumatol. 2018 Apr;37(4):869–74. [PubMed: 29455267] + +Stavropoulos PG et al. Reactive arthritis. J Eur Acad Dermatol Venereol. 2015 Mar;29(3):415–24. [PubMed: 25199646]