Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 20-33: Reactive Arthritis + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Oligoarthritis, conjunctivitis, urethritis, keratoderma blennorrhagicum, and mouth ulcers common 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 Rash (keratoderma blennorrhagicum) 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 Download Section PDF Listen +++ +++ 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 (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 Download Section PDF Listen +++ +++ 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 and the peripheral joints + Treatment Download Section PDF Listen +++ +++ Medications ++ Nonsteroidal anti-inflammatory drugs (NSAIDs) have been the mainstay of therapy Patients who do not respond to NSAIDs may respond to sulfasalazine or methotrexate 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 (eg, rifampin [300 mg orally twice daily] in combination with either doxycycline [100 mg orally twice daily] or azithromycin [500 mg orally daily for 5 days then twice weekly]) taken for 6 months is more effective than placebo + Outcome Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ + +Carter JD et al. Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial. Arthritis Rheum. 2010 May;62(5):1298–307. [PubMed: 20155838] + +Hayes KM et al. Evolving patterns of reactive arthritis. Clin Rheumatol. 2019 Aug;38(8):2083–8. [PubMed: 30919146] + +Lucchino B et al. Reactive arthritis: current treatment challenges and future perspectives. Clin Exp Rheumatol. 2019 Nov–Dec;37(6):1065–76. [PubMed: 31140399] + +Zeidler H et al. Chlamydia-induced reactive arthritis: disappearing entity or lack of research? Curr Rheumatol Rep. 2019 Nov 19;21(11):63. [PubMed: 31741118]