Arthritis, Reactive

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

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

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

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

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