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For further information, see CMDT Part 20-33: Reactive Arthritis

Key Features

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


  • 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

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


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



  • 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



  • 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 ...

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