Block 9: Reactive arthritis, RA Flashcards
Reactive arthritis
- Aseptic arthritis arising 1-6 weeks following gastrointestinal (Salmonella, Shigella Campylobacter) or urogenital pathogens (Chlamydia trachomatis). Chlamydia is the most common cause
- A seronegative spondyloarthropathy
- Triad of asymmetric oligoarthritis, urethritis and conjunctivitis
- Typical patient is a young male with lower back pain, heel pain, myalgia and multiple joint pain, stiffness or swelling with redness of eye
Seronegative spondyloarthropathy
- Includes reactive arthritis, psoriatic arthritis, ankolysing spondylitis and arthritis due to inflammatory bowel disease
- Association with HLA-B27
Clinical features of reactive arthritis- arthritic symptoms
- Peripheral arthritis: normally asymmetric oligoarthritis (knee, ankle and/or heel pain). Present especially in the morning. Some patient can develop chronic or recurrent arthritis, sacroiliitis and or spondylitis lasting more than 6 months
- Dactylitis: sausage digit- painful inflammation of an entire finger or toe
- Enthesitis: inflammation of ligaments and tendons
- Axial arthritis: spinal inflammation (sacroiliac joint and lumbosacral spine) manifests as nonspecific lower back pain and/or buttock pain and stiffness- especially during inactivity
Reactive arthritis: extra-articular manifestations
- Occular: conjunctivitis (normally appears during flares of arthritis), anterior uveitis, keratitis, corneal ulceration
- Genitourinary symptoms: prostatitis, urethritis and haemorrhagic cystitis
- Gastrointestinal symptoms: mild diarrhoea
- Mucosal and skin manifestations: Keratoderma blennorhagicum, Circinate balantitis, oral ulcers, nail changes like onycholysis, subungal keratosis or nail pitting
- Cardiac manifestations: pericarditis, aortic disease and conduction abnormalities
Reactive arthritis investigations
- Blood tests: ESR and CRP elevated
- Genetic and immunological markers: Rheumatoid factors and ANA, HLA-B27
- Urine test: leukocytes, haematuria and mild proteinuria. NAAT to detect Chlamydia
- Stool tests: Test for Salmonella, shigella, Campylobacter and Yersinia
- Radiography: changes only found in long standing disease (chronic ReA)
- MRI: to assess enthesitis and involvement in sacroiliac joints
- Synovial fluid analysis
ASAS classification criteria for axial SpA
- Back pain for 3 months or longer
- Age at onset < 45 years
- Sacroiliitis on imaging (radiographs or MRI) plus one or more SpA features or HLA-B27 plus two or more other SpA features
ASAS classification criteria for peripheral SpA
- Absence of back pain and the presence, usually in a person under 45 years old, of peripheral arthritis (usually lower limb predominant and asymmetric), enthesitis, or dactylitis, alone or in combination, along with one of two sets of additional features.
- One or more of the following from thefirst setconsists: Psoriasis, Inflammatory bowel disease, Preceding infection, Sacroiliitis on imaging (radiographs or MRI)
- Two or more features: Arthritis, Enthesitis, Dactylitis, past history or inflammatory back pain, positive family history of SpA
Reactive arthritis: treatment for arthritic symptoms
- NSAID’s
- Corticosteroids: in flare or unresponsive to NSAID’s. Intra-articular injections
- DMARD’s: second line, in chronic or erosive disease or when NSAID’s and steroids fail. Sulfasalazine is effective in peripheral. Methotrexate effective in acute and chronic disease
- Anti-TNF alpha therapy: third line
- Physiotherapy
Treatment in reactive arthritis
- Antibiotics in acute infection but not established reactive arthritis. Don’t use in gastrointestinal infections
- Remission: doxycycline or azithromycin combined with rifampicin for 6 months
- Circinate balanitis and mild to moderate keratoderma blennorrhagica should be treated with topical steroids.
- Anterior uveitis: systemic corticosteroids
Complications of reactive arthritis
- Secondary arthritis
- Ankylosing spondylitis
- Ocular complications: recurrent iritis/uveitis can cause cataracts, cystic macular oedema
- Keratoderma blennorrhagicum: pustular or plaque like lesions typically on the soles or palms
- Cardiac complication: proximal aortitis
- Rarely severe glomerulonephritis and immunoglobulin A nephropathy
Reactive arthritis: factors associated with poor outcome
- Nature of infection: ReA caused due to genitourinary pathogen have a worse outcome than those caused by gastrointestinal pathogens.
- Presence of HLA-B27 gene
- Heel and foot pain at the beginning of the disease
- Elevated ESR
- Unresponsiveness to nonsteroidal anti-inflammatory drugs (NSAIDs)
Key symptoms on reactive arthritis
- Bilateral conjunctivitis(non-infective)
- Anterior uveitis
- Urethritis(non-gonococcal)
- Circinate balanitis(dermatitis of the head of the penis)
- ‘Can’t see, can’t pee, can’t climb a tree’
Initial investigations for reactive arthritis
Patient presenting with an acute warm, swollen painful joint should have septic arthritis excluded. Antibiotics can be given until exclusion. Joint aspiration is required. Synovial fluid is sent formicroscopy,culture and sensitivity testingfor infection, andcrystal examinationfor gout and pseudogout.
Reactive arthritis prognosis
Most cases resolve within 6 months and do not recur. Recurrent cases may require DMARD’s or anti-TNF medication. Can have chronic reactive arthritis which has a relapsing/remitting pattern. Can cause secondary arthritis and deformity
Rheumatoid arthritis
Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.
Tends to be symmetrical and affect multiple joints. It is a symmetrical polyarthritis
Risk factors: women, middle age (40-60), family history, smoking, western diet, certain gut bacteria
RA: genetic association
- HLA DR4- present in RF positive patients
- HLA DR1- present in RA patients
RA: antibodies
- Rheumatoid factor- autoantibody present in 70% of RA patients, targets the FC portion of the IgG antibody. Can be positive in autoimmune inflammatory conditions, hepatitis C, TB, AIDS
- Cyclic citrullinated peptide antibodies (anti-CCP antibodies)- more specific then rheumatoid factor, can be positive whilst RF is negative
RA bloods
- U&E’s- NSAID’s can cause renal impairment
- LFT- treatment can be hepatotoxic
- FBC- normocytic anaemia due to chronic disease. Treatments can cause bone marrow suppression. Platelets are increased with inflammation.
X-ray RA
- L- loss of joint space
- E- erosions
- S- soft tissue swelling
- S- soft bones (peri-articular osteopenia, decreased density)
X-ray: OA
- L- loss of joint space
- O- osteophytes
- S- subchondral sclerosis
- S- subchondral cysts