Reactive Arthiritis

Question 1

What is Reactive Arthritis?

Answer 1

An aseptic inflammation of the joints secondary to a range of infections, typically the genital or GI tract.

It is part of a group of inflammatory conditions (Seronegative arthropathies), which share similar clinical features, pathological findings, the absence of rheumatoid factor and a strong association with the histocompatibility antigen HLA-B27.

They comprise:
Ankylosing spondylitis
Psoriatic arthropathy
Reactive arthritis

These conditions share many common clinical features

Question 2

What will you find in a history of Reactive Arthritis?

Answer 2

Symptoms:
Asymmetrical oligoarthritis - Commonly larger joints in lower limb
Spinal Arthritis
Inflammatory type pain - morning stiffness >30 minutes, improvement with use, worse at night
Reiter’s syndrome” - refers to the associated with a urethritis and iritis (cant see, pee or climb a tree)

Seronegative Symptoms:
Dactylitis
Sacroiliitis 
achilles tendinitis
plantar fasciitis
Uveitis/Conjunctivitis - Red Painful eyes 
Keratoderma blenorrhagica
circinate balanitis
Aortitis
Urethritis 
Prostatitis 

Risk Factors:
More common in young men
Recent infection

Differentials:
Rheumatoid Arthritis- Symmetrical polyarthritis,small joints mostly involved and does not affect the lumbar spine or sacroiliac joints.
Septic Arthritis - Affects single joints in most cases. The affected joint is often swollen, erythematous, and warm, and patients may have a fever.
Gout - DIP joints involved and commonly big toe, uric acid levels raised
Ankylosing Spondyltitis - Normally symmetrical
Psoriatic Arthritis - Psoriasis can help but very similar

Question 3

What will you find on examination of a patient with Reactive Arthritis?

Answer 3

End of the bed:

Pain, swelling, redness, and heat in the affected joints.

Question 4

What investigations will you order in Reactive Arthritis?

Answer 4

Bedside:
Urinalysis - Looking for UTI or evidence of STD
High vaginal/urethral swabs - Looking for STD

Bloods:
ESR/CRP - Raised
Rheumatoid Factor - Will be negative. To rule out rheumatoid arthritis
HLA-B27 - Raised in most cases
FBC - Ruling out septic arthiritis
Uric Acid - Ruling out gout
CPPD crystals - Ruling out pseudogout 

Imaging:
Plan X-ray of affected joints - May show Sacroiliitis in spine
Foot X-ray -Calcaneal spur if any plantar fasciitis

Special Tests:
Synovial fluid aspiration - To rule out septic arthritis

Question 5

What is the treatment of Reactive Arthritis?

Answer 5

Lifestyle:
Bed Rest
passive strengthening exercises at about 10 days

Medical:
Give antibiotics to treat the underlying infection
Intraarticular steroids and splinting in the acute attack
After that:
1st line - NSAIDs
2nd line - Corticosteroids
3rd Line - sulfasalazine or methotrexate

Remission is usual at 2–6 months