Reactive Arthritis

Question 1

Define reactive arthritis

Answer 1

Sterile inflammation in joints following infection, especially urogenital and gastrointestinal infections
Classes as a seronegative spondyloarthropathy

Question 2

What are the causes of reactive arthritis

Answer 2

Urogenital tract infections e.g. Chlamydia trachomatis (60%), gonorrhoea
GI tract infections e.g. salmonella, shigella, Yersinia, Campylobacter
Infection activates the immune system, which is followed by an autoimmune reaction involving the skin, eyes and joints

Question 3

What is Reiter’s syndrome

Answer 3

Reactive arthritis
Urethritis
Conjunctivitis

Question 4

What are the risk factors for Reactive arthritis

Answer 4

Immunosuppression e.g. HIV, Hep C
HLA-B27 (70-80%)
Male sex
Preceding infection

Question 5

What are the symptoms of reactive arthritis

Answer 5

1-4 weeks after initial infection

Arthritis: joint swelling and pain (asymmetrical, transient, ankles or knees (oligo large joints), worse in morning)
+ enthesitis: heel pain (achilles tendonitis) swollen fingers (dactylitis), painful feet (plantar fasciitis)
+ spondylitis: sacroiliitis (low back), spondylitis (upper back)

Extra-articular manifestations:
Sterile urethritis: dysuria
Sterile conjunctivitis: painful red eye
Circinate balanitis (glans penis), psoriasis-like rash on hands and feet, keratoderma blenorrhagica
Low-grade fever
Weight loss
Fatigue
Painless oral ulcers

Question 6

What are the signs of reactive arthritis on examination

Answer 6

Obs: low-grade fever
Joints: articular swelling (asymmetrical, transient, ankles or knees (oligo large joints), worse in morning)
ENT: conjunctivitis, oral ulceration
Skin: Circinate balanitis, psoriasis-like rash, keratoderma blennorrhagia (Brown-red macules, vesicopustules and yellowish brown scales on soles or palms)

Question 7

What investigations should be done for reactive arthritis

Answer 7

Clinical diagnosis
Investigations are to exclude other arthritides

Bedside: throat swab for strep, urethral swab, urine culture
Bloods: ESR/CRP (raised), HLA-B27 testing
Other:
- X-ray joint: normal
- X-ray spine: sacroiliitis or enthesopathy (usually asymmetrical)
- Arthrocentesis and synovial fluid analysis from joint aspiration: negative, sterile

Question 8

What is the management for reactive arthritis

Answer 8

1. Re-assure
   First line: Supportive analgesia e.g. naproxen, ibuprofen (NSAIDs)
   Second line: Corticosteroids e.g. prednisolone oral
   Persisting/chronic: DMARDs e.g. sulfasalazine

Question 9

What are the complications of reactive arthritis

Answer 9

Rheumatic fever
Secondary osteoarthritis (destruction of cartilage + bony erosions)
Iritis/uveitis
Keratoderma blennorrhhagicum

Question 10

What is the prognosis for reactive arthritis

Answer 10

Complete recovery can be expected
50% can expect resolve within 6 months