Reactive Arthritis

Question 1

Define Reactive Arthritis

Answer 1

Sterile inflammation in joints following infection, especially urogenital and gastrointestinal infections

Is a seronegative spondyloarthropathy

Question 2

Aetiology of Reactive Arthritis

Answer 2

Urogenital infection: chlamydia trachomatis (60%)
Gastrointestinal infections: salmonella, shigella, campylobacter, yersinia, E. Coli

Infection activates the immune system -> autoimmune reaction involving the skin, eyes and joints

Question 3

What is Reiter’s syndrome

Answer 3

Reactive arthritis, urethritis and conjunctivitis

Question 4

Risk factors for Reactive Arthritis

Answer 4

Immunosuppression e.g. HIV, Hep C
HLA-B27 (70-80%)
Male sex
Preceding infection
Younger adults (20-40)

Question 5

Symptoms of reactive arthritis

Answer 5

Symptoms 1-4 weeks after an initial infection

1. Arthritis
   Asymmetrical | Oligoarthritis (<5 joints) | typically lower limbs
2. Enthesitis
   Heel pain (achilles tendonitis) | swollen fingers (dactylitis) | painful feet (plantar fasciitis)
3. spondylitis
   Sacroliitis -> low back pain | spondylitis

Extra-articular:
- Skin inflammation (psoriasis-like rash on hands and feet, circinate balanitis, keratoderma blenorrhagica)
- Ocular: sterile conjunctivits
- Genito-urinary: sterile urethritis -> burning/stinging on urination
- Enthesopathy

Question 6

Signs of Reactive Arthritis on examination

Answer 6

Arthritis: Asymmetric, oligoarthritic, often affecting the lower extremities, sausage fingers

Conjunctivitis: Red eye, painful eye

Oral ulceration: usual painless

Skin: Circinate balanitis, psoriasis-like rash, keratoderma blennorrhagia (brownish-red macules, vesiculopustules + yellow/brown scales on foot

Other: Fever, nail dystrophy, hyperkeratosis or onycholysis

Question 7

Investigations for Reactive Arthritis

Answer 7

Mainly clinical diagnosis

Stool/Urethral swab/first catch urine: negative
Urine: screen for chlamydia trachomatis

CRP/ESR: raised
HLA-B27 testing
Antibodies (ANA, Rheumatoid-factor): negative
Serology: ?HIV or Hep C

X-ray: sacroiliitis or enthesopathy (erosion at sight of insertion)
Arthrocentesis and synovial fluid analysis: negative (exclude septic arthritis + gout)

Question 8

Management for reactive arthritis

Answer 8

MDT: treat underlying infection
NSAIDs
Intra-articular steroids (low dose)
Persisting or chronic reactive arthritis: DMARDs e.g. sulphasalazine or biologics

Question 9

Complications of reactive arthritis

Answer 9

Secondary osteoarthritis
Iritis/uveitis
Keratoderma blenorrhagicum

Question 10

Prognosis for reactive arthritis

Answer 10

Remission occurs within 6-12 months of arthritis onset
Approximately 50% of patients can expect symptoms to resolve within the first 6 months
However, 30% to 50% of patients will develop chronic ReA

Question 11

Signs of enteropathic arthritis

Answer 11

tender, red, stiff, swollen, warm joints +/- deformityI

Question 12

Investigations for enteropathic arthritis

Answer 12

Bloods Raised CRP, ESR
HLA-B27
X-ray
Colonoscopy +/- biopsy. Stool culture.

Question 13

Management for enteropathic arthritis

Answer 13

Physical therapy to improve function, as well as prevent joint damage and deformity.
DMARDs, which can alter the immune system and slow the disease: Includes methotrexate, sulfasalazine, hydroxychloroquine and leflunomide.
NSAIDs, which can lessen pain and swelling r.g. ibuprofen, naproxen and celecoxib.
Tumor necrosis factor-alpha inhibitors R.g. etanercept and infliximab
Surgery to correct the spine in severe cases.