Reactive Arthritis

Question 1

What is the epidemiology of reactive arthritis?

Answer 1

Most commonly affects young adults

Most frequently white and HLA-B27 carriers

Question 2

What is the aetiology and pathophysiology of reactive arthritis?

Answer 2

A seronegative spondyloarthritis

Post-venereal disease:
- Following Chlamydia tracomatis infection or with HIV

Post-enteric:
- Campylobacter, Salmonella and Shigella

(also possible following C.diff and Giardia lamblia)

Question 3

How does reactive arthritis present?

Answer 3

GI or GU infection then 2-4 (1-6)wks later:

Acute onset:
- Malaise + fever + fatigue

Additive or migratory oligoarthritis (<6):

• Asymmetrical
• Predominantly lower limb

Inflammatory back pain

Extra-articular symptoms

Question 4

What are some extra-articular symptoms in reactive arthritis?

Answer 4

• Achilles tendonitis, plantar fasciitis
• Skin = erythema nodosum
• Nails = dystrophic changes
• Mouth ulcers
• Eyes = Uveitis, episcleritis, corneal ulceration
• GI = abdo pain + diarrhoea
• CV = aortitis, conduction defects

Question 5

What is Reiter’s syndrome?

Answer 5

A reactive arthritis (following STI) with the classic triad of:

• Conjunctivitis (cant see)
• Urethritis (cant wee)
• Large joint oligoarthritis, often the knee (cant climb a tree)

Question 6

How do you investigate reactive arthritis?

Answer 6

Bloods:

• ESR + CRP - usually very high
• FBC - normocytic, normochromic anaemia, mild leukocytosis and thrombocytosis during acute phase
• HLA-B27 +ve in most
• RF + ANA -ve

Infection:

• Stool culture
• Throat and urogenital tract swabs
• Serology + PCR for Chlamydia and other possible triggers

Joint aspiration:

• To eliminate septic or crystaline arthritis
• High polymorphonuclear leukocytes in acute phase

XR:
- Normal in early stages

Question 7

How do you manage reactive arthritis?

Answer 7

Acute:

• Rest affected joints
• Aspirate synovial effusions
• NSAIDs
• Antibiotics - to treat causative organism if still present

Further management:

• Corticosteroids - IA injection or PO; if if unresponsive/intolerant to NSAIDs
• DMARDs - for some; sulfasalazine
• Possible use of TNf-alpha blockers

Physiotherapy

Question 8

What is the prognosis for reactive arthritis?

Answer 8

Usually self limiting, resolving in 3-12/12

High incidence of recurrence in those HLA-B27 +ve + arrival of another trigger