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Year 3 > Reactive arthritis (MSK) > Flashcards

Reactive arthritis (MSK) Flashcards

1
Q

What is reactive arthritis?

A

Sterile inflammatory arthritis that occurs after exposure to certain gastrointestinal and genitourinary infections

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2
Q

What family of inflammatory rheumatic diseases does reactive arthritis belong to?

A
  • belongs to the spondyloarthropathy family that also includes psoriatic arthritis, ankylosing spondylitis, IBD-related arthritis and undifferentiated spondyloarthropathy
  • they share similar clinical, radiographic and laboratory features e.g. spinal inflammation and association with HLA-B27
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3
Q

Name the bacteria that causes post-STI reactive arthritis.

A

Chlamydia trachomatis - this form of arthritis is more common in men

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4
Q

What is Reiter’s syndrome?

A

Post-infectious arthritis, non-gonococcal urethritis and conjunctivitis (classical triad but found only in a minority of cases)

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5
Q

What infections is reactive arthritis associated with?

A
  • GI (diarrhoeal illness) - salmonella, shigella, Yersinia, Campylobacter
  • urogenital (urethritis/cervicitis) - chlamydia trachomatis, ureaplasma species
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6
Q

What is the (thought) mechanism of reactive arthritis?

A

It is thought that initial activation of the immune system by a microbial antigen is followed by an autoimmune reaction that involves the skin, eyes and joints –> typically affects lower limbs 1-4 weeks after urethritis or dysentry

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7
Q

What is reactive arthritis categorised as and why?

A

Seronegative spondyloarthropathy

  • negative for rheumatoid factor
  • strong genetic association with HLA-B27
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8
Q

Who does reactive arthritis commonly affect?

A

Young men

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9
Q

What is usually seen in the history of a patient with reactive arthritis?

A

History of recent antecedent genitourinary or dysenteric infection 1-4 weeks before onset (symptoms can develop 3-30 days after infection)

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10
Q

What is the typical joint pattern for reactive arthritis?

A

Usually an asymmetrical oligoarticular arthritis affecting large joints of lower limb (but polyarticular and monoarticular can also occur)

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11
Q

What are the two types of arthritis that reactive arthritis presents with?

A
  • peripheral arthritis - clinical symptoms 1-4wks after onset of infection –> asymmetrical oligoarthritis of larger joints in lower extremity
  • axial arthritis - spinal inflammation (sacroiliac joints and lumbosacral spine) = non-specific low back/buttock pain, relieved by exercise (distinguished from mechanical back pain)
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12
Q

What are the clinical features of reactive arthritis?

A

Can’t see, can’t pee, can’t climb a tree

  • asymmetrical arthritis affecting larger joints of LL 1-4 weeks after infection –> painful, warm, swollen, red, stiff joints
  • sacroiliitis - lower back pain
  • conjunctivitis / uveitis (anterior uveitis = painful red eye)
  • urethritis - burning/stinging on urination
  • enthesitis and plantar fasciitis - painful heels
  • dactylitis (inflammation of digit)
  • fever, fatigue, weight loss
  • symptoms from preceding infection - diarrhoea, dysuria, urethritis
  • skin changes
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13
Q

What skin changes are seen in reactive arthritis? (2)

A
  • circinate balanitis - painless vesicles on the coronal margin of the prepuce (head of penis)
  • keratoderma blenorrhagica - waxy yellow/brown papules on palms and soles
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14
Q

What might be seen on examination of a patient with reactive arthritis?

A
  • asymmetrical oligoarthritis of LL
  • circinate balanitis
  • conjunctivitis (anterior uveitis = painful red eye)
  • keratoderma blenorrhagica
  • others: nail dystrophy, hyperkeratosis, onycholysis, mouth ulcers, iritis, aortitis (aortic regurgitation)
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15
Q

What can help differentiate reactive arthritis from septic arthritis?

A

Normal ROM in reactive arthritis + sterile

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16
Q

What can help differentiate reactive arthritis from mechanical back pain?

A

Pain gets better on activity in reactive arthritis

17
Q

What are the risk factors for reactive arthritis? (3)

A
  • male
  • HLA-B27 genotype
  • preceding chlamydia or GI infection
18
Q

What are the 1st-line investigations for reactive arthritis? (7)

A
  • ESR
  • CRP
  • antinuclear antibody (ANA)
  • rheumatoid factor
  • urogenital and stool cultures
  • plain x-rays
  • arthrocentesis with synovial fluid analysis
19
Q

What are ESR and CRP like for reactive arthritis?

A

Elevated (non-specific)

20
Q

What are ANA and RF like for reactive arthritis?

A

Negative - done to rule out other conditions

21
Q

What is HLA-B27 like for reactive arthritis?

A

Positive

22
Q

What are urogenital and stool cultures like for reactive arthritis?

A

Negative unless patients are tested very early after onset of primary infection

23
Q

What do plain x-rays show for reactive arthritis?

A

Sacroiliitis (asymmetrical) or enthesitis (especially at Achilles’ tendon) - more common in chronic reactive arthritis

24
Q

What is seen on arthrocentesis with synovial fluid analysis for reactive arthritis? (4)

A
  • cloudy yellow colour
  • culture negative
  • normal WBC
  • no crystals (rule out gout)
25
Q

What are some differential diagnoses for reactive arthritis?

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • rheumatoid arthritis
  • rheumatic fever
  • adult-onset Still’s disease
  • disseminated gonococcal disease
  • arthritis associated with IBD
  • gout
  • septic arthritis
  • post-viral arthritis
  • Lyme arthritis
26
Q

What is the aim of reactive arthritis management?

A

Symptomatic relief + prevent or halt further joint damage

27
Q

What is the 1st line (and 2nd line) treatment for acute reactive arthritis?

A
  • 1st line: NSAIDs - naproxen, ibuprofen, diclofenac
  • 2nd line: corticosteroids (prednisolone)
  • (next step: intra-articular steroid injections)
  • (if these do not work –> DMARDs e.g. sulfasalazine)
28
Q

What medication do we NOT use for reactive arthritis?

A

Antibiotics

29
Q

What is chronic reactive arthritis defined as?

A

Refractory to both NSAIDs and corticosteroids (30-50% develop chronic reactive arthritis)

30
Q

How do we manage chronic reactive arthritis?

A

Disease-modifying antirheumatic drugs (DMARDs) e.g. sulfasalazine

31
Q

How can we treat conjunctivitis (reactive arthritis)?

A

Antibiotics for secondary infection
Management of anterior uveitis by ophthalmologist

32
Q

How can we treat active GI/genitourinary infection (reactive arthritis)?

A
  • oral ulcers - antiseptics, local anaesthetic mouthwash
  • balanitis - 1% hydrocortisone ointment, local hygiene
33
Q

What are some complications of reactive arthritis? (5)

A
  • chronic inflammatory joint disease
  • secondary osteoarthritis
  • iritis/uveitis
  • keratoderma blennorrhagicum
  • cardiac complications similar to ankylosing spondylitis
34
Q

Describe the prognosis of reactive arthritis.

A

Resolves spontaneously within a year, high rate of recurrence

Year 3 (22 decks)

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