Reactive arthritis (MSK) Flashcards

1
Q

What is reactive arthritis?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Name the bacteria that causes post-STI reactive arthritis.

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What infections is reactive arthritis associated with?

A
  • GI (diarrhoeal illness) - salmonella, shigella, Yersinia, Campylobacter
  • urogenital (urethritis/cervicitis) - chlamydia trachomatis, ureaplasma species
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is reactive arthritis categorised as and why?

A

Seronegative spondyloarthropathy

  • negative for rheumatoid factor
  • strong genetic association with HLA-B27
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Who does reactive arthritis commonly affect?

A

Young men

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What can help differentiate reactive arthritis from septic arthritis?

A

Normal ROM in reactive arthritis + sterile

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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?

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
What are some differential diagnoses for reactive arthritis?
- ankylosing spondylitis - psoriatic arthritis - arthritis associated with IBD - rheumatoid arthritis - rheumatic fever - adult-onset Still's disease - disseminated gonococcal disease - gout - septic arthritis - post-viral arthritis - Lyme arthritis
26
What is the aim of reactive arthritis management?
Symptomatic relief + prevent or halt further joint damage
27
What is the 1st line (and 2nd line) treatment for acute reactive arthritis?
- 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
What medication do we NOT use for reactive arthritis?
Antibiotics
29
What is chronic reactive arthritis defined as?
Refractory to both NSAIDs and corticosteroids (30-50% develop chronic reactive arthritis)
30
How do we manage chronic reactive arthritis?
Disease-modifying antirheumatic drugs (DMARDs) e.g. sulfasalazine
31
How can we treat conjunctivitis (reactive arthritis)?
Antibiotics for secondary infection Management of anterior uveitis by ophthalmologist
32
How can we treat active GI/genitourinary infection (reactive arthritis)?
- oral ulcers - antiseptics, local anaesthetic mouthwash - balanitis - 1% hydrocortisone ointment, local hygiene
33
What are some complications of reactive arthritis? (5)
- chronic inflammatory joint disease - secondary osteoarthritis - iritis/uveitis - keratoderma blennorrhagicum - cardiac complications similar to ankylosing spondylitis
34
Describe the prognosis of reactive arthritis.
Resolves spontaneously within a year, high rate of recurrence