Sexually acquired reactive arthritis (SARA) Flashcards
Reactive arthritis - define?
Sterile inflammation of the synovial membrane, tendons and fascia
triggered by an infection at a distant site,
usually gastrointestinal or genital
SARA - define?
Reactive arthritis triggered by STI
What is the triad of (controversial) ‘Reiter’s’ syndrome?
urethritis, arthritis and conjunctivitis
Which sites of STI are most commonly associated with SARA?
lower genital tract
Urethra
Cervix
Which organism is most commonly linked to SARA?
Chlamydia trachomatis
How often is chlamydia linked to SARA?
35-69% of cases
What other bacterial STIs have been linked to SARA?
Neisseria gonorrhoea
Ureaplasma urealyticum
What is the possible pathogenesis of chlamydia induced SARA?
Chlamydia infection persists in the synovium
repressed synthesis of the major outer membrane protein AND
active production of heat shock protein contributes to inflammatory response
Who is SARA more common in? Men or women?
Men
How much more common is SARA in men?
10 times more common
What genetic factor may predispose to SARA?
HLA B27
How much more susceptible to SARA is a person positive for HLA B27?
50 fold
When does SARA onset following an exposure to STI?
within 30 days of sexual contact
What proportion of SARA onset within 30 days of sexual contact?
88%
What proportion of men will have a recent history of urethral discharge or dysuria?
80%
What is the typical presentation and distribution of the arthritis?
Pain +/- swelling and stiffness
1 or more joints, usually less than 6
Knees, ankles, feet
Enthesitis/fasciitis can also occur in SARA, where does it typically affect?
Posterior and plantar aspect of the heels
What proportion of patients with SARA get enthesitis or fasciitis?
40%
What other sites of the body are affected with SARA?
Dactylitis - painful swelling of toe or finger
Sacro-iliitis
Irritable eyes
What percentage of people with SARA get conjunctivitis?
20-50%
How does conjunctivitis with SARA typically present?
few days before arthritis
bilateral
How likely is upper limb involvement in SARA?
Rare in the absence of psoriasis
What is the potential complication from persistent small joint arthritis in SARA?
joint erosion
What other eye complications may occur in SARA (5)?
Corneal ulceration keratitis intra-ocular haemorrhage optic neuritis posterior uveitis
What other extra-genital complications can occur with SARA?
Skin involvement - psoriasiform was
Cardiac - often asymptomatic tachycardia, LV dilatation
Renal - proteinuria, microhaematuria, aseptic pyuria
Thrombophlebitis
What increases the risk of complications from SARA?
possession of HLAB27
What is the typical course of disease with SARA?
4-6 months
self limiting
SARA - how to treat?
Rest regular NSAIDs Antimicrobial therapy for STI Physio Consider intra-articular corticosteroid Consider systemic corticosteroid - oral or IM
What treatment may be indicated in disabling symptoms that persist or erosive disease?
DMARD
sulfasalazine
methotrexate
azathioprine
Role of antibiotics in SARA?
Short course to treat uro-genital infection
potential anticollagenolytic properties
Treatment of skin lesions in SARA?
keratinolytic agents - topical salicylic acid or corticosteroid
vitamin D3 - calcitriol ointment
methotrexate
Retinoids
If a person has eye symptoms with SARA how should they be managed?
Refer ophthalmology
Slip lamp assessment
Post-inflammatory pain and fatigue can occur, how to manage?
Explanation and patience
Low dose tricyclic - amitriptyline
