Sexually acquired reactive arthritis (SARA)

Question 1

Reactive arthritis - define?

Answer 1

Sterile inflammation of the synovial membrane, tendons and fascia
triggered by an infection at a distant site,
usually gastro­intestinal or genital

Question 2

SARA - define?

Answer 2

Reactive arthritis triggered by STI

Question 3

What is the triad of (controversial) ‘Reiter’s’ syndrome?

Answer 3

urethritis, arthritis and conjunctivitis

Question 4

Which sites of STI are most commonly associated with SARA?

Answer 4

lower genital tract
Urethra
Cervix

Question 5

Which organism is most commonly linked to SARA?

Answer 5

Chlamydia trachomatis

Question 6

How often is chlamydia linked to SARA?

Answer 6

35-69% of cases

Question 7

What other bacterial STIs have been linked to SARA?

Answer 7

Neisseria gonorrhoea

Ureaplasma urealyticum

Question 8

What is the possible pathogenesis of chlamydia induced SARA?

Answer 8

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

Question 9

Who is SARA more common in? Men or women?

Answer 9

Men

Question 10

How much more common is SARA in men?

Answer 10

10 times more common

Question 11

What genetic factor may predispose to SARA?

Answer 11

HLA B27

Question 12

How much more susceptible to SARA is a person positive for HLA B27?

Answer 12

50 fold

Question 13

When does SARA onset following an exposure to STI?

Answer 13

within 30 days of sexual contact

Question 14

What proportion of SARA onset within 30 days of sexual contact?

Answer 14

88%

Question 15

What proportion of men will have a recent history of urethral discharge or dysuria?

Answer 15

80%

Question 16

What is the typical presentation and distribution of the arthritis?

Answer 16

Pain +/- swelling and stiffness
1 or more joints, usually less than 6
Knees, ankles, feet

Question 17

Enthesitis/fasciitis can also occur in SARA, where does it typically affect?

Answer 17

Posterior and plantar aspect of the heels

Question 18

What proportion of patients with SARA get enthesitis or fasciitis?

Answer 18

40%

Question 19

What other sites of the body are affected with SARA?

Answer 19

Dactylitis - painful swelling of toe or finger
Sacro-iliitis
Irritable eyes

Question 20

What percentage of people with SARA get conjunctivitis?

Answer 20

20-50%

Question 21

How does conjunctivitis with SARA typically present?

Answer 21

few days before arthritis

bilateral

Question 22

How likely is upper limb involvement in SARA?

Answer 22

Rare in the absence of psoriasis

Question 23

What is the potential complication from persistent small joint arthritis in SARA?

Answer 23

joint erosion

Question 24

What other eye complications may occur in SARA (5)?

Answer 24

Corneal ulceration
keratitis
intra-ocular haemorrhage
optic neuritis
posterior uveitis

Question 25

What other extra-genital complications can occur with SARA?

Answer 25

Skin involvement - psoriasiform was Cardiac - often asymptomatic tachycardia, LV dilatation Renal - proteinuria, microhaematuria, aseptic pyuria Thrombophlebitis

Question 26

What increases the risk of complications from SARA?

Answer 26

possession of HLAB27

Question 27

What is the typical course of disease with SARA?

Answer 27

4-6 months | self limiting

Question 28

SARA - how to treat?

Answer 28

``` Rest regular NSAIDs Antimicrobial therapy for STI Physio Consider intra-articular corticosteroid Consider systemic corticosteroid - oral or IM ```

Question 29

What treatment may be indicated in disabling symptoms that persist or erosive disease?

Answer 29

DMARD sulfasalazine methotrexate azathioprine

Question 30

Role of antibiotics in SARA?

Answer 30

Short course to treat uro-genital infection | potential anticollagenolytic properties

Question 31

Treatment of skin lesions in SARA?

Answer 31

keratinolytic agents - topical salicylic acid or corticosteroid vitamin D3 - calcitriol ointment methotrexate Retinoids

Question 32

If a person has eye symptoms with SARA how should they be managed?

Answer 32

Refer ophthalmology | Slip lamp assessment

Question 33

Post-inflammatory pain and fatigue can occur, how to manage?

Answer 33

Explanation and patience | Low dose tricyclic - amitriptyline