Reactive Arthritis

Two forms of reactive arthritis are common: sexually transmitted and dysenteric.

The sexually transmitted form occurs primarily in men aged 20 to 40. Genital infections with Chlamydia trachomatis are most often implicated.

Men or women can acquire the dysenteric form after enteric infections, primarily Shigella, Salmonella, Clostridioides difficile, Yersinia, or Campylobacter.

Bacille Calmette-Guerin injection for bladder cancer has also been reported to trigger reactive arthritis.

In approximately in 40% of cases, infectious pathogens cannot be identified.

Reactive arthritis is postinfectious arthritis. Although there is evidence of microbial antigens in the synovium, organisms cannot be cultured from joint fluid.

The prevalence of the human leukocyte antigen B27 (HLA-B27) allele in patients is 63 to 96% versus 6 to 15% in healthy White controls, thus supporting a genetic predisposition.

Compared to patients without HLA-B27 allele, patients with HLA-B27 allele have more severe arthritis, extraarticular manifestations, and more prolonged courses.

Reactive arthritis can range from transient monarticular arthritis to a severe, multisystem disorder. Constitutional symptoms may include fever, fatigue, and weight loss. Arthritis may be mild or severe. Joint involvement is generally asymmetric and oligoarticular or polyarticular, occurring predominantly in the toes and large joints of the lower extremities and may include large knee effusions. Back pain may occur, usually with severe disease. Joint damage occurs rarely. Axial involvement is more often reported in patients with positive HLA-B27 and usually is asymmetric with large and bulky syndesmophytes.

Enthesopathy (inflammation at tendinous insertion into bone—eg, plantar fasciitis Plantar Fasciosis Plantar fasciosis is pain at the site of the attachment of the plantar fascia and the calcaneus (calcaneal enthesopathy), with or without accompanying pain along the medial band of the plantar... read more , digital periostitis, Achilles tendinitis Achilles Tendinitis Achilles tendon injuries include inflammation of the paratenon and partial or complete tears. Achilles tendinitis is very common among running athletes. The calf muscles attach to the calcaneus... read more ) is common and characteristic.

Mucocutaneous lesions—small, transient, relatively painless, superficial ulcers—commonly occur on the oral mucosa, tongue, and glans penis (balanitis circinata). Particularly characteristic are vesicles (sometimes identical to pustular psoriasis Psoriasis Psoriasis is an inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with silvery scales. Multiple factors contribute, including... read more ) of the palms and soles and around the nails that become hyperkeratotic and form crusts (keratoderma blennorrhagicum). Keratoderma blennorrhagicum can also include erythema, plaques, and scaling. Nails may become dystrophic. Erythema nodosum Erythema Nodosum Erythema nodosum is a specific form of panniculitis characterized by tender, red or violet, palpable, subcutaneous nodules on the shins and occasionally other locations. It often occurs with... read more has also been reported in reactive arthritis, especially after Yersinia infection.

Urethritis may develop 7 to 14 days after sexual contact (or occasionally after dysentery); low-grade fever, conjunctivitis, and arthritis develop over the next few weeks. Not all features may occur, so incomplete forms need to be considered. In men, the urethritis is less painful and productive of purulent discharge than acute gonococcal urethritis and may be associated with hemorrhagic cystitis or prostatitis. In women, urethritis and cervicitis may be mild (with dysuria or slight vaginal discharge) or asymptomatic.

Conjunctivitis is the most common eye lesion. It usually causes mild eye redness and grittiness, but keratitis and anterior uveitis can develop also, causing eye pain, photophobia, and tearing.

Rarely, cardiovascular complications (eg, aortitis, aortic insufficiency, cardiac conduction defects), pleuritis, and central nervous system or peripheral nervous system symptoms develop.

Reactive arthritis should be suspected in patients with acute, asymmetric arthritis affecting the large joints of the lower extremities or toes, particularly if there is tendinitis or a history of an antecedent diarrhea or dysuria. Diagnosis is ultimately clinical and requires the typical peripheral arthritis with symptoms of genitourinary or gastrointestinal infection or one of the other extra-articular features. Because these features may manifest at different times, definitive diagnosis may require several months. Serum and synovial fluid complement levels are high, but these findings are not usually diagnostic and need not be measured.

Disseminated gonococcal infection Gonorrhea Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more can closely simulate reactive arthritis. Arthrocentesis may fail to differentiate them, owing to inflammatory characteristics of synovial fluid in both disorders and the difficulty of culturing gonococci from this fluid. Clinical characteristics may help; disseminated gonococcal infection tends to involve upper and lower extremities equally, be more migratory, and not cause back pain, and vesicles tend not to be hyperkeratotic. A positive gonococcal culture from blood or skin lesions helps differentiate the two disorders, but a positive culture from the urethra or cervix, although suggestive, does not. If differentiation is still difficult, a response to ceftriaxone treatment after about a week may be required for simultaneous diagnosis and treatment.

Psoriatic arthritis Psoriatic Arthritis Psoriatic arthritis is a seronegative spondyloarthropathy and chronic inflammatory arthritis that occurs in people with psoriasis of the skin or nails. The arthritis is often asymmetric, and... read more can simulate reactive arthritis, causing similar skin lesions, uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more , and asymmetric arthritis. However, psoriatic arthritis often affects mostly the upper extremities and especially the distal interphalangeal joints, may be abrupt in onset but may also develop gradually, and tends not to cause mouth ulcers or symptoms of genitourinary or gastrointestinal infection.

Reactive arthritis often resolves in 3 to 4 months, but up to 50% of patients experience recurrent or prolonged symptoms over several years, especially if induced by chlamydial infection and in patients with positive HLA-B27 alleles. Joint, spinal, or sacroiliac inflammation or deformity may occur with chronic or recurrent disease. Some patients become disabled.

NSAIDs (eg, indomethacin 25 to 50 mg orally 3 times a day) usually help relieve symptoms of reactive arthritis. If induced by infection with C. trachomatis, doxycycline 100 mg orally 2 times a day for up to 3 months may accelerate recovery, but this is controversial. Sulfasalazine Traditional disease-modifying antirheumatic drugs (DMARDs) as used to treat rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more may also be helpful. If symptoms are severe despite NSAIDs and sulfasalazine, methotrexate may be considered.

Local injection of depot corticosteroids for enthesopathy or resistant oligoarthritis may relieve symptoms. Physical therapy aimed at maintaining joint mobility is helpful during the recovery phase. Anterior uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more is treated as usual, with corticosteroid and mydriatic eye drops to prevent scarring. Conjunctivitis and mucocutaneous lesions require only symptomatic treatment.

Screening for human immunodeficiency virus (HIV) Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more and other sexually transmitted infections and treating sex partners are recommended.