Makindo Medical Notes

Related Subjects: |Monoarticular arthritis |Polyarticular arthritis |Seronegative Spondyloarthropathies |Ankylosing spondylitis |Enteropathic Spondyloarthritis |Reactive Arthritis |Dermatomyositis |Polyarteritis nodosa |Osteoporosis |Rheumatoid Arthritis |Systemic Sclerosis (Scleroderma) |Rheumatology Autoantibodies |Overlap Syndrome

Reactive arthritis is an infection-induced systemic illness characterized by inflammatory synovitis from which no viable microorganisms can be cultured.

About

• Seronegative Spondyloarthritis (Rheumatoid factor negative)
• Reiter's syndrome is a sterile reactive synovitis
• Following STD or Genitourinary infection or dysentery

Aetiology

• Joint aspirate is sterile and microorganism cannot be found
• Usually have additional extra articular features

Infections

• Gastrointestinal: Salmonella, Yersinia, Campylobacter, Shigella
• STD: Chlamydia trachomatis or Ureaplasma urealyticum

Aetiology

• Usually post-infectious cross-reaction to an antigen in the pathogen
• Causes features seen in some of the spondyloarthropathies
• Seen several weeks after the infection
• Genetically susceptible individual

Clinical

• Asymmetrical inflammatory oligoarthritis or monoarthritis predominantly affecting the lower limbs with the involvement of knees, feet, toes, hips and ankles.
• MTP joint synovitis, sausage toe Dactylitis, Achilles tendonitis, Plantar fasciitis
• Conjunctivitis, Anterior Uveitis (Like Ankylosing spondylitis)
• Oral ulcers, Circinate balanitis
• Keratoderma Blennorrhagicum - red scaly rash soles of feet with pustules
• Nail dystrophy (psoriasis), Erythema nodosum (inflammatory bowel disease)
• Aortitis (Ankylosing spondylitis) and conduction defects

Reiter's syndrome

• Actually well quoted and often asked about but clinically not very useful
• Arthritis, Conjunctivitis, Urethritis/Cervicitis
• Historically came to note in WW1 soldiers with venereal diseases or dysentery

Investigations

• Elevated CRP or ESR or WCC non specific
• Aspirated synovial fluid is sterile, with a high neutrophil count.
• Stool cultures may identify a triggering pathogen e.g. salmonella, campylobacter, Shigella, Yersinia
• Screening for Chlamydia trachomatis and Gonorrhoea referral to GUM
• Rheumatoid factor usually negative

Management

• Bed rest plus NSAID inadequate dose +/- intra-articular steroid.
• Treat associated/triggering infection. If active arthritis persists consult a Rheumatologist.
• NSAIDs are the main treatment with analgesic and anti-inflammatory properties
• Sulfasalazine may be useful
• Intra articular steroid injections may be tried
• Anti TNF agents have been tried in those non-responsive to other therapies
• Antibiotic therapies for active chlamydia infection

References

• Aetiology and pathogenesis of reactive arthritis: role of non-antigen-presenting effects of HLA-B27