Introduction
Reactive arthritis is an acute form of spondyloarthritis associated with sexually transmitted infection (STI) and acute diarrhoea. It occurs shortly after the initial infection, although the reactive arthritis itself is an autoimmune reaction.
It is usually self limiting, and the typical management is the use of NSAIDs.
Formally known as Reiter’s syndrome or Reiter’s Disease after the German physician Hans Reiter who initially described it. However, Dr Reiter was a convinced Nazi war criminal who performed medical “experiments” at concentration camps, and the use of this term should be discouraged.
Aetiology
- Associated with STI – most commonly chlamydia – and typically affects men aged 20-40.
- Associated with GI infection:
- Less common than STI involvement
- Could be salmonella, shingella, Yersinia, or campylobacter
Presentation
- Acute, asymmetrical, polyarthritis
- The classic triad of:
- Conjunctivitis – can’t see
- Non specific urethritis – can’t pee
- Acute arthritis – can’t bend the knee
- May be an oligoarthritis
- Tends to affect the large joints, particularly the ankle and knee. May sometimes involve the feet.
- May also involve:
- Keratinous brown plaques on soles and palms
- Mouth ulcers
- Fever
- Fatigue
- Weight loss
- Pustular vesicles (rare) – sometimes look like those seen in psoriasis
- CNS involvement (rare)
- Cardiovascular involvement (rare)
- Can vary from a very mild arthritis, to a serious multi-systemic condition.
- Presents 1-4 weeks after the initial infection
Pathology
Not fully understood. It is thought that there is probably some sort of joint infection, or infection related inflammation, but aspirate is always aseptic. Those with HLA-B27 have predisposition.
Diagnosis
- High degree of clinical suspiscion:
- STI / GI infection
- Acute onset polyarthritis of lower limbs and feet
- Bloods:
- ↑ESR
- ↑CRP
- Consider:
- Stool sample / culture
- Test for chlamydia / other STI infection
Treatment
Treating the original infection (although useful!) will rarely affect the symptoms of arthritis
- Rest / splint affected joints
- Up to 50% will resolve within 4 months
- Use NSAID’s and Steroid injections if necessary
- These only provide symptomatic releif
- Steroid injections are only rarely indicated in more severe cases of large joint involvement
- In some cases, may be chronic. This can result in deformity. In some patients, it may also relapse and remit. In these individuals, consider:
- Sulfasalazine
- Methotrexate
Anterior uveitis – may be treated with steroid eye drops
References
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy