eMedicine Specialties > Dermatology > Papulosquamous Diseases

Reactive Arthritis: Differential Diagnoses & Workup

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Jorge Romaní, MD, Assistant Professor, Department of Dermatology, Hospital De Palamós Faculty of Medicine, Spain; Lluís Puig, MD, PhD, Program Director, Assistant Professor, Department of Dermatology, Hospital De La Santa Creu I Sant Pau, Universitat Autónoma De Barcelona
Contributor Information and Disclosures

Updated: Jun 12, 2009

Differential Diagnoses

Atopic Dermatitis
Lyme Disease
Balanitis Circumscripta Plasmacellularis
Psoriasis, Guttate
Balanitis Xerotica Obliterans
Psoriasis, Plaque
Balanoposthitis
Psoriasis, Pustular
Behcet Disease
Contact Dermatitis, Irritant
Lupus Erythematosus, Acute

Other Problems to Be Considered

Gonorrhea and other types of infectious urethritis must be ruled out by means of microbiologic cultures of the urethral exudate.

Gonococcal arthritis does not involve the spine.

Rheumatoid arthritis and psoriatic arthritis, and ankylosing spondylitis must be differentiated from arthritis in reactive arthritis.

Septic arthritis and pyogenic arthritis also can mimic reactive arthritis.

Oligoarticular and asymmetrical involvement, together with the clinical course, may contribute to the diagnostic suspicion.

Other seronegative arthritides can be present. Differentiating these from reactive arthritis is academic because they share a common pathophysiologic pathway and similar treatment.

Rheumatic fever and serum sickness are characterized by a course that is more acute than that of reactive arthritis.

Cutaneous lesions of reactive arthritis can mimic the following, but the characteristic clinical picture must raise a suspicion of reactive arthritis: Norwegian scabies, mycosis fungoides, subcorneal pustulosis of Sneddon-Wilkinson, atopic dermatitis, acute exanthematic pustulosis, and other causes of erythroderma.

Workup

Laboratory Studies

  • No laboratory or imaging finding is diagnostic of reactive arthritis. The diagnosis is based on clinical data.
  • Although a positive HLA-B27 result is not specific of the disease, haplotyping can be used to diagnose reactive arthritis.
  • Microbiologic examination of smears, immunofluorescence results, and cultures of the urethral secretion must be considered.
  • Microbiologic studies of urine and stool are less helpful; nevertheless, in the dysenteric form, stool culture for enteric pathogens (eg, Salmonella, Shigella, and Yersinia species) should be considered.
  • Aspirates of joint fluid usually are sterile.
  • A Japanese man with reactive arthritis was negative for HLA-B27 and other HLA-B27 cross-reactive major histocompatibility complex (MHC) class I antigens, but he was positive for human leukocyte antigen B51 (HLA-B51).21
    • The laboratory examination findings showed significant elevation of serum levels of immunoglobulin G (IgG) and IgA antichlamydial antibodies.
    • A combination of Chlamydia infection and HLA-B51 presence was suggested to play a role in the pathogenesis of reactive arthritis in this patient. The US Preventive Services Task Force guidelines for screening for chlamydial infections were updated in 2007.22

Imaging Studies

  • Radiologic signs are present in only 40% of the cases. These signs can be completely absent regardless of the severity.
  • Whole-body scintigraphy is a sensible diagnostic tool for use in screening for enthesopathy and arthropathy.23

Other Tests

  • The incidence of reactive arthritis is high among patients with AIDS, and HIV testing is mandatory in patients in whom reactive arthritis is newly diagnosed, even if they do not have the risk factors.

Histologic Findings

Histopathologic changes are not different from the histopathologic picture of a psoriasis vulgaris. Acanthosis, with elongation of the rete ridges, psoriasiform hyperplasia, subcorneal abscesses, and spongiform pustules, are observed. The upper dermis shows a mixed inflammatory infiltrate with neutrophils.

More on Reactive Arthritis

Overview: Reactive Arthritis
Differential Diagnoses & Workup: Reactive Arthritis
Treatment & Medication: Reactive Arthritis
Follow-up: Reactive Arthritis
Multimedia: Reactive Arthritis
References
[ CLOSE WINDOW ]

References

  1. Wu IB, Schwartz RA. Reiter's syndrome: the classic triad and more. J Am Acad Dermatol. Jul 2008;59(1):113-21. [Medline].

  2. Fiessinger N, Leroy E. Contribution a l etude d'une epidemie de dysenterie dans la somme. Bull Soc Med Hop. 1916;40:2030-2069.

  3. Reiter H. Spirochateninfektion (Spirochaetosis arthritica). Deutsche Medizinische Wochenschrift. 1916;42:1535-6.

  4. Bauer W, Engelman EP. A syndrome of unknown etiology characterized by urethritis, conjunctivitis, and arthritis (so-called Reiter's disease). Trans Assoc Am Physicians. 1942;57:307-313.

  5. Panush RS, Wallace DJ, Dorff RE, Engleman EP. Retraction of the suggestion to use the term "Reiter's syndrome" sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum. Feb 2007;56(2):693-4. [Medline].

  6. Wallace DJ, Weismann M. Should a war criminal be rewarded with eponymous distinction?. J Clin Rheumatol. 2000;6:49-54.

  7. Weyers W. The fame and infamy of Hans Reiter. Dermatopathol Pract Concept. 2000;6:340-343.

  8. Ackerman AB. Reiter syndrome and Hans Reiter: Neither legitimate!. J Am Acad Dermatol. Mar 2009;60(3):517-8; author reply 518. [Medline].

  9. Mahmood A, Ackerman AB. Reiter's syndrome is psoriasis!. Dermatopathol Pract Concept. 2000;6:337-339.

  10. Kousa M, Saikku P, Richmond S, Lassus A. Frequent association of chlamydial infection with Reiter's syndrome. Sex Transm Dis. Apr-Jun 1978;5(2):57-61. [Medline].

  11. Berlau J, Junker U, Groh A, Straube E. In situ hybridisation and direct fluorescence antibodies for the detection of Chlamydia trachomatis in synovial tissue from patients with reactive arthritis. J Clin Pathol. Nov 1998;51(11):803-6. [Medline].

  12. Russell AL. Glycoaminoglycan (GAG) deficiency in protective barrier as an underlying, primary cause of ulcerative colitis, Crohn's disease interstitial cystitis and possibly Reiter's syndrome. Med Hypotheses. Apr 1999;52(4):297-301. [Medline].

  13. Savolainen E, Kettunen A, Narvanen A, et al. Prevalence of antibodies against Chlamydia trachomatis and incidence of C. trachomatis-induced reactive arthritis in an early arthritis series in Finland in 2000. Scand J Rheumatol. Mar 18 2009;1-4. [Medline].

  14. Townes JM, Deodhar AA, Laine ES, et al. Reactive arthritis following culture-confirmed infections with bacterial enteric pathogens in Minnesota and Oregon: a population-based study. Ann Rheum Dis. Dec 2008;67(12):1689-96. [Medline].

  15. Arora S, Arora G. Reiter's disease in a six-year-old girl. Indian J Dermatol Venereol Leprol. Jul-Aug 2005;71(4):285-6. [Medline].

  16. Satko SG, Iskandar SS, Appel RG. IgA nephropathy and Reiter's syndrome. Report of two cases and review of the literature. Nephron. Feb 2000;84(2):177-82. [Medline].

  17. Lin RY. Reiter's syndrome and human immunodeficiency virus infection. Dermatologica. 1988;176(1):39-42. [Medline].

  18. Romaní J, Puig L, Baselga E, De Moragas JM. Reiter's syndrome-like pattern in AIDS-associated psoriasiform dermatitis. Int J Dermatol. Jul 1996;35(7):484-8. [Medline].

  19. Thielen AM, Barde C, Janer V, Borradori L, Saurat JH. Reiter syndrome triggered by adalimumab (Humira) and leflunomide (Arava) in a patient with ankylosing spondylarthropathy and Crohn disease. Br J Dermatol. Jan 2007;156(1):188-9. [Medline].

  20. Siala M, Gdoura R, Younes M, et al. Detection and frequency of Chlamydia trachomatis DNA in synovial samples from Tunisian patients with reactive arthritis and undifferentiated oligoarthritis. FEMS Immunol Med Microbiol. Mar 2009;55(2):178-86. [Medline].

  21. Shimamoto Y, Sugiyama H, Hirohata S. Reiter's syndrome associated with HLA-B51. Intern Med. Feb 2000;39(2):182-4. [Medline].

  22. [Guideline] U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Jul 17 2007;147(2):128-34. [Medline].

  23. Kim SH, Chung SK, Bahk YW, Park YH, Lee SY, Sohn HS. Whole-body and pinhole bone scintigraphic manifestations of Reiter's syndrome: distribution patterns and early and characteristic signs. Eur J Nucl Med. Feb 1999;26(2):163-70. [Medline].

  24. Kiss S, Letko E, Qamruddin S, Baltatzis S, Foster CS. Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome. Ophthalmology. Sep 2003;110(9):1764-9. [Medline].

  25. Amor B. Reiter's syndrome. Diagnosis and clinical features. Rheum Dis Clin North Am. Nov 1998;24(4):677-95, vii. [Medline].

  26. Barth WF, Segal K. Reactive arthritis (Reiter's syndrome). Am Fam Physician. Aug 1999;60(2):499-503, 507. [Medline].

  27. Carter JD, Gerard HC, Hudson AP. Psoriasiform lesions induced by tumour necrosis factor antagonists: a skin-deep medical conundrum. Ann Rheum Dis. Aug 2008;67(8):1181-3. [Medline].

  28. Goyal NN, Dhurat RS, Jerajani HR. Carbamazepine in Reiter's syndrome. Sex Transm Infect. Jun 2000;76(3):220. [Medline].

  29. Kim YA, Bagley MP, Thomas I. Incomplete Reiter's syndrome in a black patient showing HLA B 27. Cutis. Apr 1991;47(4):253-4. [Medline].

  30. Reiter H. Vorschlage zur Neugestaltung des Hygieneunterrichts und zur Sicherung des Nachwuchses auf dem Gebiet der Hygiene. Munch Med Wschr. 1938;85:16-19.

  31. Zivony D, Nocton J, Wortmann D, Esterly N. Juvenile Reiter's syndrome: a report of four cases. J Am Acad Dermatol. Jan 1998;38(1):32-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

RS, Reiter disease, Reiter syndrome, Reiter's syndrome, Fiessinger-Leroy-Reiter syndrome, Fiessinger-Leroy syndrome, arthritis urethritica, blennorrheal idiopathic arthritis, reactive arthritis, conjunctivo-urethro-synovial syndrome, polyarthritis enterica, keratoderma blenorrhagica, urethritis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Jorge Romaní, MD, Assistant Professor, Department of Dermatology, Hospital De Palamós Faculty of Medicine, Spain
Disclosure: Nothing to disclose.

Lluís Puig, MD, PhD, Program Director, Assistant Professor, Department of Dermatology, Hospital De La Santa Creu I Sant Pau, Universitat Autónoma De Barcelona
Lluís Puig, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, European Academy of Dermatology and Venereology, and International Society of Dermatopathology
Disclosure: Nothing to disclose.

Medical Editor

Robin Travers, MD, Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians
Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.