Ophthalmologic Manifestations of Reactive Arthritis Clinical Presentation

  • Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 14, 2012
 

History

  • Presenting signs and symptoms (in order of frequency) include polyarthritis, urethritis or cervicitis, pain in the back or the heel, eye disease, stomatitis, keratoderma blenorrhagica, balanitis, and diarrhea.
  • Typically, a latent interval period occurs from the onset of urethritis or diarrhea to the development of rheumatic disease.
  • While eliciting the history, ask the patient for symptoms associated with arthritis, conjunctivitis, iridocyclitis, nonbacterial urethritis or cervicitis, dysentery, mucocutaneous disease with circinate balanitis, painless oral ulceration, and keratodermia blennorrhagica.
  • Dystrophic nail lesions may also be present. These lesions most commonly manifest as nail pitting, but they may progress to excoriative dystrophic changes.
  • The diagnosis is sometimes hard to establish because urethritis or cervicitis may have been forgotten or suppressed and because enteritis and other symptoms may have been mild.
  • Pain in the lower back due to insertional tendinitis and sacroiliitis is common.
  • The associated arthritis is a migratory, asymmetric, and episodic oligoarthritis, primarily affecting the weightbearing large joints of the lower extremities, especially the knees and the ankles.
  • The arthritis often produces swelling and pain in the hindfoot, plantar fasciitis, and Achilles tendinitis. These arthritic manifestations may be acute and short-lived but are often recurrent or chronic. Pedal arthritic changes may be mistaken for chronic injury, occasionally leading to inappropriate surgery.
  • Secondary ankylosing spondylitis is not uncommon.
  • Other articular features include "sausage digits" due to interphalangeal arthritis of the toes and/or the fingers.
  • Systemic symptoms, including fever and weight loss, may occur.
  • The disease tends to follow an episodic and relapsing course.
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Physical

  • Musculoskeletal system
    • Reactive arthritis usually involves the large weightbearing joints of the lower extremities. The knees and the ankles are most frequently involved, with redness and diffuse swelling. Multiple joint involvement is usual.
    • Periostitis and tendinitis may occur, especially involving the Achilles tendon, which produces pain in the heel.
  • Dermatologic
    • The dermal lesions are typified by keratoderma blenorrhagica, which begins as discrete vesicles that thicken and become hyperkeratotic nodules. This is described as a hyperkeratotic erythematous dermatitis, which resembles pustular psoriasis. It may not be present until the later course of the disease.
    • Lesions of keratoderma blenorrhagica occur most commonly on plantar surfaces and toes but may appear on the palms. Circinate balanitis refers to small shallow painless ulcers of the urethral meatus or the glans penis.
  • Gastrointestinal
    • Superficial oral ulcers are frequent.
    • Enteritis is usually a prolonged diarrheal episode with frequent passage of bloody loose stools, but it can manifest as a 24-hour episode of increased bowel activity.
  • Cardiovascular: Cardiac arrhythmias and aortic regurgitation may be evident. Aortitis may be accompanied by coronary inflammation, which can be fatal in rare cases.
  • Ophthalmic
    • Conjunctivitis
      • Conjunctivitis is one component of the original triad (as described by Reiter) and is one of the hallmarks of the disease. It tends to occur early in the disease, especially during the initial attack. Conjunctivitis may be missed if patients are seen only during subsequent attacks.
      • Conjunctivitis is usually described as mucopurulent and is often sterile. It is included in the differential diagnosis for chronic follicular conjunctivitis.
      • The frequency of conjunctivitis in patients with reactive arthritis is reportedly 33-100%.
      • It may be accompanied by iridocyclitis, episcleritis, or scleritis. Punctate and subepithelial corneal involvement has also been reported.
    • Uveitis
      • The more serious ocular manifestation is recurrent nongranulomatous iridocyclitis. Iridocyclitis may be the initial ocular manifestation in some patients. Uveitis may occur in as many as 50% of patients with reactive arthritis.
      • Recurrences are usually associated with an acute iridocyclitis that has a rapid onset with conjunctival and episcleral edema and injection.
      • The corneal endothelium has cellular debris and poorly defined, small- to medium-sized keratic precipitates.
      • Heavy flare and cells and a very early tendency toward formation of posterior synechiae are characteristic, more so than in most other forms of acute iridocyclitis.
      • Even the most aggressive pupil-dilation management is sometimes not adequate to prevent synechiae formation.
      • A peripheral iridectomy may be necessary to prevent iris bombé and angle closure if the synechiae cannot be broken.
      • Heavy flare is sometimes so plasmoid that cells are immobile, and a fibrinlike clot may be seen in the pupillary opening as the inflammation resolves. An acute hypopyon may occur.
      • Cells and inflammatory debris may be seen in the vitreous, and blurring of the disc margins and macular edema may occur with severe or prolonged episodes. Spillover vitritis may be more common in patients with reactive arthritis than those with ankylosing spondylitis.
  • Keratitis: Rarely, patients may develop a punctate epithelial keratitis that may lead to central loss of the corneal epithelium and subepithelial infiltrates.[2]
  • Cataracts: Lens clouding and posterior subcapsular cataracts occur with prolonged or repeated episodes.
  • Hypotony: This condition can occur following a severe or prolonged course and may persist after resolution.
  • Glaucoma
    • Secondary open-angle glaucoma may occur because of the anterior chamber reaction and the trabecular obstruction or trabeculitis. This glaucoma usually resolves with aggressive anti-inflammatory therapy.
    • With repeated recurrences, damage to the trabecular meshwork may occur, resulting in secondary glaucoma.
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Causes

  • In reactive arthritis, infectious organisms are suggested to be the etiologic agents by reports of clinically indistinguishable acute disease following epidemic dysentery and sexually transmitted nongonococcal urethritis believed to be due to Chlamydia species or, possibly, Mycoplasma species or Ureaplasma urealyticum.
  • Large epidemics of dysentery have been linked to multiple occurrences of arthritis, urethritis, and iridocyclitis. Shigella, Campylobacter, Salmonella, and Yersinia have been implicated. The risk of individuals who are HLA-B27–positive developing reactive arthritis following Shigella infection is approximately 25%.
  • Although the cause is unknown, the high correlation with the presence of HLA-B27 (75-95%) is clearly recognized. The B27 allele may be closely linked on chromosome 6 to an immune response gene causing uveitis and reactive arthritis.
  • The mechanism by which the HLA-B27 gene product predisposes to the disease is unknown, but 3 theories have been proposed. These theories include molecular mimicry, the suggestion that HLA-B27 provides a receptor for the inciting organism, and the possibility that HLA-B27 is associated with a defective class I antigen-mediated cellular response.
    • The molecular mimicry hypothesis suggests that a similarity exists at the molecular level between the HLA-B27 molecule and the inciting organisms, allowing for the triggering of an immune response and the subsequent development of clinical disease.
    • The possibility that the HLA-B27 molecule may act as a receptor for certain types of bacteria that then lead to the arthritis has been proposed, but little evidence exists to either confirm or refute this hypothesis.
    • Another hypothesis suggests that the HLA-B27 molecule may be a defective molecule associated with an aberrant cytotoxic T-cell response. The importance of the cytotoxic T-cell response in the development of reactive arthritis has been underscored by the coexistence of reactive arthritis in patients with acquired immunodeficiency syndrome (AIDS).
    • Yersinia antigens have been detected in the synovial fluid of patients with reactive arthritis after Yersinia infection, suggesting that persistent antigenic stimulation may contribute to the inflammatory response.
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Contributor Information and Disclosures
Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS  Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

John D Sheppard Jr, MD, MMSc  Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Garg AX, Pope JE, Thiessen-Philbrook H, Clark WF, Ouimet J. Arthritis risk after acute bacterial gastroenteritis. Rheumatology (Oxford). Feb 2008;47(2):200-4. [Medline].

  2. Kozeis N, Trachana M, Tyradellis S. Keratitis in reactive arthritis (Reiter syndrome) in childhood. Cornea. Aug 2011;30(8):924-5. [Medline].

  3. Rudwaleit M, Braun J, Sieper J. Treatment of reactive arthritis: a practical guide. BioDrugs. Jan 2000;13(1):21-8. [Medline].

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

  5. Banares A, Hernandez-Garcia C, Fernandez-Gutierrez B, Jover JA. Eye involvement in the spondyloarthropathies. Rheum Dis Clin North Am. Nov 1998;24(4):771-84, ix. [Medline].

  6. Kohnke SJ. Reactive arthritis. A clinical approach. Orthop Nurs. Jul-Aug 2004;23(4):274-80. [Medline].

  7. Lee DA, Barker SM, Su WP, Allen GL, Liesegang TJ, Ilstrup DM. The clinical diagnosis of Reiter's syndrome. Ophthalmic and nonophthalmic aspects. Ophthalmology. Mar 1986;93(3):350-6. [Medline].

  8. Mahoney BP. Rheumatologic disease and associated ocular manifestations. J Am Optom Assoc. Jun 1993;64(6):403-15. [Medline].

  9. Ostler HB. Oculogenital disease. Surv Ophthalmol. Jan-Feb 1976;20(4):233-46. [Medline].

 
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