eMedicine Specialties > Rheumatology > Spondyloarthropathies

Reactive Arthritis: Differential Diagnoses & Workup

Author: Carlos J Lozada, MD, Director of Rheumatology Fellowship Program, Associate Professor, Department of Medicine, Division of Rheumatology and Immunology, Jackson Memorial Medical Center, University of Miami School of Medicine
Contributor Information and Disclosures

Updated: Oct 1, 2008

Differential Diagnoses

Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy
Psoriatic Arthritis
Gonococcal Arthritis
Rheumatic Fever
Gout
Rheumatoid Arthritis
Inflammatory Bowel Disease
Septic Arthritis

Workup

Laboratory Studies

  • The values of acute-phase reactants, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are usually elevated markedly but later return to the reference range when the inflammation subsides.
  • Other laboratory findings include a normocytic normochromic anemia along with mild leukocytosis and thrombocytosis during the acute phase. IgA antibodies to specific bacterial antigens have been reported. Urinalysis may reveal aseptic pyuria.
  • Synovial fluid analysis reveals a high WBC count, most often with elevated polymorphonuclear leukocytes acutely. Gram stain and culture results are negative and are necessary to exclude septic arthritis. Microbial components and antigens have been identified in joint fluid using sophisticated laboratory techniques.
  • Throat, stool, or urogenital tract cultures can be performed in an attempt to isolate the causative organism. Other serologic techniques for the detection of Chlamydia species, including PCR, may be considered.
  • Test results for rheumatoid factor and antinuclear antibodies are negative.

Imaging Studies

  • Radiography
    • Early in the disease process, radiography reveals no abnormalities.
    • In more advanced or long-term reactive arthritis, periosteal reaction and proliferation at sites of tendon insertion are visible.
    • Exuberant plantar spurs are a common sign in long-term reactive arthritis.
    • In the hands and feet, marginal erosions with adjacent bone proliferation occur.
    • Spinal radiographic findings include sacroiliitis and syndesmophytes. Sacroiliitis occurs in less than 10% of acute cases but develops in half of patients with chronic severe disease.
    • Syndesmophytes are usually asymmetrical and are found most commonly in the thoracolumbar region.
    • Severe ankylosing spondylitis occurs in less than 5% of cases.
  • MRI: MRI of the sacroiliac joints may reveal disease earlier than conventional radiography.

Other Tests

  • ECG should be performed in patients with a prolonged course of reactive arthritis to evaluate for conduction disturbances.
  • HLA-B27 testing results are positive in 65-96% of cases. HLA-B27 testing is not necessary in classic Reiter syndrome but may be helpful to support the diagnosis of reactive arthritis in patients with joint-restricted symptoms.

Procedures

  • Needle aspiration of a joint may be necessary to rule out septic or crystalline arthritis.

More on Reactive Arthritis

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

References

  1. Reiter H. Ueber cine bisher unbekannte spirochaeten-infektion (spirochaetosis arthritica). Dtsche Med Wschr. 1916;42:1535-6.

  2. Lu DW, Katz KA. Declining use of the eponym "Reiter's syndrome" in the medical literature, 1998-2003. J Am Acad Dermatol. Oct 2005;53(4):720-3. [Medline].

  3. Braun J, Laitko S, Treharne J, et al. Chlamydia pneumoniae--a new causative agent of reactive arthritis and undifferentiated oligoarthritis. Ann Rheum Dis. Feb 1994;53(2):100-5. [Medline].

  4. Lauhio A, Leirisalo-Repo M, Lahdevirta J, et al. Double-blind, placebo-controlled study of three-month treatment with lymecycline in reactive arthritis, with special reference to Chlamydia arthritis. Arthritis Rheum. Jan 1991;34(1):6-14. [Medline].

  5. Carter JD, Valeriano J, Vasey FB. Doxycycline versus doxycycline and rifampin in undifferentiated spondyloarthropathy, with special reference to chlamydia-induced arthritis. A prospective, randomized 9-month comparison. J Rheumatol. Oct 2004;31(10):1973-80. [Medline].

  6. Amor B, Santos RS, Nahal R, et al. Predictive factors for the longterm outcome of spondyloarthropathies. J Rheumatol. Oct 1994;21(10):1883-7. [Medline].

  7. De Vos M, Cuvelier C, Mielants H, et al. Ileocolonoscopy in seronegative spondylarthropathy. Gastroenterology. Feb 1989;96(2 Pt 1):339-44. [Medline].

  8. Maugars Y, Mathis C, Vilon P, et al. Corticosteroid injection of the sacroiliac joint in patients with seronegative spondylarthropathy. Arthritis Rheum. May 1992;35(5):564-8. [Medline].

  9. Clegg DO, Reda DJ, Weisman MH, et al. Comparison of sulfasalazine and placebo in the treatment of reactive arthritis (Reiter's syndrome). A Department of Veterans Affairs Cooperative Study. Arthritis Rheum. Dec 1996;39(12):2021-7. [Medline].

  10. Calin A. A placebo controlled, crossover study of azathioprine in Reiter's syndrome. Ann Rheum Dis. Aug 1986;45(8):653-5. [Medline].

  11. Bravo G, Zazueta B, Lavalle C. An acute remission of Reiter's syndrome in male patients treated with bromocriptine. J Rheumatol. May 1992;19(5):747-50. [Medline].

  12. Aho K. Bowel infection predisposing to reactive arthritis. Baillieres Clin Rheumatol. Aug 1989;3(2):303-19. [Medline].

  13. Ahvonen P, Sievers K, Aho K. Arthritis associated with Yersinia enterocolitica infection. Acta Rheumatol Scand. 1969;15(3):232-53. [Medline].

  14. Anandarajah A, Ritchlin CT. Treatment update on spondyloarthropathy. Curr Opin Rheumatol. May 2005;17(3):247-56. [Medline].

  15. Arnett F. Reactive arthritis and enteropathic arthritis. In: Klippel J, Weyand C, Wortmann R, eds. Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: National Arthritis Foundation; 1997:184-8.

  16. Arnett FC. Incomplete Reiter's syndrome: clinical comparisons with classical triad. Ann Rheum Dis. 1979;38 Suppl 1:suppl 73-8. [Medline].

  17. Brower A. Arthritis in Black and White. 2nd ed. Philadelphia, Pa: WB Saunders; 1997:252.

  18. Fiessenger N, Leroy E. Contribution a l'etude d'une epidemie de dysenterie dans la Somme. Bull Mem Soc Med Hop Paris. 1916;40:2030-69.

  19. Flagg SD, Meador R, Hsia E, et al. Decreased pain and synovial inflammation after etanercept therapy in patients with reactive and undifferentiated arthritis: an open-label trial. Arthritis Rheum. Aug 15 2005;53(4):613-7. [Medline].

  20. Iliopoulos A, Karras D, Ioakimidis D, et al. Change in the epidemiology of Reiter's syndrome (reactive arthritis) in the post-AIDS era? An analysis of cases appearing in the Greek Army. J Rheumatol. Feb 1995;22(2):252-4. [Medline].

  21. Isomäki H, Raunio J, von Essen R, et al. Incidence of inflammatory rheumatic diseases in Finland. Scand J Rheumatol. 1978;7(3):188-92. [Medline].

  22. Keat A. Reiter's syndrome and reactive arthritis in perspective. N Engl J Med. Dec 29 1983;309(26):1606-15. [Medline].

  23. Kingsley G, Panayi G. Antigenic responses in reactive arthritis. Rheum Dis Clin North Am. Feb 1992;18(1):49-66. [Medline].

  24. Kvien TK, Gaston JS, Bardin T, et al. Three month treatment of reactive arthritis with azithromycin: a EULAR double blind, placebo controlled study. Ann Rheum Dis. Sep 2004;63(9):1113-9. [Medline].

  25. Lee AT, Hall RG, Pile KD. Reactive joint symptoms following an outbreak of Salmonella typhimurium phage type 135a. J Rheumatol. Mar 2005;32(3):524-7. [Medline].

  26. Leirisalo M, Skylv G, Kousa M, et al. Followup study on patients with Reiter's disease and reactive arthritis, with special reference to HLA-B27. Arthritis Rheum. Mar 1982;25(3):249-59. [Medline].

  27. Moll JM, Haslock I, Macrae IF, et al. Associations between ankylosing spondylitis, psoriatic arthritis, Reiter's disease, the intestinal arthropathies, and Behcet's syndrome. Medicine (Baltimore). Sep 1974;53(5):343-64. [Medline].

  28. Noer HR. An "experimental" epidemic of Reiter's syndrome. JAMA. Nov 14 1966;198(7):693-8. [Medline].

  29. Petersel DL, Sigal LH. Reactive arthritis. Infect Dis Clin North Am. Dec 2005;19(4):863-83. [Medline].

  30. Reveille JD, Arnett FC. Spondyloarthritis: update on pathogenesis and management. Am J Med. Jun 2005;118(6):592-603. [Medline].

  31. Rohekar S, Tsui FW, Tsui HW, Xi N, Riarh R, Bilotta R, et al. Symptomatic acute reactive arthritis after an outbreak of salmonella. J Rheumatol. Aug 2008;35(8):1599-602. [Medline].

  32. Sieper J, Fendler C, Laitko S, et al. No benefit of long-term ciprofloxacin treatment in patients with reactive arthritis and undifferentiated oligoarthritis: a three-month, multicenter, double-blind, randomized, placebo-controlled study. Arthritis Rheum. Jul 1999;42(7):1386-96. [Medline].

  33. Solitar BM, Lozada CJ, Tseng CE, et al. Reiter's syndrome among Asian shipboard immigrants: the case of The Golden Venture. Semin Arthritis Rheum. Apr 1998;27(5):293-300. [Medline].

  34. Toivanen A, Toivanen P. Aetiopathogenesis of reactive arthritis. Rheumatol Eur. 1995;24(1):5-8.

  35. Toivanen A, Toivanen P. Epidemiologic, clinical, and therapeutic aspects of reactive arthritis and ankylosing spondylitis. Curr Opin Rheumatol. Jul 1995;7(4):279-83. [Medline].

  36. Townes JM, Deodhar AA, Laine ES, Smith K, Krug HE, Barkhuizen A, et al. Reactive arthritis following culture-confirmed infections with bacterial enteric pathogens in Minnesota and Oregon: a population-based study. Ann Rheum Dis. Feb 13 2008;[Medline].

  37. van Bohemen CG, Lionarons RJ, van Bodegom P, et al. Susceptibility and HLA-B27 in post-dysenteric arthropathies. Immunology. Oct 1985;56(2):377-9. [Medline].

  38. Wakefield D, McCluskey P, Verma M, et al. Ciprofloxacin treatment does not influence course or relapse rate of reactive arthritis and anterior uveitis. Arthritis Rheum. Sep 1999;42(9):1894-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

reactive arthritis, Reiter syndrome, Reiter's syndrome, RS, ReA, nongonococcal urethritis, conjunctivitis, oculo-urethro-synovial syndrome, Chlamydia reactive arthritis, chlamydial reactive arthritis , Shigella dysentery, gastrointestinal infections, Salmonella, Campylobacter, Chlamydia trachomatis, C trachomatis, Yersinia, ankylosing spondylitis, psoriatic arthritis, seronegative spondyloarthropathy, infectious diarrhea, genitourinary infection

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Carlos J Lozada, MD, Director of Rheumatology Fellowship Program, Associate Professor, Department of Medicine, Division of Rheumatology and Immunology, Jackson Memorial Medical Center, University of Miami School of Medicine
Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology
Disclosure: Nothing to disclose.

Medical Editor

John Varga, MD, Professor, Department of Internal Medicine, Division of Rheumatology, Northwestern University
John Varga, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, Central Society for Clinical Research, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Elliot Goldberg, MD, Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine
Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; Merck, Amgen, Biogen, Zimmer, Wyeth, Johnson&Johnson, Stryker, Medtronic, Zimmer.Abbott,  Ownership interest Other; West Penn Allegheny Health System Consulting fee Consulting; Alpharma Honoraria Consulting; Proctor&Gamble Grant/research funds Independent contractor

 
 
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.