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Reactive Arthritis Treatment & Management

  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
 
Updated: Oct 31, 2015
 

Approach Considerations

No curative treatment for reactive arthritis (ReA) exists. Instead, treatment aims at relieving symptoms and is based on symptom severity. Almost two thirds of patients have a self-limited course and need no treatment other than symptomatic and supportive care. As many as 30% of patients develop chronic symptoms, posing a therapeutic challenge.[81]

Physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and intralesional corticosteroids may be helpful for joint, tendon, and fascial inflammation. Phenylbutazone may be effective when other NSAIDs fail. Low-dose prednisone may be prescribed, but prolonged treatment is not advisable. Antibiotics may be given to treat underlying infection, and disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine and methotrexate may be used safely and are often beneficial. No specific surgical treatment is indicated.

Hospitalization of a patient with uncomplicated ReA is not usually indicated. Inpatient care may be considered for patients who are unable to tolerate oral administration of medications, who are unable to ambulate because of significant joint involvement, who have intractable pain, or who have concomitant disease necessitating admission.

Few treatment options exist for HIV-infected patients with severe ReA. Treatment of ReA in the setting of HIV infection poses special problems. However, potentially immunosuppressive therapies (eg, cyclosporine, methotrexate, and psoralen plus ultraviolet A [PUVA]) have been used in some cases, with variable success and relatively few severe complications. A case report from the United Kingdom suggests that antiretroviral therapy may be considered in HIV-infected ReA patients who are unresponsive to standard therapy.[82]

No dietary limitations are necessary unless the patient is receiving steroid therapy. Efforts should be made to maintain joint function with physical activity, joint protection, and suppression of inflammation. Physical therapy may be instituted to avoid muscle wasting and to reduce pain in severe cases. Although no limitations on physical activity need be imposed, symptoms of arthritis will usually limit patients’ activity to some extent.

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Pharmacologic Therapy

NSAIDs (eg, indomethacin and naproxen) are the foundation of therapy for ReA.[83] Etretinate/acitretin has been shown to decrease the required dosage of NSAIDs.[58] Sulfasalazine or methotrexate may be used for patients who do not experience relief with NSAIDs after 1 month or who have contraindications to NSAIDs. In addition, sulfasalazine-resistant ReA may be successfully treated with methotrexate.[84]

In a series of 22 pediatric ReA patients from the Republic of China, NSAIDs and sulfasalazine were the mainstays of treatment, with cyclophosphamide used in 14 patients and methotrexate and corticosteroids added in a few.[85] Most achieved full remission within 6 months.

Antibiotic treatment is indicated for cervicitis or urethritis but generally not for postdysenteric ReA. In Chlamydia -induced ReA, some data suggest that prolonged combination antibiotic therapy could be an effective treatment strategy.[27]

Case reports exist that demonstrate the effectiveness of anti−tumor necrosis factor (TNF) medications,[46, 86] such as etanercept and infliximab. No published data are available on the effectiveness of selective cyclooxygenase (COX)–2 inhibitors; however, COX-2 inhibitors may be tried in patients who do not tolerate NSAIDs and in whom no preexisting contraindication to COX-2 use exists.

Symptom-specific approaches

Arthritis and enthesitis

Joint symptoms are best treated with aspirin or other short-acting and long-acting anti-inflammatory drugs (eg, indomethacin, naproxen). In one report, a patient became asymptomatic after 3 months of aspirin at a dosage of 80 mg/kg/day; the dosage was gradually reduced and eventually discontinued. A combination of NSAIDs is reportedly effective in severe cases. There are no published data to suggest that any NSAID is more effective or less toxic than another (controlled treatment trials are difficult to conduct with an uncommon disease).

Varying success in treating severe cases of ReA with other medications (eg, sulfasalazine, methotrexate, etretinate, ketoconazole, azathioprine, or intra-articular steroid injections) has been reported. In a refractory case or a patient with HIV-associated ReA, the anti−TNF-α agent infliximab may be successful.[87] Depending on the culture results, a short course of antibiotics may be needed; however, treatment may not affect the disease course. Longer-term administration of antibiotics to treat joint symptoms provides no established benefits.

Conjunctivitis and uveitis

Transient and mild conjunctivitis is usually not treated. Mydriatics and cycloplegics (eg, atropine) with topical corticosteroids may be administered in patients with acute anterior uveitis. Patients with recurrent ocular involvement may require systemic corticosteroid therapy and immunomodulators to preserve vision and prevent ocular morbidity.[88]

Urethritis and gastroenteritis

Antibiotics may be considered for urethritis and gastroenteritis, depending on the cultures used and their sensitivity. In general, urethritis may be treated with a 7- to 10-day course of erythromycin or tetracycline. Antibiotic treatment of enteritis is controversial.

Mucocutaneous lesions

Only local care is necessary for mucosal lesions. Topical steroids may be needed for psoriasiform lesions; the use of hydrocortisone or triamcinolone may be beneficial. A topical keratolytic, such as 10% salicylic acid ointment, can be added if needed. Topical salicylic acid and hydrocortisone with oral aspirin has also been suggested.[68]

Hydrocortisone 2.5% cream and salicylic acid 10% ointment are effective in treating chronic keratoderma blennorrhagicum and circinate balanitis, though either condition may heal without medical treatment. Circinate balanitis usually responds to topical steroids; however, it can be recurrent and create a therapeutic challenge. Balanitis refractory to conventional therapy can be successfully treated with the complementary use of topical 0.1% tacrolimus.[15]

Systemic therapy, if required, consists of the administration of oral acitretin, PUVA, methotrexate, cyclosporine, or some combination thereof.

Nonsteroidal anti-inflammatory drugs

The choice of a specific NSAID depends on the individual response to treatment. Phenylbutazone may work in patients refractive to other NSAIDs. These agents should be used regularly to achieve a good anti-inflammatory effect. Patients must be instructed on compliance and the possible need to adjust the dosage or switch to another agent. Treatment must be continued for 1 month at maximum dosage before effectiveness can be fully evaluated.

NSAIDs may reduce the intensity and the frequency of recurrences of ocular inflammation and allow a decrease in the corticosteroid dosage, which helps decrease the chances of cataract formation and other associated corticosteroid effects.

The decreased awareness of pain sometimes seen with the use of NSAIDs may alter the patient’s recognition of recurrences. Patients should be examined whenever any change in symptoms occurs to evaluate for recurrence of an acute episode of inflammation. Ocular involvement may parallel systemic and joint disease relapses.

Corticosteroids

Corticosteroids may be given either via intra-articular injection or as systemic therapy. For ocular manifestations of ReA, they may also be given topically.

Joint injections can produce long-lasting symptomatic improvement and help avoid the use of systemic therapy. Sacroiliac joints can be injected, usually under fluoroscopic guidance.[89]

Systemic corticosteroids may be particularly useful in patients who do not respond well to NSAIDs or who experience adverse effects related to the use of NSAIDs. The starting dose is guided by a patient’s symptoms and objective evidence of inflammation. Prednisone can be used initially at a dosage of 0.5-1 mg/kg/day, tapered according to response.

Topical corticosteroids and mydriatics should be used early and aggressively to reduce tissue damage. Prolonged topical treatment is necessary for several weeks after the inflammation has cleared; early withdrawal of topical corticosteroids frequently results in the return of inflammatory changes. Keratolytics or topical corticosteroids may improve cutaneous lesions. Topical corticosteroids may be useful for iridocyclitis.

Antibiotics

The current view of the pathogenesis of ReA indicates that an infectious agent is the trigger of the disease, but antibiotic treatment does not change the course of the disease, even when a microorganism is isolated. In these cases, antibiotics are used to treat the underlying infection, but specific treatment guidelines for ReA are lacking.

However, in Chlamydia -induced ReA, studies have suggested that appropriate treatment of the acute genitourinary (GU) infection can prevent ReA and that treatment of acute ReA with a 3-month course of tetracycline reduces the duration of illness. Empiric antibiotics may be considered after appropriate cultures have been taken. Nongonococcal urethritis and other infections can be treated specifically with systemic antibiotics. In the absence of contraindications, treatment of urethritis is recommended, even if improvement is not certain.

Although urethritis and cervicitis are commonly treated with antibiotics, diarrhea generally is not. No evidence indicates that antibiotic therapy benefits enteric-related ReA or chronic ReA of any cause.

Long-term antibiotic therapy may be warranted in cases of poststreptococcal ReA; however, this is currently a controversial topic.[78, 79]

Lymecycline (a tetracycline available outside the United States) was studied in a double-blind placebo-controlled study of patients with chronic ReA for a treatment period of 3 months.[14] The duration of illness was significantly shorter in patients with Chlamydia -induced disease than in those with disease triggered by enteric infections.

Azithromycin was shown to be ineffective in a placebo-controlled trial.[90] Nevertheless, in another study, azithromycin or doxycycline in combination with rifampin for 6 months was reported to be significantly superior to placebo and significantly improved symptoms associated with Chlamydia -induced ReA.[91]

Quinolones have been studied because of their broad coverage, but no clear benefit has been reported.[92] In a randomized, double-blind, placebo-controlled study of 56 patients with recent-onset ReA, 3 months of treatment with a combination of ofloxacin and roxithromycin was not better than placebo in improving outcomes.

More studies are needed before definite recommendations can be made for the role of antibiotics in the management of ReA.[93]

Disease-modifying antirheumatic drugs

In patients who have chronic symptoms or have persistent inflammation despite the use of the agents mentioned above, other second-line drugs may be used. Clinical experience with these DMARDs has been mostly in rheumatoid arthritis and in psoriatic arthritis. However, DMARDs have also been used in ReA, though their disease-modifying effects in this setting are uncertain.

Sulfasalazine has been shown to be beneficial in some patients. The use of this drug in ReA is of interest because of the finding of clinical or subclinical inflammation of the bowel in many patients. Sulfasalazine is more widely used in ankylosing spondylitis. In a 36-week trial of sulfasalazine versus placebo to treat spondyloarthropathies, patients with ReA who were taking sulfasalazine had a 62.3% response rate, compared with a 47.7% rate for the placebo group in peripheral arthritis.[94]

Methotrexate may be used in patients who present with rheumatoidlike disease. Several reports have shown good response, but controlled studies are lacking. Reports also describe the use of azathioprine and bromocriptine in ReA, but again, large studies have not been published.[95, 96] Patients with ReA who have HIV infection or AIDS should not receive methotrexate or other immunosuppressive agents.

Case reports have demonstrated the effectiveness of anti-TNF medications, such as etanercept and infliximab,[46, 86, 87, 97] though there remains a need for randomized, double-blind trials. The high concentrations of TNF-α in the serum and joints of patients with persistent ReA suggest that this cytokine could be targeted in patients who do not respond to NSAIDS and DMARDs. Anti−TNF-α therapy has been demonstrated to be effective treatment for ReA, with a corticosteroid-sparing effect.[98]

However, TNF-α antagonists can increase the risk of serious infection, and it is important to conduct infectious screening and monitoring with a high index of suspicion, as well as preemptive treatment, when such medications are used.[99] Anti-TNF medications can also be associated with severe glomerulonephritis, and it is recommended that renal function be closely monitored in patients treated with these agents.[5]

Interleukin (IL)-6 plays an important role in regulating immune response. Unregulated overproduction of IL-6, however, is pathologically involved in various immune-mediated inflammatory diseases, including ReA. Tocilizumab, a humanized anti–IL-6 receptor antibody, may provide clinical benefit in patients who are refractory to conventional therapy or anti-TNF therapy.[100] However, further clinical studies are required.

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Surgical Intervention

No surgical therapy for ReA is recommended. However, surgical intervention may be warranted for certain ocular manifestations of the disease.

The posterior spillover of inflammatory material in the chronic iridocyclitis associated with ReA may result in persistent vitreous opacification. The cumulative effects of secondary involvement of the vitreous may result in visually disabling vitreous debris and opacification, making these eyes good candidates for vitrectomy. Although vitrectomy should be considered only after prolonged follow-up care and thorough planning, it appears to offer a definitive improvement in vision in certain cases.

Because of the intense episodes of recurrent inflammation, it is essential to render the eyes as quiet as possible before surgery by using topical, periocular, or systemic corticosteroids. At least 3 months of cell-free slit lamp examinations—6 months for younger patients and severe cases—should be documented before elective surgical intervention.

Preoperative ultrasonography is helpful in determining the degree of vitreous opacification, the thickening of the choroid, and the presence of a cyclitic membrane, which can create significant problems at surgery.

The major objective of surgery in patients with complicated uveitic cataract and vitreous opacification is to improve vision. Vitrectomy may favorably modify the dynamics of the uveitic process, though lensectomy-vitrectomy does not reduce the inflammatory reaction in all cases.

Cystoid macular edema is the major cause of decreased visual acuity after surgery; however, this is a common and serious complication of chronic uveitis even without surgery. Vitrectomy may actually reduce cystoid macular edema with gradual resolution over 1 year and an improvement in vision in some patients.

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Prevention

In Chlamydia -induced ReA, studies have suggested that appropriate treatment of the acute GU infection can prevent ReA and that treatment of acute ReA with a 3-month course of antibiotics can reduce the duration of illness. Currently, there is no evidence to indicate that antibiotic therapy is effective for enteric-related ReA or chronic ReA of any cause.

Education on the prevention of the spread of sexually transmitted diseases with condoms has been associated with a decrease in the incidence of postvenereal ReA.

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Consultations

Appropriate consultations should be obtained as necessary.

A rheumatologist may be consulted to discuss appropriate additional tests and medications for symptomatic relief and to ensure follow-up treatment. In particular, the consulting rheumatologist may be extremely helpful in suggesting an appropriate oral NSAID or immunosuppressive agent to augment topical and periocular corticosteroid therapy.

Consultation with a urologist may be necessary if particularly prominent genitourinary manifestations develop.

An ophthalmologist may be consulted to confirm the diagnosis and to treat the ophthalmologic manifestations of ReA.

Consultation with a dermatologist is often helpful. For example, dermatologic involvement may occur with several uveitic syndromes; an accurate description of these lesions may help establish the diagnosis in some cases.

Consultation with and treatment by a dentist, an oral surgeon, or a periodontist may be useful for patients with aphthous ulcers.

An internal medicine consultation should be sought when prolonged systemic corticosteroid therapy is anticipated, especially in patients with concomitant diabetes or hypertension.

An infectious disease consultation may be sought when empiric antibiotic therapy is being considered or when the patient has manifestations of coincident AIDS-defining illnesses.

In cases of poststreptococcal ReA, a cardiology consultation is necessary because serial echocardiography and long-term antibiotic therapy may be of benefit to the patient. It should be kept in mind that patients with ReA symptoms who have evidence of preceding streptococcal infection are likely meet the Jones criteria for acute rheumatic fever. Many cardiologists elect to place these patients on long-term penicillin treatment.[78, 79]

It should be noted that current data show no increased risk of valvular heart disease in adult poststreptococcal ReA. On the basis of these findings, routine long-term antibiotic prophylaxis is not recommended in adult poststreptococcal ReA.[24, 44, 32, 31] The above recommendation is valid in pediatric patients with ReA.

Physical and occupational therapists may be consulted for assistance with maintenance of function and gait.

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Contributor Information and Disclosures
Author

Carlos J Lozada, MD Director of Rheumatology Fellowship Training Program, Professor of Clinical Medicine, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine

Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Received honoraria from Pfizer for consulting; Received grant/research funds from AbbVie for other; Received honoraria from Heel for consulting.

Coauthor(s)

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Maria F Carpintero, MD Assistant Professor of Clinical Medicine, Division Rheumatology/Immunology, University of Miami, Leonard M Miller School of Medicine

Maria F Carpintero, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

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.

Igor Boyarsky, DO Emergency Room Physician, Kaiser Permanente Southern California

Igor Boyarsky, DO is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Emergency Medicine, American College of Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Bo Burns, DO, FACEP, FAAEM Assistant Professor, Associate Residency Director, Medical Clerkship Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine; Attending Physician, Department of Emergency Medicine

Bo Burns, DO, FACEP, FAAEM, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gino A Farina, MD, FACEP, FAAEM Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Lawrence K Jung, MD Chief, Division of Pediatric Rheumatology, Children's National Medical Center

Lawrence K Jung, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Rheumatology, Clinical Immunology Society, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department 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.

Jeffrey Meffert, MD Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at 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.

Barry L Myones, MD Associate Professor, Departments of Pediatrics and Immunology, Pediatric Rheumatology Section, Baylor College of Medicine; Director of Research, Pediatric Rheumatology Center, Texas Children's Hospital

Barry L Myones, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American College of Rheumatology, American Heart Association, American Society for Microbiology, Clinical Immunology Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

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.

Jorge Romaní, MD Assistant Professor, Department of Dermatology, Hospital De Palamós Faculty of Medicine, Spain

Disclosure: Nothing to disclose.

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.

Nima Sarani, MD Resident Physician, Department of Emergency Medicine, Oklahoma University College of Medicine

Nima Sarani, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians, and Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Thomas Scoggins, MD Consulting Staff, Department of Emergency Medicine, Blount Memorial Hospital

Thomas Scoggins, MD is a member of the following medical societies: American College of Emergency Physicians and Flying Physicians Association

Disclosure: Nothing to disclose.

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.

David D Sherry, MD Director, Clinical Rheumatology, Attending Physician, Pain Management, The Children's Hospital of Philadelphia; Professor of Pediatrics, University of Pennsylvania School of Medicine

David D Sherry, MD is a member of the following medical societies: American College of Rheumatology and American Pain Society

Disclosure: Nothing to disclose.

Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Akaluck Thatayatikom, MD Associate Professor and Chief, Department of Pediatrics, Division of Pediatric Allergy, Immunology, and Rheumatology, University of Kentucky College of Medicine

Akaluck Thatayatikom, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Rheumatology, Childhood Arthritis and Rheumatology Research Alliance, and Clinical Immunology Society

Disclosure: Nothing to disclose.

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.

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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

  2. Kataria RK, Brent LH. Spondyloarthropathies. Am Fam Physician. 2004 Jun 15. 69(12):2853-60. [Medline].

  3. Kaarela K, Jäntti JK, Kotaniemi KM. Similarity between chronic reactive arthritis and ankylosing spondylitis.A 32-35-year follow-up study. Clin Exp Rheumatol. 2009 Mar-Apr. 27(2):325-8. [Medline].

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

  5. Braun J, Laitko S, Treharne J, Eggens U, Wu P, Distler A, et al. Chlamydia pneumoniae--a new causative agent of reactive arthritis and undifferentiated oligoarthritis. Ann Rheum Dis. 1994 Feb. 53(2):100-5. [Medline]. [Full Text].

  6. Carter JD, Hudson AP. Reactive arthritis: clinical aspects and medical management. Rheum Dis Clin North Am. 2009 Feb. 35(1):21-44. [Medline].

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

  8. Savolainen E, Kettunen A, Närvänen A, Kautiainen H, Kärkkäinen U, Luosujärvi R, 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. 2009. 38(5):353-6. [Medline].

  9. Singh AK, Misra R, Aggarwal A. Th-17 associated cytokines in patients with reactive arthritis/undifferentiated spondyloarthropathy. Clin Rheumatol. 2011 Jun. 30(6):771-6. [Medline].

  10. Shen H, Goodall JC, Gaston JS. Frequency and phenotype of T helper 17 cells in peripheral blood and synovial fluid of patients with reactive arthritis. J Rheumatol. 2010 Oct. 37(10):2096-9. [Medline].

  11. Eliçabe RJ, Cargnelutti E, Serer MI, Stege PW, Valdez SR, Toscano MA, et al. Lack of TNFR p55 results in heightened expression of IFN-? and IL-17 during the development of reactive arthritis. J Immunol. 2010 Oct 1. 185(7):4485-95. [Medline].

  12. Pöllänen R, Sillat T, Pajarinen J, Levón J, Kaivosoja E, Konttinen YT. Microbial antigens mediate HLA-B27 diseases via TLRs. J Autoimmun. 2009 May-Jun. 32(3-4):172-7. [Medline].

  13. Inman RD. Innate immunity of spondyloarthritis: the role of toll-like receptors. Adv Exp Med Biol. 2009. 649:300-9. [Medline].

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

  15. 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. 2004 Oct. 31(10):1973-80. [Medline].

  16. Alvarez-Navarro C, Cragnolini JJ, Dos Santos HG, Barnea E, Admon A, Morreale A, et al. Novel HLA-B27-restricted epitopes from Chlamydia trachomatis generated upon endogenous processing of bacterial proteins suggest a role of molecular mimicry in reactive arthritis. J Biol Chem. 2013 Sep 6. 288(36):25810-25. [Medline]. [Full Text].

  17. Sahlberg AS, Granfors K, Penttinen MA. HLA-B27 and host-pathogen interaction. Adv Exp Med Biol. 2009. 649:235-44. [Medline].

  18. El Karoui K, Méchaï F, Ribadeau-Dumas F, Viard JP, Lecuit M, de Barbeyrac B, et al. Reactive arthritis associated with L2b lymphogranuloma venereum proctitis. Sex Transm Infect. 2009 Jun. 85(3):180-1. [Medline].

  19. Dworkin MS, Shoemaker PC, Goldoft MJ, Kobayashi JM. Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis. Clin Infect Dis. 2001 Oct 1. 33(7):1010-4. [Medline].

  20. Arnedo-Pena A, Beltrán-Fabregat J, Vila-Pastor B, Tirado-Balaguer MD, Herrero-Carot C, Bellido-Blasco JB, et al. Reactive arthritis and other musculoskeletal sequelae following an outbreak of Salmonella hadar in Castellon, Spain. J Rheumatol. 2010 Aug 1. 37(8):1735-42. [Medline].

  21. Kroot EJ, Hazes JM, Colin EM, Dolhain RJ. Poncet's disease: reactive arthritis accompanying tuberculosis. Two case reports and a review of the literature. Rheumatology (Oxford). 2007 Mar. 46(3):484-9. [Medline].

  22. Connor BA, Johnson EJ, Soave R. Reiter syndrome following protracted symptoms of Cyclospora infection. Emerg Infect Dis. 2001 May-Jun. 7(3):453-4. [Medline]. [Full Text].

  23. Townes JM. Reactive arthritis after enteric infections in the United States: the problem of definition. Clin Infect Dis. 2010 Jan 15. 50(2):247-54. [Medline].

  24. van Bemmel JM, Delgado V, Holman ER, Allaart CF, Huizinga TW, Bax JJ, et al. No increased risk of valvular heart disease in adult poststreptococcal reactive arthritis. Arthritis Rheum. 2009 Apr. 60(4):987-93. [Medline].

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

  26. 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. 1998 Nov. 51(11):803-6. [Medline]. [Full Text].

  27. Carter JD, Hudson AP. The evolving story of Chlamydia-induced reactive arthritis. Curr Opin Rheumatol. 2010 Jul. 22(4):424-30. [Medline].

  28. Siala M, Mahfoudh N, Fourati H, Gdoura R, Younes M, Kammoun A, et al. MHC class I and class II genes in Tunisian patients with reactive and undifferentiated arthritis. Clin Exp Rheumatol. 2009 Mar-Apr. 27(2):208-13. [Medline].

  29. Pope JE, Krizova A, Garg AX, Thiessen-Philbrook H, Ouimet JM. Campylobacter reactive arthritis: a systematic review. Semin Arthritis Rheum. 2007 Aug. 37(1):48-55. [Medline]. [Full Text].

  30. Mortensen NP, Kuijf ML, Ang CW, Schiellerup P, Krogfelt KA, Jacobs BC, et al. Sialylation of Campylobacter jejuni lipo-oligosaccharides is associated with severe gastro-enteritis and reactive arthritis. Microbes Infect. 2009 Oct. 11(12):988-94. [Medline].

  31. van der Helm-van Mil AH. Acute rheumatic fever and poststreptococcal reactive arthritis reconsidered. Curr Opin Rheumatol. 2010 Jul. 22(4):437-42. [Medline].

  32. Sarakbi HA, Hammoudeh M, Kanjar I, Al-Emadi S, Mahdy S, Siam A. Poststreptococcal reactive arthritis and the association with tendonitis, tenosynovitis, and enthesitis. J Clin Rheumatol. 2010 Jan. 16(1):3-6. [Medline].

  33. Kobayashi S, Ichikawa G. Reactive arthritis induced by tonsillitis: a type of 'focal infection'. Adv Otorhinolaryngol. 2011. 72:79-82. [Medline].

  34. Garg S, Malaviya AN, Kapoor S, Rawat R, Agarwal D, Sharma A. Acute inflammatory ankle arthritis in northern India--Löfgren's syndrome or Poncet's disease?. J Assoc Physicians India. 2011 Feb. 59:87-90. [Medline].

  35. Ideguchi H, Ohno S, Takase K, Tsukahara T, Kaneko T, Ishigatsubo Y. A case of Poncet's disease (tuberculous rheumatism). Rheumatol Int. 2009 Jul. 29(9):1097-9. [Medline].

  36. Rueda JC, Crepy MF, Mantilla RD. Clinical features of Poncet's disease. From the description of 198 cases found in the literature. Clin Rheumatol. 2013 Jul. 32(7):929-35. [Medline].

  37. Prati C, Bertolini E, Toussirot E, Wendling D. Reactive arthritis due to Clostridium difficile. Joint Bone Spine. 2010 Mar. 77(2):190-2. [Medline].

  38. Durand CL, Miller PF. Severe Clostridium difficile colitis and reactive arthritis in a ten-year-old child. Pediatr Infect Dis J. 2009 Aug. 28(8):750-1. [Medline].

  39. Okamoto K, Hamano T, Kawaguchi T. [Reiter's syndrome following intravesical instillation of Bacillus Calmette-Guerin]. Hinyokika Kiyo. 2010 Feb. 56(2):111-3. [Medline].

  40. Murata H, Adachi Y, Ebitsuka T, Chino Y, Takahashi R, Hayashi T, et al. Reiter's syndrome following intravesical bacille biliE de Calmette-GuErin treatment for superficial bladder carcinoma: report of six cases. Mod Rheumatol. 2004. 14(1):82-6. [Medline].

  41. Macía Villa C, Sifuentes Giraldo W, Boteanu A, González Lanza M, Bachiller Corral J. Reactive arthritis after the intravesical instillation of BCG. Reumatol Clin. 2012 Sep-Oct. 8(5):284-6. [Medline].

  42. Tektonidou MG. Reiter's syndrome during intravesical BCG therapy for bladder carcinoma. Clin Rheumatol. 2007 Aug. 26(8):1368-9. [Medline].

  43. Bernini L, Manzini CU, Giuggioli D, Sebastiani M, Ferri C. Reactive arthritis induced by intravesical BCG therapy for bladder cancer: our clinical experience and systematic review of the literature. Autoimmun Rev. 2013 Oct. 12(12):1150-9. [Medline].

  44. Sahin N, Salli A, Enginar AU, Ugurlu H. Reactive arthritis following tetanus vaccination: a case report. Mod Rheumatol. 2009. 19(2):209-11. [Medline].

  45. Aksu K, Keser G, Doganavsargil E. Reactive arthritis following tetanus and rabies vaccinations. Rheumatol Int. 2006 Dec. 27(2):209-10. [Medline].

  46. Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. 2009 Apr. 44(4):309-15. [Medline].

  47. Rihl M, Barthel C, Klos A, Schmidt RE, Tak PP, Zeidler H, et al. Identification of candidate genes for susceptibility to reactive arthritis. Rheumatol Int. 2009 Oct. 29(12):1519-22. [Medline].

  48. 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. 2007 Jan. 156(1):188-9. [Medline].

  49. Braun J, Kingsley G, van der Heijde D, Sieper J. On the difficulties of establishing a consensus on the definition of and diagnostic investigations for reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3-6, 1999. J Rheumatol. 2000 Sep. 27(9):2185-92. [Medline].

  50. Rohekar S, Pope J. Epidemiologic approaches to infection and immunity: the case of reactive arthritis. Curr Opin Rheumatol. 2009 Jul. 21(4):386-90. [Medline].

  51. Carter JD, Espinoza LR, Inman RD, Sneed KB, Ricca LR, Vasey FB, et al. Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial. Arthritis Rheum. 2010 May. 62(5):1298-307. [Medline]. [Full Text].

  52. 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. 2008 Dec. 67(12):1689-96. [Medline].

  53. Hajjaj-Hassouni N, Burgos-Vargas R. Ankylosing spondylitis and reactive arthritis in the developing world. Best Pract Res Clin Rheumatol. 2008 Aug. 22(4):709-23. [Medline].

  54. Hanova P, Pavelka K, Holcatova I, Pikhart H. Incidence and prevalence of psoriatic arthritis, ankylosing spondylitis, and reactive arthritis in the first descriptive population-based study in the Czech Republic. Scand J Rheumatol. 2010 Aug. 39(4):310-7. [Medline].

  55. Lahu A, Backa T, Ismaili J, Lahu V, Saiti V. Modes of presentation of reactive arthritis based on the affected joints. Med Arch. 2015 Feb. 69 (1):42-5. [Medline].

  56. Wechalekar MD, Rischmueller M, Whittle S, Burnet S, Hill CL. Prolonged remission of chronic reactive arthritis treated with three infusions of infliximab. J Clin Rheumatol. 2010 Mar. 16(2):79-80. [Medline].

  57. Amor B, Santos RS, Nahal R, Listrat V, Dougados M. Predictive factors for the longterm outcome of spondyloarthropathies. J Rheumatol. 1994 Oct. 21(10):1883-7. [Medline].

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

  59. Kanwar AJ, Mahajan R. Reactive arthritis in India: a dermatologists' perspective. J Cutan Med Surg. 2013 May-Jun. 17(3):180-8. [Medline].

  60. Ngaruiya CM, Martin IB. A case of reactive arthritis: a great masquerader. Am J Emerg Med. 2013 Jan. 31(1):266.e5-7. [Medline].

  61. Kober C, Richardson D, Bell C, Walker-Bone K. Acute seronegative polyarthritis associated with lymphogranuloma venereum infection in a patient with prevalent HIV infection. Int J STD AIDS. 2011 Jan. 22(1):59-60. [Medline].

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

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

  64. Sieper J. Developments in the scientific and clinical understanding of the spondyloarthritides. Arthritis Res Ther. 2009. 11(1):208. [Medline]. [Full Text].

  65. Mansour AM, Jaroudi MO, Medawar WA, Tabbarah ZA. Bilateral multifocal posterior pole lesions in Reiter syndrome. BMJ Case Rep. 2013 Apr 9. 2013:[Medline].

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

  67. Madge SN, James C, Selva D. Bilateral dacryoadenitis: a new addition to the spectrum of reactive arthritis?. Ophthal Plast Reconstr Surg. 2009 Mar-Apr. 25(2):152-3. [Medline].

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

  69. Birnbaum J, Bartlett JG, Gelber AC. Clostridium difficile: an under-recognized cause of reactive arthritis?. Clin Rheumatol. 2008 Feb. 27(2):253-5. [Medline].

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

  71. Manoj E, Ragunathan M. Disease flare of ankylosing spondylitis presenting as reactive arthritis with seropositivity: a case report. J Med Case Rep. 2012 Feb 14. 6(1):60. [Medline]. [Full Text].

  72. da Silva Carneiro SC, Pirmez R, de Hollanda TR, Cuzzi T, Ramos-E-Silva M. Syphilis mimicking other dermatological diseases: reactive arthritis and mucha-habermann disease. Case Rep Dermatol. 2013 Jan. 5(1):15-20. [Medline]. [Full Text].

  73. Kuipers JG, Sibilia J, Bas S, Gaston H, Granfors K, Vischer TL, et al. Reactive and undifferentiated arthritis in North Africa: use of PCR for detection of Chlamydia trachomatis. Clin Rheumatol. 2009 Jan. 28(1):11-6. [Medline].

  74. [Guideline] LeFevre ML, U.S. Preventive Services Task Force. Screening for Chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Dec 16. 161 (12):902-10. [Medline].

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

  76. 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. 1999 Feb. 26(2):163-70. [Medline].

  77. Taniguchi Y, Kumon Y, Nakayama S, Arii K, Ohnishi T, Ogawa Y, et al. F-18 FDG PET/CT provides the earliest findings of enthesitis in reactive arthritis. Clin Nucl Med. 2011 Feb. 36(2):121-3. [Medline].

  78. Simonini G, Taddio A, Cimaz R. No evidence yet to change American Heart Association recommendations for poststreptococcal reactive arthritis: comment on the article by van Bemmel et al. Arthritis Rheum. 2009 Nov. 60(11):3516-8; author reply 3518-9. [Medline].

  79. Moorthy LN, Gaur S, Peterson MG, Landa YF, Tandon M, Lehman TJ. Poststreptococcal reactive arthritis in children: a retrospective study. Clin Pediatr (Phila). 2009 Mar. 48(2):174-82. [Medline].

  80. Siala M, Gdoura R, Younes M, Fourati H, Cheour I, Meddeb N, 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. 2009 Mar. 55(2):178-86. [Medline].

  81. Rihl M, Kuipers JG. [Reactive arthritis: from pathogenesis to novel strategies]. Z Rheumatol. 2010 Dec. 69(10):864-70. [Medline].

  82. Scott C, Brand A, Natha M. Reactive arthritis responding to antiretroviral therapy in an HIV-1-infected individual. Int J STD AIDS. 2012 May. 23(5):373-4. [Medline].

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

  84. Nanke Y, Yago T, Kobashigawa T, Kotake S. Efficacy of methotrexate in the treatment of a HLA-B27-positive Japanease patient with reactive arthritis. Nihon Rinsho Meneki Gakkai Kaishi. 2010. 33(5):283-5. [Medline].

  85. Li CW, Ma JJ, Yin J, Liu L, Hu J. [Reiter's syndrome in children: a clinical analysis of 22 cases]. Zhonghua Er Ke Za Zhi. 2010 Mar. 48(3):212-5. [Medline].

  86. Schafranski MD. Infliximab for reactive arthritis secondary to Chlamydia trachomatis infection. Rheumatol Int. 2010 Mar. 30(5):679-80. [Medline].

  87. Gill H, Majithia V. Successful use of infliximab in the treatment of Reiter's syndrome: a case report and discussion. Clin Rheumatol. 2008 Jan. 27(1):121-3. [Medline].

  88. 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. 2003 Sep. 110(9):1764-9. [Medline].

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

  90. Kvien TK, Gaston JS, Bardin T, Butrimiene I, Dijkmans BA, Leirisalo-Repo M, et al. Three month treatment of reactive arthritis with azithromycin: a EULAR double blind, placebo controlled study. Ann Rheum Dis. 2004 Sep. 63(9):1113-9. [Medline]. [Full Text].

  91. Carter JD et al. Combination Antibiotics as a Treatment for Chronic Chlamydia-Induced Reactive Arthritis. Philadelphia PA. (abstract 1152).: ACR/ARHP Annual Scientific Meeting; October 19, 2009.

  92. Yli-Kerttula T, Luukkainen R, Yli-Kerttula U, Möttönen T, Hakola M, Korpela M, et al. Effect of a three month course of ciprofloxacin on the late prognosis of reactive arthritis. Ann Rheum Dis. 2003 Sep. 62(9):880-4. [Medline]. [Full Text].

  93. Barber CE, Kim J, Inman RD, Esdaile JM, James MT. Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis. J Rheumatol. 2013 Jun. 40(6):916-28. [Medline].

  94. Clegg DO, Reda DJ, Weisman MH, Cush JJ, Vasey FB, Schumacher HR Jr, 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. 1996 Dec. 39(12):2021-7. [Medline].

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

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

  97. Abdelmoula LC, Yahia CB, Testouri N, Tekaya R, Ben M'barek R, Chaabouni L, et al. [Treatment of reactive arthritis with infliximab]. Tunis Med. 2008 Dec. 86(12):1095-7. [Medline].

  98. Meyer A, Chatelus E, Wendling D, Berthelot JM, Dernis E, Houvenagel E, et al. Safety and efficacy of anti-tumor necrosis factor a therapy in ten patients with recent-onset refractory reactive arthritis. Arthritis Rheum. 2011 May. 63(5):1274-80. [Medline].

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

  100. Tanaka T, Kuwahara Y, Shima Y, Hirano T, Kawai M, Ogawa M, et al. Successful treatment of reactive arthritis with a humanized anti-interleukin-6 receptor antibody, tocilizumab. Arthritis Rheum. 2009 Dec 15. 61(12):1762-4. [Medline].

  101. Kuuliala A, Julkunen H, Paimela L, Peltomaa R, Kautiainen H, Repo H, et al. Double-blind, randomized, placebo-controlled study of three-month treatment with the combination of ofloxacin and roxithromycin in recent-onset reactive arthritis. Rheumatol Int. 2013 Nov. 33 (11):2723-9. [Medline].

 
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Balanitis circinata (circinate balanitis) in patient with reactive arthritis.
Plaques on soles of patient with reactive arthritis.
Painful erosions on fingers in patient with reactive arthritis.
Plaques and erosions of tongue in patient with reactive arthritis.
Radiograph of feet of 27-year-old man shows erosions in all left metatarsophalangeal (MTP) joints with subluxation and valgus deformity of most toes. Smaller erosions are also visible in fourth and fifth MTP joints of right foot.
Lateral radiograph of foot reveals calcaneal spur and enthesitis.
Radiograph of both hands shows small erosive changes in both first metacarpal heads associated with minimal subluxation. Bone density is normal.
Radiography of pelvis reveals bilateral asymmetric sacroiliitis.
Radiograph in 40-year-old man shows nonmarginal syndesmophytes predominantly in lower thoracic and upper lumbar spine.
Swelling of right knee with effusion caused by arthritis. Image courtesy of Gun Phongsamart, MD.
Remarkable tenderness of left sacroiliac joint caused by sacroiliitis. Image courtesy of Gun Phongsamart, MD.
Balanitis circinata (circinate balanitis). Image courtesy of Gun Phongsamart, MD.
Achilles tendinitis and swelling of retrocalcaneal bursa.
 
 
 
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