eMedicine Specialties > Radiology > Musculoskeletal
Reactive Arthritis, Musculoskeletal: Imaging
Updated: Feb 21, 2007
Radiography
Findings
In early stage, radiographs are normal. The synovial joint, symphyses, and entheses are affected. An asymmetric distribution with predominant involvement of lower extremities is seen.
The general radiographic changes are similar to those of psoriatic arthritis, but the characteristic sites of abnormality are the small joints of the foot, the calcaneus, the ankle, the knee, and the sacroiliac joint. Nonspecific soft-tissue swelling is frequently seen in the toes and fingers, resulting in sausage-shaped digits.
Periarticular osteoporosis is seen with acute episode of arthritis. Diffuse loss of the articular space is characteristic and is frequently affects the small joints of the foot, hand, wrist, knee, and ankle. Bone erosions may also occur at these joints, resulting in sacroiliitis. Erosions initially occur at the joint margins and later progress to involve subchondral bone in the central portion.
Bone proliferation is characteristic of all seronegative spondyloarthropathies and is the most helpful radiographic feature in distinguishing these conditions from rheumatoid arthritis. Linear and fluffy periosteal bone proliferations are common in Reiter syndrome, especially in the calcaneus; knee; and metacarpal, metatarsal, and phalangeal shafts. A second variety of bone proliferation occurs at the sites of tendon and ligament attachments to the bone.
Intra-articular bony ankylosis is seen in small joints of hands and feet but is less common than with ankylosing spondylitis and psoriatic arthritis.
Forefoot
Radiographs of the foot show asymmetric involvement of the metatarsophalangeal and interphalangeal joints. Any joint may be affected; the joints of the great toe are commonly involved (see Image 1)
Calcaneum
Calcaneal enthesopathy is characteristic of Reiter syndrome and occurs in 25-50% of cases. Both the posterior and plantar aspects of the bone are affected (see Image 2). Bilateral changes are common.
Ankle
Radiographic findings are seen in 30-50% of patients. Changes include soft tissue swelling, linear or fluffy periostitis of the distal tibial and fibular diaphyses and metaphysis, and articular space loss and marginal erosions.
Knee
Knee changes are seen in 25-50% of patients. The most common abnormality is joint effusion.
Hand and wrist
Changes in the upper extremity are unusual and seen in 10-30% of cases. Abnormalities of the proximal interphalangeal joint are more common than changes in the metacarpophalangeal and distal interphalangeal joints. Involvement of the wrist is usually asymmetric (see Image 3).
Manubriosternal joint and symphysis pubis
Osseous erosions and adjacent bony proliferation at the manubriosternal joints are seen in Reiter disease and may be associated with local pain and tenderness. Similar changes are seen at the symphysis pubis.
Temporomandibular joint
Patients with Reiter disease often have condylar erosions that cause pain and dysfunction in the temporomandibular joints. These abnormalities can be demonstrated by plain radiography. When the radiographs are inconclusive, the changes can be depicted by MRI or CT.
Sacroiliac joint
Sacroiliitis is common in Reiter syndrome, seen in 5-10% of patients with acute disease and 40-60% of those with chronic severe disease. If supplemented with radionuclide investigation, sacroiliitis is found in 60-75% of patients.
Bilateral asymmetric changes are most typical (see Image 4). Less commonly, unilateral abnormalities of the sacroiliac joint are seen in Reiter syndrome, particularly early in the disease process.
Spine
Spinal changes are less common than the other changes in Reiter disease and seen less often than in ankylosing spondylitis and psoriatic arthritis. An early finding in Reiter syndrome is the appearance of paravertebral syndesmophytes about the lower 3 thoracic and upper 3 lumbar vertebrae (see Image 5).
Degree of Confidence
Radiographs are a reliable means of diagnosing Reiter syndrome, particularly if the typical clinical features are present.
Computed Tomography
Findings
Sacroiliitis is demonstrable on CT earlier than on plain radiography. Early sacroiliitis manifests with small joint erosions and irregularities in the articular surfaces of the sacroiliac joint (see Image 6). Unilateral or asymmetric involvement of the sacroiliac joints is also common. Enthesopathies are also demonstrable.
The high radiation dose to the patient makes CT an unattractive modality for screening large areas of the body in cases of suspected Reiter disease, but CT is useful in localized evaluations or in determining the extent of complications such as bony ankylosis when plain radiographs are inconclusive.
CT is also useful in interventions such as CT-guided injections of the sacroiliac joint and in the management of chronic severe sacroiliac joint pain (see Image 7).
Degree of Confidence
CT is a reliable means of establishing diagnosis of sacroiliitis and in demonstrating enthesopathies. However, the findings are generally nonspecific and should be correlated with the clinical picture.
Magnetic Resonance Imaging
Findings
In Reiter disease, MRI reveals the extent of the process; the presence of bursitis and tenosynovitis, especially in the peroneal, anterior tibial, and posterior tibial tendons; and the presence of complications such as synovial cysts. Erosive arthritis and synovitis may develop in the hands and wrists.
Synovitis and tenosynovitis are hypointense on T1-weighted images and hyperintense on T2-weighted spin-echo images. These appearances reflect the water content of the affected areas. Short-tau inversion recovery (STIR) images show strong hyperintensity is seen in the affected joints and adjacent marrow, as well as in sites of enthesitis (see Images 8-10).
Degree of Confidence
MRI has extremely high sensitivity for active Reiter disease but low specify. Correlation with the clinical and radiographic findings is usually necessary to differentiate Reiter disease from other seronegative arthropathies.
Ultrasonography
Findings
Plantar fasciitis is the most common cause of inferior heel pain, and Reiter disease is one of the causes of plantar fasciitis.
High-resolution ultrasonography reveals decreased echogenicity and increased thickness of the plantar fascia (normal thickness, 3-4 mm).
Degree of Confidence
In addition to Reiter disease, a variety of rheumatologic conditions can cause plantar fasciitis. Examples include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and gout. The sonographic findings of these conditions are identical. These other disease should be considered in the differential diagnosis and excluded with clinical history taking and other means.
Nuclear Imaging
Findings
Bone scintigraphy with bone-seeking radiopharmaceutical agents allows the early detection of Reiter syndrome and provides accurate details about the extent of the disease. The distribution of abnormal radionuclide accumulation parallels that obtained by radiographic examination and may occur before radiographic and clinical alterations are apparent.
Asymmetric involvement of lower extremity is usually seen. Increasing radioactivity related to the plantar and posterior aspects of the calcaneus is observed.
Degree of Confidence
Scintigraphy provides high sensitivity but low specificity for the diagnosis of sacroiliitis.
The interpretation of scintigraphic abnormalities at sacroiliac joints is difficult because prominent uptake at this site is a normal finding.
False Positives/Negatives
Abnormal radionuclide uptake in the sacroiliac joint and other locations may not be specific for Reiter syndrome. Other seronegative spondyloarthropathies, such as psoriatic arthritis, may have similar findings.
More on Reactive Arthritis, Musculoskeletal |
| Overview: Reactive Arthritis, Musculoskeletal |
 Imaging: Reactive Arthritis, Musculoskeletal |
| Follow-up: Reactive Arthritis, Musculoskeletal |
| Multimedia: Reactive Arthritis, Musculoskeletal |
| References |
| « Previous Page | Next Page » |
References
Bergman AG. Synovial lesions of the hand and wrist. Magn Reson Imaging Clin N Am. May 1995;3(2):265-79. [Medline].
Cardinal E, Chhem RK, Beauregard CG, et al. Plantar fasciitis: sonographic evaluation. Radiology. Oct 1996;201(1):257-9. [Medline].
Conway WF, Totty WG. Synovial arthritis. In: Stark DD, Bradley WG, eds. Magnetic Resonance Imaging. 3rd ed. Vol 2. 1999: 807.
El-Khoury GY, Kathol MH, Brandser EA. Seronegative spondyloarthropathies. Radiol Clin North Am. Mar 1996;34(2):343-57, xi. [Medline].
Fan PT, Yu DT. Reiter's syndrome. In: Kelley's Textbook of Rheumatology. 2001: 1039-67.
Jevtic V, Rozman B, Kos-Golja M, Watt I. [MR imaging in seronegative spondyloarthritis]. Radiology. Aug 1996;36(8):624-31. [Medline].
Jevtic V, Watt I, Rozman B. Distinctive radiological features of small hand joints in rheumatoid arthritis and seronegative spondyloarthritis demonstrated by contrast-enhanced (Gd-DTPA) magnetic resonance imaging. Skeletal Radiol. Jul 1995;24(5):351-5. [Medline].
Könönen M, Kovero O, Wenneberg B, Konttinen YT. Radiographic signs in the temporomandibular joint in Reiter's disease. J Orofac Pain. 2002;16(2):143-7. [Medline].
Lanjewar DN, Bhosale A, Iyer A. Spectrum of dermatopathologic lesions associated with HIV/AIDS in India. Indian J Pathol Microbiol. Jul 2002;45(3):293-8.
Lin WY, Wang SJ, Lan JL. Evaluation of arthritis in Reiter's disease by bone scintigraphy and radiography. Clin Rheumatol. Jul 1995;14(4):441-4. [Medline].
Lotery HE, Galask RP, Stone MS, Sontheimer RD. Ulcerative vulvitis in atypical Reiter's syndrome. J Am Acad Dermatol. Apr 2003;48(4):613-6. [Medline].
Lysenko OV. Reiter''s Disease in Children. Characteristic of Cellular Compartment of Immunity. Russ J Immunol. Dec 2000;5(4):407-412.
Manaster BJ. Arthritis. In: Manaster BJ, Disler DG, eds. Musculoskeletal Imaging: The Requisites. 2nd ed. 2002: 130-1.
Nuki G, Ralston SH, Luqmani R. Inflammatory joint disease. In: Haslett C, et al, eds. Davidson's Principles and Practice of Medicine. 18th ed. 1999: 850-2.
Pego JM, Lamas C, Hernández I, Suso J. [Relapsing Reiter''s syndrome after Bacillus Calmette-Guérin immunotherapy for bladder carcinoma]. Med Clin (Barc). Sep 20 2003;121(9):356-7. [Medline].
Resnik D. Reiter's syndrome. In:. Diagnosis of Bone and Joint Disorders. Vol 2. 2002: 1110.
Shiba M, Fujii T, Takatera H. [Reiter syndrome after intravesical Bacillus Calmette-Guerin (BCG) immunotherapy: a case report]. Hinyokika Kiyo. Oct 2003;49(10):599-601. [Medline].
Further Reading
Keywords
Reiter syndrome, Reiter's syndrome, Reiter disease, Reiter's disease, reactive arthritis, human leukocyte antigen B27, HLA-B27, seronegative spondyloarthropathy
