eMedicine Specialties > Emergency Medicine > Rheumatology

Reactive Arthritis: Differential Diagnoses & Workup

Author: Thomas Scoggins, MD, Consulting Staff, Department of Emergency Medicine, Blount Memorial Hospital
Coauthor(s): Igor Boyarsky, DO, Director of Triage, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center, University of California at Los Angeles
Contributor Information and Disclosures

Updated: Jun 18, 2009

Differential Diagnoses

Arthritis, Rheumatoid
Rheumatic Fever
Conjunctivitis
Sarcoidosis
Gonorrhea
Syphilis
Gout and Pseudogout
Tendonitis
Inflammatory Bowel Disease
Tenosynovitis
Iritis and Uveitis
Tick-Borne Diseases, Lyme

Other Problems to Be Considered

Septic arthritis
Other reactive arthritides and spondyloarthropathies

Workup

Laboratory Studies

  • Documentation of specific bacterial infection
    • Cervical or urethral swab may be performed. Look for Chlamydia in every case of reactive arthritis, preferably by direct florescent antibody, enzyme immunoassay, or DNA probe for ribosomal RNA. Culture techniques are unreliable; however, serology is useful in some cases.
    • Obtain stool cultures even when bowel symptoms are inapparent or mild.
    • Arthrocentesis and fluid analysis often are needed to rule out an infectious process, especially in monoarticular arthritis with constitutional symptoms.
  • Acute cases
    • Neutrophilic leukocytosis
    • Elevated C-reactive protein or C3 and C4 (nonspecific)
    • Erythrocyte sedimentation rate (ESR) - Usually elevated during acute phase of disease
  • Chronic cases - Mild normocytic anemia

Imaging Studies

  • Plain radiography - May show no abnormalities early in the disease
    • Asymmetric, oligoarticular, and more common in the lower extremities pattern of joint involvement
    • Juxta-articular osteoporosis in acute episodes of arthritis - Erosions have indistinct margins and are surrounded by periosteal new bone.
    • Spinal pattern - Unilateral or bilateral sacroiliitis, asymmetric paravertebral comma-shaped ossification involving the lower thoracic and upper lumbar vertebrae

Other Tests

  • Test results for rheumatoid factor and antinuclear antibody are negative. (Test results usually are not available during the ED evaluation.)
  • HLA-B27 may be useful when extra-articular features are not present. The presence of antigen correlates with axial disease, carditis, and uveitis. (Test results usually are not available during the ED evaluation.)
  • Consider referral for HIV testing in patients presenting with history, symptoms, or findings suggesting increased risk for the disease.

Procedures

  • Synovial fluid: Macrophages with vacuoles filled with nuclear debris and whole leukocytes may be found but are nonspecific.
  • Synovial biopsy: Nonspecific inflammatory changes; infectious antigens have been found in synovium; immunohistochemistry, polymerase chain reaction, and molecular hybridization may become more useful. (Procedure usually is not performed during the ED evaluation.)

More on Reactive Arthritis

Overview: Reactive Arthritis
Differential Diagnoses & Workup: Reactive Arthritis
Treatment & Medication: Reactive Arthritis
Follow-up: Reactive Arthritis
References
Further Reading
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References

  1. 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].

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

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

  4. 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. Jun 9 2009;[Medline].

  5. 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. Oct 1 2001;33(7):1010-4. [Medline].

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

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

  8. Bauman C, Cron RQ, Sherry DD, Francis JS. Reiter syndrome initially misdiagnosed as Kawasaki disease. J Pediatr. Mar 1996;128(3):366-9. [Medline].

  9. Cuttica RJ, Scheines EJ, Garay SM, Romanelli MC, Maldonado Cocco JA. Juvenile onset Reiter's syndrome. A retrospective study of 26 patients. Clin Exp Rheumatol. May-Jun 1992;10(3):285-8. [Medline].

  10. Fan PT, Yu DTY. Reiters syndrome. In: Ruddy S, Harris ED Jr, Sledge CB, eds. Kelley's Textbook of Rheumatology. 6th ed. WB Saunders; 2001:1039-1067.

  11. Hoogland YT, Alexander EP, Patterson RH, Nashel DJ. Coronary artery stenosis in Reiter's syndrome: a complication of aortitis. J Rheumatol. Apr 1994;21(4):757-9. [Medline].

  12. Hughes RA, Keat AC. Reiter's syndrome and reactive arthritis: a current view. Semin Arthritis Rheum. Dec 1994;24(3):190-210. [Medline].

  13. Kasper DL, ed. Reactive arthritis. In: Harrison's Online. Part 13. Section 2. Chap 305. McGraw Hill;2004.

  14. Natarajan UR, Tan TL, Lau R. Reiter's disease following Mycoplasma pneumoniae infection. Int J STD AIDS. May 2001;12(5):349-50. [Medline].

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

  16. Rihl M, Klos A, Kohler L, Kuipers JG. Infection and musculoskeletal conditions: Reactive arthritis. Best Pract Res Clin Rheumatol. Dec 2006;20(6):1119-37. [Medline].

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Further Reading

Clinical guidelines

Chlamydial urethritis and cervicitis.
Finnish Medical Society Duodecim - Professional Association.  2001 Jun 5 (revised 2006 Jun 3).  Various pagings.  NGC:005276

Diagnostic imaging guideline for musculoskeletal complaints in adults - an evidence-based approach. Part 2: upper extremity disorders.
Canadian Protective Chiropractic Association - Professional Association l'Université du Québec à Trois-Rivières - Academic Institution.  2008 Jan.  31 pages.  NGC:006702

Clinical trials

New Immunomodulatory Therapy Strategies in Chronic Reactive Arthritis

Lovastatin for the Treatment of Mildly Active Rheumatoid Arthritis

Related eMedicine topics

 Reactive Arthritis (Dermatology)

Reactive Arthritis (Rheumatology)

Reactive Arthritis, Musculoskeletal (Radiology)

Reactive Arthritis (Ophthalmology)

Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy (Rheumatology)

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Keywords

Reiter's syndrome, Reiter syndrome, reactive arthritis, ReA, peripheral arthritis, arthritis, nongonococcal urethritis, conjunctivitis, seronegative spondyloarthropathies, rheumatic disease, urogenital infections, chronic arthritis, Shigella flexneri, Salmonella typhimurium, Salmonella enteritidis, Streptococcus viridans, Mycoplasma pneumonia, Cyclospora, Chlamydia trachomatis, Yersinia enterocolitica, Yersinia pseudotuberculosis

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

Igor Boyarsky, DO, Director of Triage, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center, University of California at Los Angeles
Igor Boyarsky, DO is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, American Osteopathic Association, American Society of Addiction Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

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

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

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.

 
 
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