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Reactive Arthritis: Differential Diagnoses & Workup
Updated: Feb 1, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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. Serology is useful in some cases; however, culture techniques are unreliable, causative agents are only indentified in 58% of cases with urogenital symptoms, and there is a high positive rate in control populations (people without reactive arthritis).15
- Obtaining stool cultures even when bowel symptoms are inapparent or mild may help direct treatment; however, cultures are often negative by the time of presentation.8
- Arthrocentesis and fluid analysis are often needed to rule out an infectious process, especially in monoarticular arthritis with constitutional symptoms. Polymerase chain reaction (PCR) has been used to detect Chlamydia and Yersinia antigenic DNA in synovial fluid, but, again, there is a high prevalence in the control population and results have proven highly variable between institutions.9 Interestingly, using synovial fluid PCR, bacterial antigenic material has been detected in up to 50% of patients previously diagnosed with undifferentiated spondyloarthropathy.16
- Acute cases:
- Neutrophilic leukocytosis
- Elevated C-reactive protein or C3 and C4 (nonspecific)
- Erythrocyte sedimentation rate (ESR) - Usually elevated during acute phase of disease
- Antistreptolysin- O (ASO) or anti-DNase B, if poststreptococcal infection is suspected17,18
- HIV and tuberculosis (TB) testing may be warranted, depending on treatment modality. Certain therapies are contraindicated in these populations.11
- Echocardiography may reveal carditis or valvular dysfunction in patients with poststreptococcal reactive arthritis.17,18
- 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 and periostitis. Examples are shown in the radiographs below.
Radiograph of the feet in a 27-year-old man shows erosions in all the left metatarsophalangeal (MTP) joints with subluxation and valgus deformity of most of the toes. Smaller erosions in the four and fifth MTP joints of the right foot are also shown.
Lateral radiograph of the foot (same patient as in the photo above) reveals a 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.
- Spinal pattern - Unilateral or bilateral sacroiliitis, nonmarginal syndesmophytes, which are asymmetric, paravertebral, bulky, discontinuous, comma-shaped ossifications involving the lower thoracic and upper lumbar vertebrae; these are shown in the radiographs below
Radiography of the pelvis reveals bilateral asymmetric sacroiliitis.
Image in 40-year-old man with nonmarginal syndesmophytes predominantly in the lower thoracic and upper lumbar spine.
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 and TB testing in patients presenting with history, symptoms, or findings suggesting increased risk for the disease.
- Ultrasonography may reveal enthesitis, as periosteal reaction and tendinosis, more accurately that physical examination.14
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 |
| Multimedia: Reactive Arthritis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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].
Carter JD, Hudson AP. Reactive arthritis: clinical aspects and medical management. Rheum Dis Clin North Am. Feb 2009;35(1):21-44. [Medline].
Kataria RK, Brent LH. Spondyloarthropathies. Am Fam Physician. Jun 15 2004;69(12):2853-60. [Medline].
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].
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].
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].
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].
Rohekar S, Pope J. Epidemiologic approaches to infection and immunity: the case of reactive arthritis. Curr Opin Rheumatol. Jul 2009;21(4):386-90. [Medline].
Pope JE, Krizova A, Garg AX, Thiessen-Philbrook H, Ouimet JM. Campylobacter reactive arthritis: a systematic review. Semin Arthritis Rheum. Aug 2007;37(1):48-55. [Medline].
Sahlberg AS, Granfors K, Penttinen MA. HLA-B27 and host-pathogen interaction. Adv Exp Med Biol. 2009;649:235-44. [Medline].
Hajjaj-Hassouni N, Burgos-Vargas R. Ankylosing spondylitis and reactive arthritis in the developing world. Best Pract Res Clin Rheumatol. Aug 2008;22(4):709-23. [Medline].
Wu IB, Schwartz RA. Reiter's syndrome: the classic triad and more. J Am Acad Dermatol. Jul 2008;59(1):113-21. [Medline].
Sieper J. Developments in the scientific and clinical understanding of the spondyloarthritides. Arthritis Res Ther. 2009;11(1):208. [Medline].
Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. Apr 2009;44(4):309-15. [Medline].
Savolainen E, Kettunen A, Narvanen A, Kautiainen H, Karkkainen U, Luosujarvi 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. Mar 18 2009;1-4. [Medline].
Siala M, Gdoura R, Younes M, Fourati H, Cheour I, Meddeb N. Detection and frequency of Chlamydia trachomatis DNA in synovial samples from Tunisian patients with reactive arthritis and undifferentiated oligoarthritis. FEMS Immunol Med Microbiol. Mar 2009;55(2):178-86. [Medline].
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. Nov 2009;60(11):3516-8. [Medline].
Moorthy LN, Gaur S, Peterson MG, Landa YF, Tandon M, Lehman TJ. Poststreptococcal reactive arthritis in children: a retrospective study. Clin Pediatr (Phila). Mar 2009;48(2):174-82. [Medline].
Schafranski MD. Infliximab for reactive arthritis secondary to Chlamydia trachomatis infection. Rheumatol Int. May 23 2009;[Medline].
Amor B. Reiter's syndrome. Diagnosis and clinical features. Rheum Dis Clin North Am. Nov 1998;24(4):677-95, vii. [Medline].
Bauman C, Cron RQ, Sherry DD, Francis JS. Reiter syndrome initially misdiagnosed as Kawasaki disease. J Pediatr. Mar 1996;128(3):366-9. [Medline].
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].
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.
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].
Hughes RA, Keat AC. Reiter's syndrome and reactive arthritis: a current view. Semin Arthritis Rheum. Dec 1994;24(3):190-210. [Medline].
Kasper DL, ed. Reactive arthritis. In: Harrison's Online. Part 13. Section 2. McGraw Hill; 2004:Chap 305.
Natarajan UR, Tan TL, Lau R. Reiter's disease following Mycoplasma pneumoniae infection. Int J STD AIDS. May 2001;12(5):349-50. [Medline].
Petersel DL, Sigal LH. Reactive arthritis. Infect Dis Clin North Am. Dec 2005;19(4):863-83. [Medline].
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].
Schafranski MD. Infliximab for reactive arthritis secondary to Chlamydia trachomatis infection. Rheumatol Int. May 23 2009;[Medline].
Keywords
reactive arthritis symptoms, reactive arthritis treatment, reactive arthritis causes, Reiter's syndrome, Reiter syndrome, reactive arthritis, peripheral arthritis, seronegative spondyloarthropathies, rheumatic disease, chronic arthritis
