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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.
- 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
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
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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










Differential Diagnoses & Workup: Reactive Arthritis