eMedicine Specialties > Emergency Medicine > Rheumatology
Reactive Arthritis: Differential Diagnoses & Workup
Updated: Jun 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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 |
| « 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].
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].
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. Chap 305. McGraw Hill;2004.
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].
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)
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
Differential Diagnoses & Workup: Reactive Arthritis