Introduction
Background
In 1916, Hans Reiter described the classic triad of arthritis, nongonococcal urethritis, and conjunctivitis.1
What used to be known as Reiter syndrome is now referred to as reactive arthritis (ReA).1 This change has occurred in part because of Hans Reiter's affiliation and activities with the Nazis during WWII.
Reactive arthritis refers to acute nonpurulent arthritis complicating an infection elsewhere in the body.
Reactive arthritis falls under the rheumatic disease category of seronegative spondyloarthropathies, which includes ankylosing spondylitis, psoriatic arthritis, the arthropathy of associated inflammatory bowel disease, juvenile-onset ankylosing spondylitis, and juvenile chronic arthritis.2
A study by Kaarela et al reported that reactive arthritis and ankylosing spondylitis appear to be identical. They assessed long-term outcome of reactive arthritis and ankylosing spondylitis to identify similarities in manifestations of disease. A number of similarities were found; among them, sacroiliitis, peripheral arthritis, and iritis developed most often in both chronic reactive arthritis and ankylosing spondylitis.3
Pathophysiology
Reactive arthritis is triggered following enteric or urogenital infections. Reactive arthritis is associated with human leukocyte antigen (HLA)–B27, although HLA-B27 is not always present in an affected individual, particularly in the presence of HIV.
Rihl et al found a high proportion of proangiogenic factors accounting for a genetically determined susceptibility to reactive arthritis.4
Bacteria associated with reactive arthritis are generally enteric or venereal and include the following: Shigella flexneri, Salmonella typhimurium, Salmonella enteritidis,5 Streptococcus viridans, Mycoplasma pneumonia, Cyclospora,6 Chlamydia trachomatis, Yersinia enterocolitica, and Yersinia pseudotuberculosis. Bacteria or their components (RNA, DNA) have been identified in synovial fluid cells, synovial biopsy specimens, and circulatory monocytes.
Frequency
United States
Frequency is estimated at 3.5 cases per 100,000. (Because of uncertainty of diagnosis and variations in definitions, epidemiologic features are difficult to calculate.)
An estimated 1-3% of all patients with a nonspecific urethritis develop an episode of arthritis. Prevalence of inapparent chlamydial infections may make incidence even higher.
After outbreak of S enteritidis, 29% had reactive arthritis.
International
In Norway, an annual incidence of chlamydia-induced reactive arthritis of 4.6 cases per 100,000 population and an incidence of enteric bacteria–induced reactive arthritis of 5 cases per 100,000 population were reported in 1988-1990.
Occurrence appears to be related to the prevalence of HLA-B27 in a population and the rate of urethritis/cervicitis and infectious diarrhea.
Mortality/Morbidity
Most patients have severe symptoms lasting weeks to 6 months. Approximately 15-50% have recurrent bouts of arthritis. Chronic arthritis or sacroiliitis occurs in 15-30% of cases.
Race
Reactive arthritis is reported most frequently in whites. When reactive arthritis occurs in black persons, it is frequently B27-negative.
Occurrence appears to be related to HLA-B27 prevalence in the population.
Sex
The male-to-female postvenereal ratio is traditionally 5-10:1. The postenteric ratio is 1:1.
Age
The peak onset is in persons aged 15-35 years; reactive arthritis is rarely seen in children. Cases in children are almost entirely postenteric.
Clinical
History
- Symptoms generally appear within 1-3 weeks but can range from 4-35 days from onset of inciting episode of urethritis/cervicitis or diarrhea.
- Constitutional symptoms (usually mild)
- Fever (usually low grade)
- Malaise
- Musculoskeletal
- Myalgias (early)
- Asymmetric joint stiffness, primarily involving the knees, ankles, and feet (wrist may be early target)
- Low back pain with radiation to the buttocks or thighs
- Symptoms worse with rest or inactivity
- Urethritis associated with reactive arthritis may be postdysenteric or postvenereal, with frequency, dysuria, urgency, and urethral discharge. It may be mild or inapparent.
- Ophthalmologic
- Erythema
- Burning
- Tearing
- Photophobia
- Pain
- Decreased vision (rare)
- Patients may have mild recurrent abdominal complaints after precipitating episode of diarrhea.
Physical
- A scoring system for diagnostic points in Reiterlike spondyloarthropathies exists. Two or more of the following points establishes diagnosis (one of which must pertain to the musculoskeletal system):
- Asymmetric oligoarthritis, predominantly of the lower extremity
- Sausage-shaped finger (dactylitis), toe or heel pain, or other enthesitis
- Cervicitis or acute diarrhea within 1 month of the arthritis
- Conjunctivitis or iritis
- Genital ulceration or urethritis
- Musculoskeletal
- Oligoarthritis affecting mainly lower extremities with low-grade inflammation.
- Knee may become markedly edematous.
- Distinctive arthropathy of reactive arthritis includes local enthesopathy, which is inflammation at the tendinous insertion into bone, rather than synovium (common in insertions into calcaneus, talar, and subtalar joints).
- Sausage finger or toe is caused by uniform inflammation.
- Urogenital
- Meatal edema and erythema and clear mucoid discharge
- Prostatic tenderness (up to 80%) and vulvovaginitis
- Dermatologic
- Balanitis circinata - Shallow painless ulcers at meatus and glans penis; moist on uncircumcised patients; may harden and crust on circumcised patients, causing pain and scarring
- Keratoderma blennorrhagica - Hyperkeratotic skin, which begins as clear vesicles on erythematous bases and progresses to macules, papules, and nodules (found on soles of feet, toes, palms, scrotum, trunk, and scalp)
- Nail thickening and ridging and superficial oral ulcers
- Ophthalmologic signs - Conjunctivitis (most common), with mucopurulent discharge, chemosis, lid edema, and iritis
- Occurs in the majority of reactive arthritis because of Shigella infection. Occurs in approximately 35% of postvenereal cases.
- Cardiac signs - Aortic regurgitation caused by inflammation of aortic wall and valve
Causes
- Nongonococcal venereal disease (most often Chlamydia) and infectious diarrhea (Shigella, Salmonella, Yersinia) precipitate reactive arthritis.
- HLA-B27 contributes to the pathogenesis of the disease.
More on Reactive Arthritis |
Overview: Reactive Arthritis |
| Differential Diagnoses & Workup: Reactive Arthritis |
| Treatment & Medication: Reactive Arthritis |
| Follow-up: Reactive Arthritis |
| References |
| Further Reading |
| 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
Overview: Reactive Arthritis