eMedicine Specialties > Emergency Medicine > Rheumatology

Reactive Arthritis

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

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.

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