Reactive Arthritis in Emergency Medicine Workup

  • Author: Nima Sarani, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: May 21, 2012
 

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).[37]
    • Obtaining stool cultures even when bowel symptoms are in apparent or mild may help direct treatment; however, cultures are often negative by the time of presentation.[11]
    • 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.[17] Interestingly, using synovial fluid PCR, bacterial antigenic material has been detected in up to 50% of patients previously diagnosed with undifferentiated spondyloarthropathy.[38]
  • 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 suspected[39, 40]
    • HIV and tuberculosis (TB) testing may be warranted, depending on treatment modality. Certain therapies are contraindicated in these populations.[21]
    • Echocardiography may reveal carditis or valvular dysfunction in patients with poststreptococcal reactive arthritis.[39, 40]
  • Chronic cases: Mild normocytic anemia
Next

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 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 inLateral radiograph of the foot (same patient as in the photo above) reveals a calcaneal spur and enthesitis. Radiograph of both hands shows small erosive changRadiograph 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 asymmeRadiography of the pelvis reveals bilateral asymmetric sacroiliitis. Image in 40-year-old man with nonmarginal syndesmoImage in 40-year-old man with nonmarginal syndesmophytes predominantly in the lower thoracic and upper lumbar spine.
Previous
Next

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.[26]
  • It has been shown that positron emission tomography scanning allows recognition of enthesitis in the early stage of reactive arthritis, before detection by other modalities.[41]
Previous
Next

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.)
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Nima Sarani, MD  Resident Physician, Department of Emergency Medicine, Oklahoma University College of Medicine

Nima Sarani, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians, and Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Bo Burns, DO, FACEP, FAAEM  Assistant Professor, Associate Residency Director, Medical Clerkship Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine; Attending Physician, Department of Emergency Medicine

Bo Burns, DO, FACEP, FAAEM, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gino A Farina, MD, FACEP, FAAEM  Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Thomas Scoggins, MD, and Igor Boyarsky, DO, to the development and writing of this article.

References

  1. 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].

  2. Carter JD, Hudson AP. Reactive arthritis: clinical aspects and medical management. Rheum Dis Clin North Am. Feb 2009;35(1):21-44. [Medline].

  3. Kataria RK, Brent LH. Spondyloarthropathies. Am Fam Physician. Jun 15 2004;69(12):2853-60. [Medline].

  4. 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].

  5. Rihl M, Barthel C, Klos A, et al. Identification of candidate genes for susceptibility to reactive arthritis. Rheumatol Int. Oct 2009;29(12):1519-22. [Medline].

  6. 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].

  7. 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]. [Full Text].

  8. Townes JM. Reactive arthritis after enteric infections in the United States: the problem of definition. Clin Infect Dis. Jan 15 2010;50(2):247-54. [Medline].

  9. van Bemmel JM, Delgado V, Holman ER, Allaart CF, Huizinga TW, Bax JJ. No increased risk of valvular heart disease in adult poststreptococcal reactive arthritis. Arthritis Rheum. Apr 2009;60(4):987-93. [Medline].

  10. van der Helm-van Mil AH. Acute rheumatic fever and poststreptococcal reactive arthritis reconsidered. Curr Opin Rheumatol. Jul 2010;22(4):437-42. [Medline].

  11. 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].

  12. Noto Llana M, Sarnacki SH, Giacomodonato MN, Caccuri RL, Blanco GA, Cerquetti MC. Sublethal infection with Salmonella Enteritidis by the natural route induces intestinal and joint inflammation in mice. Microbes Infect. Jan 2009;11(1):74-82. [Medline].

  13. Pollanen R, Sillat T, Pajarinen J, Levon J, Kaivosoja E, Konttinen YT. Microbial antigens mediate HLA-B27 diseases via TLRs. J Autoimmun. May-Jun 2009;32(3-4):172-7. [Medline].

  14. Singh AK, Misra R, Aggarwal A. Th-17 associated cytokines in patients with reactive arthritis/undifferentiated spondyloarthropathy. Clin Rheumatol. Jun 2011;30(6):771-6. [Medline].

  15. Shen H, Goodall JC, Gaston JS. Frequency and phenotype of T helper 17 cells in peripheral blood and synovial fluid of patients with reactive arthritis. J Rheumatol. Oct 2010;37(10):2096-9. [Medline].

  16. Eliçabe RJ, Cargnelutti E, Serer MI, Stege PW, Valdez SR, Toscano MA. Lack of TNFR p55 results in heightened expression of IFN-? and IL-17 during the development of reactive arthritis. J Immunol. Oct 1 2010;185(7):4485-95. [Medline].

  17. 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]. [Full Text].

  18. Carter JD, Espinoza LR, Inman RD, Sneed KB, Ricca LR, Vasey FB. Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial. Arthritis Rheum. May 2010;62(5):1298-307. [Medline].

  19. Hanova P, Pavelka K, Holcatova I, Pikhart H. Incidence and prevalence of psoriatic arthritis, ankylosing spondylitis, and reactive arthritis in the first descriptive population-based study in the Czech Republic. Scand J Rheumatol. Aug 2010;39(4):310-7. [Medline].

  20. Sahlberg AS, Granfors K, Penttinen MA. HLA-B27 and host-pathogen interaction. Adv Exp Med Biol. 2009;649:235-44. [Medline].

  21. 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].

  22. Wechalekar MD, Rischmueller M, Whittle S, Burnet S, Hill CL. Prolonged remission of chronic reactive arthritis treated with three infusions of infliximab. J Clin Rheumatol. Mar 2010;16(2):79-80. [Medline].

  23. Arnedo-Pena A, Beltran-Fabregat J, Vila-Pastor B, Tirado-Balaguer MD, Herrero-Carot C, Bellido-Blasco JB. Reactive arthritis and other musculoskeletal sequelae following an outbreak of Salmonella hadar in Castellon, Spain. J Rheumatol. Aug 1 2010;37(8):1735-42. [Medline].

  24. Wu IB, Schwartz RA. Reiter's syndrome: the classic triad and more. J Am Acad Dermatol. Jul 2008;59(1):113-21. [Medline].

  25. Sieper J. Developments in the scientific and clinical understanding of the spondyloarthritides. Arthritis Res Ther. 2009;11(1):208. [Medline]. [Full Text].

  26. Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. Apr 2009;44(4):309-15. [Medline].

  27. Madge SN, James C, Selva D. Bilateral dacryoadenitis: a new addition to the spectrum of reactive arthritis?. Ophthal Plast Reconstr Surg. Mar-Apr 2009;25(2):152-3. [Medline].

  28. Carter JD, Hudson AP. The evolving story of Chlamydia-induced reactive arthritis. Curr Opin Rheumatol. Jul 2010;22(4):424-30. [Medline].

  29. Mortensen NP, Kuijf ML, Ang CW, Schiellerup P, Krogfelt KA, Jacobs BC. Sialylation of Campylobacter jejuni lipo-oligosaccharides is associated with severe gastro-enteritis and reactive arthritis. Microbes Infect. Oct 2009;11(12):988-94. [Medline].

  30. Garg S, Malaviya AN, Kapoor S, Rawat R, Agarwal D, Sharma A. Acute inflammatory ankle arthritis in northern India--Löfgren's syndrome or Poncet's disease?. J Assoc Physicians India. Feb 2011;59:87-90. [Medline].

  31. Ideguchi H, Ohno S, Takase K, Tsukahara T, Kaneko T, Ishigatsubo Y. A case of Poncet's disease (tuberculous rheumatism). Rheumatol Int. Jul 2009;29(9):1097-9. [Medline].

  32. Durand CL, Miller PF. Severe Clostridium difficile colitis and reactive arthritis in a ten-year-old child. Pediatr Infect Dis J. Aug 2009;28(8):750-1. [Medline].

  33. Sahin N, Salli A, Enginar AU, Ugurlu H. Reactive arthritis following tetanus vaccination: a case report. Mod Rheumatol. 2009;19(2):209-11. [Medline].

  34. Siala M, Mahfoudh N, Fourati H, Gdoura R, Younes M, Kammoun A. MHC class I and class II genes in Tunisian patients with reactive and undifferentiated arthritis. Clin Exp Rheumatol. Mar-Apr 2009;27(2):208-13. [Medline].

  35. Sarakbi HA, Hammoudeh M, Kanjar I, Al-Emadi S, Mahdy S, Siam A. Poststreptococcal reactive arthritis and the association with tendonitis, tenosynovitis, and enthesitis. J Clin Rheumatol. Jan 2010;16(1):3-6. [Medline].

  36. Kobayashi S, Ichikawa G. Reactive arthritis induced by tonsillitis: a type of 'focal infection'. Adv Otorhinolaryngol. 2011;72:79-82. [Medline].

  37. Savolainen E, Kettunen A, Narvanen A, 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. 2009;38(5):353-6. [Medline].

  38. Siala M, Gdoura R, Younes M, et al. 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].

  39. 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; author reply 3518-9. [Medline].

  40. 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].

  41. Taniguchi Y, Kumon Y, Nakayama S, et al. F-18 FDG PET/CT provides the earliest findings of enthesitis in reactive arthritis. Clin Nucl Med. Feb 2011;36(2):121-3. [Medline].

  42. Nanke Y, Yago T, Kobashigawa T, Kotake S. Efficacy of methotrexate in the treatment of a HLA-B27-positive Japanease patient with reactive arthritis. Nihon Rinsho Meneki Gakkai Kaishi. 2010;33(5):283-5. [Medline].

  43. Schafranski MD. Infliximab for reactive arthritis secondary to Chlamydia trachomatis infection. Rheumatol Int. Mar 2010;30(5):679-80. [Medline].

  44. Meyer A, Chatelus E, Wendling D, Berthelot JM, Dernis E, Houvenagel E. Safety and efficacy of anti-tumor necrosis factor a therapy in ten patients with recent-onset refractory reactive arthritis. Arthritis Rheum. May 2011;63(5):1274-80. [Medline].

  45. Suwannalai P, Auethavekiat P, Udomsubpayakul U, Janvitayanujit S. The infectious profiles of anti-tumor necrosis factor agents in a Thai population: a retrospective study a the university-based hospital. Int J Rheum Dis. Jul 2009;12(2):118-24. [Medline].

  46. Chen TJ, Yang YF, Huang PH, Lin HH, Huang CC. Permanent renal loss following tumor necrosis factor a antagonists for arthritis. Rheumatol Int. Jun 2010;30(8):1077-9. [Medline].

  47. Murakami M, Nishimoto N. The value of blocking IL-6 outside of rheumatoid arthritis: current perspective. Curr Opin Rheumatol. May 2011;23(3):273-7. [Medline].

  48. Herrera-Esparza R, Medina F, Avalos-Díaz E. Tacrolimus therapy for circinate balanitis associated with reactive arthritis. J Clin Rheumatol. Dec 2009;15(8):377-9. [Medline].

  49. Singh JA, Strand V. Spondyloarthritis is associated with poor function and physical health-related quality of life. J Rheumatol. May 2009;36(5):1012-20. [Medline].

  50. Amor B. Reiter's syndrome. Diagnosis and clinical features. Rheum Dis Clin North Am. Nov 1998;24(4):677-95, vii. [Medline].

  51. Bauman C, Cron RQ, Sherry DD, Francis JS. Reiter syndrome initially misdiagnosed as Kawasaki disease. J Pediatr. Mar 1996;128(3):366-9. [Medline].

  52. Buschiazzo E, Maldonado-Cocco JA, Arturi P, Citera G, Berman A, Nitsche A. Epidemiology of spondyloarthritis in Argentina. Am J Med Sci. Apr 2011;341(4):289-92. [Medline].

  53. 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].

  54. 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.

  55. 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].

  56. Hughes RA, Keat AC. Reiter's syndrome and reactive arthritis: a current view. Semin Arthritis Rheum. Dec 1994;24(3):190-210. [Medline].

  57. Kasper DL, ed. Reactive arthritis. In: Harrison's Online. Part 13. Section 2. McGraw Hill; 2004:Chap 305.

  58. Marquardt AL, Hackshaw KV. Reactive arthritis associated with hidradenitis suppurativa. J Natl Med Assoc. Apr 2009;101(4):367-9. [Medline].

  59. Natarajan UR, Tan TL, Lau R. Reiter's disease following Mycoplasma pneumoniae infection. Int J STD AIDS. May 2001;12(5):349-50. [Medline].

  60. Nielsen LN, Sheppard SK, McCarthy ND, Maiden MC, Ingmer H, Krogfelt KA. MLST clustering of Campylobacter jejuni isolates from patients with gastroenteritis, reactive arthritis and Guillain-Barré syndrome. J Appl Microbiol. Feb 2010;108(2):591-9. [Medline].

  61. Petersel DL, Sigal LH. Reactive arthritis. Infect Dis Clin North Am. Dec 2005;19(4):863-83. [Medline].

  62. Rihl M, Barthel C, Klos A, Schmidt RE, Tak PP, Zeidler H. Identification of candidate genes for susceptibility to reactive arthritis. Rheumatol Int. Oct 2009;29(12):1519-22. [Medline].

  63. 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].

  64. Sampaio-Barros PD. Epidemiology of spondyloarthritis in Brazil. Am J Med Sci. Apr 2011;341(4):287-8. [Medline].

  65. Schafranski MD. Infliximab for reactive arthritis secondary to Chlamydia trachomatis infection. Rheumatol Int. Mar 2010;30(5):679-80. [Medline].

  66. Turan Y, Duruoz MT, Cerrahoglu L. Relationship between enthesitis, clinical parameters and quality of life in spondyloarthritis. Joint Bone Spine. Dec 2009;76(6):642-7. [Medline].

 
Previous
Next
 
Circinate balanitis in a patient with reactive arthritis.
Plaques on the soles of a patient with reactive arthritis.
Painful erosions on the fingers in a patient with reactive arthritis.
Plaques and erosions of the tongue in a patient with reactive arthritis.
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.
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.