Presented By: Dr Bushu Harna
36 y/o gentleman admitted to the hospital with 2 days of
acute onset of arthritis in his right knee that progressed
to the left knee. The patient was investigated and
discharged on Paracetamol + Ibroprofen TDS. But not
Patient had red eyes for past 7 days
Past History: 3 weeks previous to admission he had
an episode of diarrhea that lasted for 10 days and
improved after treatment with Ciprofloxacin.
Family History: Sister had a similar episode 2 years
General Examination: fever 1010 F. Otherwise within
Joint exam: tenderness, redness and effusions in both
Labs: Normal CBC, ESR 60, CRP 32. Synovial fluid
showed no crystals and Gram stain revealed no
RA Factor: Negative. HLA B-27 positive.
Eye Examination: Anterior Uvetitis
Patient was started on indomethacin 50 mg PO QID
with significant improvement of his symptoms.
“Reactive Arthritis (ReA) is an infectious induced
systemic illness characterized by an ASEPTIC
inflammatory joint involvement occurring in a
genetically predisposed patient with a bacterial infection
localized in a distant organ/system”.
First described by Hans Reiter in 1916. Also known as
Triad: Arthritis, Urethritis, Conjunctivitis
Name changed to Reactive Arthritis
What’s So Reactive??
Aberrant autoimmune response to infection
Occurs in 20-40 years.
Begins with an enteric, urogenital or upper respiratory
Arthritis occurs few days to 6 weeks after infection
30-70% positive for HLA-B27.
Incidence more in urethritis, cervicitis and infectious
Incidence varies widely (1% to 20%).
Frequency varies after infection with Salmonella,
Shigella, Campylobacter or Yersinia.
1. Microbes-host interaction.
Components of triggering bacteria includes protein and
nucleic acid. These can be found in the synovium and
2. Role of immune system
In patients with ReA, they have an elevated production
of Th2 cytokines, such us IL-10 and a possible decrease
production in Th1 cytokines.
Macrophages, CD4+ and CD8+ lymphocytes are
activated in the joints of the patients.
Some bacterial antigens like heat shock protein 60
present in Chlamydia and Yersinia.
Molecular cross reactive has been also associated
All these factors cause a decrease in the effective
clearance of bacteria.
HLA-B27 probably works as an antigen presenting
Some arthritogenic peptide from chlamydia and yersinia
can be presented by HLA-B27 leading to stimulation of
CD8+ T cells.
IFN-gamma: low level
IL-10: High level
Infection: History: diarrhea, urethritis, cervicitis,
Postenteric ReA is described equally in men an women.
The episode of diarrhea is usually prolonged.
Postchlamydial is most common in men.
In females episodes of cervicitis, vaginitis can precede.
In patients with postchlamydial disease, urethritis is
usually mild, painless and nonpurulent.
Conjunctivitis is usually observed very early, before
the onset of arthritis. Uveitis is less common but
occurs in 15% of patients with chronic persistent
Skin manifestations include: Keratoderma
blenorrhagica, Circinate balanitis and oral ulcers.
Less common patients can develop valvulitis, rhythm
Asymmetric mono or oligo arthritis often of lower
limbs including knees, ankles and feet.
Musculoskeletal: peripheral arthritis, inflammatory
pain in cervical, thoracic, and lumbar spine
Enthesitis: plantar facisitis, heel pain, patellar
tendon insertion pain, GT hip pain, base 5th MT, MT
Sausage digits: IP joints with digital tendonitis and
multiple entheseal lesion
Predictors of more severe disease: hip arthritis,
ESR>30, poor response to NSAIDS, Lumbar spine
stiffness, dactylitis, oligoarthritis, <16 years.
In HLA-B27 positive patients: more severity and
increased markers like ESR and CRP.
Eye: conjunctivitis, anterior uveitis, episcleritis and
Genitourinary: urethritis, cervicitis, prostatitis,
cystitis, circinate balanitis, salpingo-oophoritis
Mucosal and skin: mucosal ulcers, keratoderma
blenorrhagica, erythema nodosum
Nail changes: onycholysis, subungual keratosis, nail
Bases on observational data from Germany and Scandinavia
Mono or oligo arthritis
Exclusion of other diagnosis
Both criteria present: probability is 40%.
Evidence of previous infection
Then chances are 60%.
If the bacteria can be culture, then 70%
If there is history of symptomatic preceding infection with
Chlamdydia trachomatis, then 90%
*Sieper J, Rudwaleit M, Braun J, et al. Diagnosing reactive arthritis: Role of clinical
Definitive: Both Major criteria + 1 Minor Criteria
Probable: Both Major criteria
Lab: raised ESR and CRP
Rule out: RF, ANA, Gram staining and culture of the joint
Radiographs: Not required to diagnose. A large bulky
paravertebral area of ossification "floating osteophyte" is often seen.
Early juxta-articular osteoporosis, uniform joint space loss and
fusiform soft tissue swelling.
Others: ECG, ophthalmological examination, urine
and stool examination, Nucleic acid amplification
Histopathological dermal features similar to
Synovial fluid reveals large macrophages, reiter cell
that have phagocytosed neutrophils, lymphocytes
and plasma cells. Extensive pannus formation is
1. Decrease pain and inflammation
2. Minimize disability
3. Prevent relapse or progression to chronic disease
Early diagnosis and treatment
It can be self limiting, recurrent or chronic
Depends on triggering pathogen and genetic
background of the host.
Chronic arthritis (>6months) occurs in 4-19% patients.
(arthritis caused by salmonella or shigella).
Chronic relapsing arthritis is seen in 6-8% patients
(induced by salmonella, shigella or chlamydia).
Good history taking: Past history and family
Good General Physical Examination: EYE,
Exclude other Spondyloarthropathy
Involve Physician & Rheumatologist
NSAIDs, Steroids and DMARDs form the main
basis of treatment.
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