Reactive arthritis

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Reactive arthritis
Reactive arthritis of the knee
SpecialtyRheumatology

Reactive arthritis, also known as Reiter's syndrome, is a form of inflammatory arthritis[1] that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can trigger the disease.[2] By the time the patient presents with symptoms, often the "trigger" infection has been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.

The arthritis often is coupled with other characteristic symptoms; this has been called Reiter's syndrome, Reiter's disease or Reiter's arthritis. The term "reactive arthritis" is increasingly used as a substitute for this designation because of Hans Reiter's war crimes with the Nazi Party.

The manifestations of reactive arthritis include the following triad of symptoms: an inflammatory arthritis of large joints, inflammation of the eyes in the form of

circinate balanitis, and keratoderma blennorrhagicum. Enthesitis can involve the Achilles tendon resulting in heel pain.[3]
Not all affected persons have all the manifestations.

The clinical pattern of reactive arthritis commonly consists of an inflammation of fewer than five joints which often includes the knee or sacroiliac joint. The arthritis may be "additive" (more joints become inflamed in addition to the primarily affected one) or "migratory" (new joints become inflamed after the initially inflamed site has already improved).[4][5]

Reactive arthritis is an

RF-seronegative, HLA-B27-linked arthritis[6] often precipitated by genitourinary or gastrointestinal infections. The most common triggers are intestinal infections (with Salmonella, Shigella or Campylobacter) and sexually transmitted infections (with Chlamydia trachomatis);[7] however, it also can happen after group A streptococcal infections.[8][9]

It most commonly strikes individuals aged 20–40 years of age, is more common in men than in women, and more common in white than in black people. This is owing to the high frequency of the HLA-B27 gene in the white population.[10][11] It can occur in epidemic form. Patients with HIV have an increased risk of developing reactive arthritis as well.

Numerous cases during World Wars I and II focused attention on the triad of arthritis, urethritis, and conjunctivitis (often with additional mucocutaneous lesions), which at that time was also referred to as Fiessenger–Leroy–Reiter syndrome.[12]

Signs and symptoms

Keratoderma blennorrhagicum due to reactive arthritis
  • Because common systems involved include the eye, the urinary system, and the hands and feet, one clinical mnemonic in reactive arthritis is "Can't see, can't pee, can't climb a tree."[13]
  • The classic triad consists of:
    • Conjunctivitis
    • Nongonococcal urethritis
    • Asymmetric oligoarthritis
  • Symptoms generally appear within 1–3 weeks but can range from 4 to 35 days from the onset of the inciting episode of the disease.
  • The classical presentation of the syndrome starts with urinary symptoms such as burning pain on urination (
    vulvovaginitis
    in women.
  • It presents with monoarthritis affecting the large joints such as the
    swelling. An asymmetrical inflammatory arthritis
    of interphalangeal joints may be present but with relative sparing of small joints such as the wrist and hand.
  • Patient can have enthesitis presenting as heel pain, Achilles tendinitis or plantar fasciitis, along with balanitis circinata (circinate balanitis), which involves penile lesions present in roughly 20 to 40 percent of the men with the disease.
  • A small percentage of men and women develop small hard nodules called keratoderma blennorrhagicum on the soles of the feet and, less commonly, on the palms of the hands or elsewhere. The presence of keratoderma blennorrhagica is diagnostic of reactive arthritis in the absence of the classical triad. Subcutaneous nodules are also a feature of this disease.
  • Ocular involvement (mild bilateral conjunctivitis) occurs in about 50% of men with urogenital reactive arthritis syndrome and about 75% of men with enteric reactive arthritis syndrome. Conjunctivitis and uveitis can include redness of the eyes, eye pain and irritation, or blurred vision. Eye involvement typically occurs early in the course of reactive arthritis, and symptoms may come and go.
  • Dactylitis, or "sausage digit", a diffuse swelling of a solitary finger or toe, is a distinctive feature of reactive arthritis and other peripheral spondylarthritides but can also be seen in polyarticular gout and sarcoidosis.
  • Mucocutaneous lesions can be present. Common findings include oral ulcers that come and go. In some cases, these ulcers are painless and go unnoticed. In the
    migratory stomatitis in higher prevalence than the general population.[14]
  • Some patients experience serious gastrointestinal problems similar to those of Crohn's disease.
  • About 10 percent of people with reactive arthritis, especially those with a prolonged course of the disease, will develop cardiac manifestations, including aortic regurgitation and pericarditis. Reactive arthritis has been described as a precursor of other joint conditions, including ankylosing spondylitis.

Causes

See also: List of human leukocyte antigen alleles associated with cutaneous conditions

Reactive arthritis is associated with the

gastrointestinal infection may also precede the disease (the last four genera of bacteria mentioned above are enteric bacteria).[17] Shigella is the most common organism causing reactive arthritis following diarrhea. Chlamydia trachomatis is the most common cause of reactive arthritis following urethritis. Ureaplasma and mycoplasma are rare causes. There is some circumstantial evidence for other organisms causing the disease, but the details are unclear.[17]

Reactive arthritis usually manifests about 1–3 weeks after a known infection. The mechanism of interaction between the infecting organism and the host is unknown. Synovial fluid cultures are negative, suggesting that reactive arthritis is caused either by an autoimmune response involving cross-reactivity of bacterial antigens with joint tissues or by bacterial antigens that have somehow become deposited in the joints.[citation needed]

Diagnosis

There are few clinical symptoms, but the clinical picture is dominated by arthritis in one or more joints, resulting in pain, swelling, redness, and heat sensation in the affected areas.

The urethra, cervix and the throat may be swabbed in an attempt to culture the causative organisms. Cultures may also be carried out on urine and stool samples or on fluid obtained by arthrocentesis.

Tests for C-reactive protein and erythrocyte sedimentation rate are non-specific tests that can be done to corroborate the diagnosis of the syndrome. A blood test for the genetic marker HLA-B27 may also be performed. About 75 percent of all the patients with reactive arthritis have this gene.

Diagnostic criteria

Although there are no definitive criteria to diagnose the existence of reactive arthritis, the American College of Rheumatology has published sensitivity and specificity guidelines.[18]

Percent Sensitivity and Specificity of Various Criteria for Typical Reactive Arthritis
Method of diagnosis Sensitivity Specificity
1. Episode of arthritis of more than 1 month with urethritis and/or cervicitis 84.3% 98.2%
2. Episode of arthritis of more than 1 month and either urethritis or cervicitis, or bilateral conjunctivitis 85.5% 96.4%
3. Episode of arthritis, conjunctivitis, and urethritis 50.6% 98.8%
4. Episode of arthritis of more than 1 month, conjunctivitis, and urethritis 48.2% 98.8%

Treatment

The main goal of treatment is to identify and eradicate the underlying infectious source with the appropriate

iritis.[citation needed
]

Prognosis

Reactive arthritis may be self-limiting, frequently recurring, chronic or progressive. Most patients have severe symptoms lasting a few weeks to six months. 15 to 50 percent of cases involve recurrent bouts of arthritis. Chronic arthritis or sacroiliitis occurs in 15–30 percent of cases. Repeated attacks over many years are common, and patients sometimes end up with chronic and disabling

nephropathy, cardiac conduction abnormalities, or aortitis with aortic regurgitation.[19] However, most people with reactive arthritis can expect to live normal life spans
and maintain a near-normal lifestyle with modest adaptations to protect the involved organs.

Epidemiology

Because women may be underdiagnosed, the exact incidence of reactive arthritis is difficult to estimate. A few studies have been completed, though. In

enteric bacteria.[20] In 1978 in Finland, the annual incidence was found to be 43.6 per 100,000.[21]

History

When reactive arthritis appears in a triad that also includes ophthalmic and urogenital manifestations, the

Hans Conrad Julius Reiter described the condition in a soldier he treated during World War I
.

A number of physicians have suggested that the eponym is undeserved. Reiter's

war criminal), have come to overshadow his medical accomplishments. Furthermore, he was not the first physician to make associations between the arthritis and other symptoms—the names arthritis urethritica, venereal arthritis and polyarteritis enterica had previously been applied—and the full triad was described by another physician in the 19th century.[22]

Notable cases

See also

References

  1. ^ American College of Rheumatology. "Reactive Arthritis". Retrieved 24 January 2017.
  2. ^ Mayo Staff (5 March 2011). "Reactive Arthritis (Reiter's Syndrome)". Mayo Clinic. Retrieved 16 May 2011.
  3. ISBN 978-0-07-026033-7
    .
  4. ^ Primer on the Rheumatic Diseases, By John H. Klippel, page 218
  5. ^ Rheumatology in Practice, By J. A. Pereira da Silva, Anthony D. Woolf page 5.9
  6. ISBN 978-0-7216-9033-9
    .
  7. PMID 18412942
    .
  8. PMID 22514384
    .
  9. ^ "Reactive Arthritis". www.rheumatology.org. Retrieved 18 September 2019.
  10. S2CID 45438826
    .
  11. PMID 20406616
    .
  12. ^ Harrison's Rheumatology, Second Edition [Anthony Fauci, Carol Langford], Ch.9 THE SPONDYLOARTHRITIDES, Reactive Arthritis, page.134
  13. ISBN 978-1-56053-485-3
    .
  14. PMID 21763590
    .
  15. PMID 15222650. Archived from the original
    on 9 July 2008. Retrieved 16 June 2013.
  16. PMID 12787523
    .
  17. ^
    ISBN 978-0-7817-1576-8
    .
  18. ^ American College of Rheumatology. "Arthritis and Rheumatism". Retrieved 16 May 2011.
  19. ^ eMedicine/Medscape (5 January 2010). "Reactive Arthritis". Retrieved 16 May 2011.
  20. PMID 8151565
    .
  21. PMID 310157
    .
  22. PMID 19078450
    .
  23. ^ "Cause of the death of Columbus (in Spanish)". Eluniversal.com.mx. Archived from the original on 24 September 2014. Retrieved 29 July 2009.
  24. ^ Kelly, Fiach (4 January 2008). "Comedian reveals how he tracked birth parents to solve family health mystery". Irish Independent. Retrieved 4 January 2008.
  25. ^ Lisa Gray (29 November 2006). "Murray targets Christmas as date for Rangers return". The Independent.
  26. ^ "Silverchair frontman's dramatic fight-back from crippling illness". The Sydney Morning Herald. 1 December 2002. Retrieved 22 July 2016.
  27. ^ Daniel Taylor (22 November 2016). "Second footballer reveals abuse by serial paedophile Barry Bennell". The Guardian.

External links

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