Reactive Arthritis

Andres Quiceno, MDRheumatology DivisionPresbyterian Hospital of Dallas

Reactive Arthritis

32 y/o WM admitted to the hospital with 2 days of acute onset of arthritis in his right knee that progressed to the left knee. The day previous to the admission, he was evaluated in the ER, and an arthrocenthesis was attempted. The patient was discharged on Keflex 500 mg QID and Hydrocodone.

ROS: 3 weeks previous to admission he had an episode of diarrhea that lasted for 10 days and improved after treatment with Cipro.

Family History: Sister with recurrent uveitis.

Reactive Arthritis

PE: fever 101. Otherwise within normal limits. Joint exam: tenderness, redness and effusions in

both knees.

Labs: ESR 60, Synovial fluid showed no crystals and Gram stain revealed no organisms. HLA B-27 positive.

Patient was started on indomethacin 50 mg PO QID with significant improvement of his symptoms.

Reactive Arthritis

“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”.

Reactive Arthritis

Epidemiology ReA is an acute and insidious polyarthritis after an

enteric and urogenital infections. Incidence varies widely (1% to 20%). Frequency varies from 0 to 15% after infection with

Salmonella, Shigella, Campylobacter or Yersinia. HLA-B27 can be present in 72% to 84% of the

cases. Incidence after Chlamydia trachomatis is not well

known.

Reactive Arthritis

ReA can occurs in the absence of HLA-B27, this play a very important role.

HLA-B27 probably works as an antigen presenting molecule.

Comparison of ReA with IBD had suggest a possible common antigen associated to the gut flora.

An ineffective immune response seems to play a very important role.

Th1 cytokines such us IL-12, INF-gamma and TNF-alpha are essential for the clearance of bacteria.

Reactive Arthritis

In patients with ReA, they have an elevated production of Th2 cytokines, such us IL-10 and a possible decrease production in Th1 cytokines.

All these factors cause a decrease in the effective clearance of bacteria.

Macrophages, CD4+ and CD8+ lymphocytes are activated in the joints of this patients.

Some bacterial antigens like heat shock protein 60 present in Chlamydia and Yersinia.

Molecular cross reactive has been also associated.

Reactive Arthritis

Causative organisms Frequent association: Chlamydial trachomatis Ureaplasma urealyticum Salmonella enteritidis Salmonella typhimurium Shigella flexneri Shigella dysenteriae Campylobacter jejuni Yersinia enterocolitica Streptococcus SP

Reactive Arthritis

Less common association: Chlamydia pneumoniae Neisseria meningitidis serogroup B Bacillus cereus Pseudomonas Clostridium difficile Borrelia burgdorferi Escherichia coli Helicobacter pillory Lactobacillus Brucella abortus Hafnia alvei

Reactive Arthritis

Clinical Manifestations: Postenteric ReA is described equally in men an

women. Postchlamydial is most common in men. In patients with postenteric ReA, the episode of

diarrhea is usually prolonged. Arthritis presents usually 2 to 3 weeks after the

episode of diarrhea. Arthritis usually resolves within 6 months, but a few

patients had recurrences an a minority develops a chronic arthritis.

Reactive Arthritis

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 disease.

Skin manifestations include: Keratoderma blenorrhagica, Circinate balanitis and oral ulcers.

Less common patients can develop valvulitis, rhythm disturbances.

Reactive Arthritis

Treatment: NSAIDS are the first line of treatment. In patient with frequent recurrences or chronic

arthritis benefit from DMARDS such us sulfasalazine or methotrexate.

If there is axial involvement they will benefit from TNF-alpha blockers.

Topical steroids are indicated in conjunctivitis and uveitis.

In monoarthritis steroid injections could be beneficial.