Reactive arthritis



Reactive arthritis


Sara Samimi, Leslie Castelo-Soccio and Abby S. Van Voorhees


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


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Reactive arthritis (ReA) is one of the reactive forms of seronegative spondyloarthropathies. It is both a genetically determined and immune-mediated disease that primarily affects the skin and joints 2 to 4 weeks after an enteric or urogenital infection. Implicated gastrointestinal pathogens include Yersinia, Salmonella, Shigella, Campylobacter, and Clostridium difficile; implicated urogenital pathogens include Chlamydia trachomatis and Ureaplasma urealyticum. Rarely, ReA can manifest after a respiratory infection with Chlamydia pneumoniae or group A β-hemolytic Streptococcus.


ReA is characterized by a triad of urethritis, conjunctivitis, and oligoarthritis. The classic skin manifestations include keratoderma blennorrhagica and circinate balanitis. Erythema nodosum can also occur and is more common in the setting of a Yersinia infection. Additional extra-articular findings include enthesitis, tendinitis, bursitis, conjunctivitis, anterior uveitis, and keratitis. ReA was formerly known as Reiter syndrome, but was renamed when the Nazi war crime past of Hans Reiter was revisited.



Management strategy


The mucocutaneous lesions of uncomplicated ReA are usually self-limited and clear within a few months. Severe, extensive and chronic cutaneous presentations, which are more common in the setting of HIV infection, are generally treated in the same manner as pustular psoriasis. Initial therapy for limited skin disease includes topical steroids, topical vitamin D preparations, tacrolimus, and tazarotene. Second-line agents include UVB and systemic retinoids. Severe disease can be treated with psoralen plus UVA (PUVA) and immunosuppressive agents such as methotrexate and cyclosporine. Anti-tumor necrosis factor (TNF) agents have also been used successfully in patients with refractory disease as well as those with HIV.



Antibiotic use


The effects of short-term and long-term antibiotic therapy for reactive arthritis are controversial. While there is some evidence that antibiotics may be beneficial during the infectious phase before arthritis has developed, it is not clear whether the introduction of antibiotics after the development of arthritis will modify the disease course. One large double-blind, placebo-controlled study suggests no effect, but another small study reports a beneficial effect of combination treatment with doxycycline and rifampin for chronic spondyloarthritis. If the inciting organism is documented by culture or PCR, antibiotics are indicated. The true benefit of antibiotics, their dose and duration remains to be clarified. However, when evaluating a patient with reactive arthritis after a urogenital infection, it is also important to consider treatment of the patient’s partner for further disease prevention.


ReA in HIV-infected individuals may be more severe and progressive, being refractory to treatment. However, one report describes ReA as part of immune reconstitution syndrome that is rapidly responsive to a 2-week course of doxycycline.



Other modalities


The symptoms of arthritis and inflammation of the peripheral ligamentous or muscular attachments (enthesis) usually dictate the focus of treatment in most patients. Non-steroidal anti-inflammtory drugs (NSAIDs) are the first-line therapy. Corticosteroids injections can provide temporary relief of the pain caused by arthritis or bursitis while oral corticosteroids may also be beneficial when severe. Sulfasalazine and methotrexate have been shown to be effective and well tolerated in cases refractory to both NSAIDs and steroids. TNF inhibitors have also shown efficacy in treating severe disease.


Transient and mild conjunctivitis does not require specific therapeutic intervention. Symptoms of eye pain or blurry vision require immediate referral to ophthalmology to determine if these symptoms are due to conjunctivitis or a more serious eye problem such as uveitis, iritis or keratitis. Treatment often involves topical steriods and systemic corticosteriods as well other immunosuppressive medications such as methotrexate.



Specific investigations














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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Reactive arthritis

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