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Emergency And Acute Medicine – Reactive Arthritis
Reactive arthritis is an inflammatory syndrome classically described by the triad of conjunctivitis, urethritis, and arthritis. Historically referred to as Reiter syndrome, the eponym is no longer favored. The condition is commonly remembered by the phrase “can’t see, can’t pee, can’t climb a tree,” although only about one-third of patients present with the full triad.
The exact incidence is difficult to determine due to the absence of standardized diagnostic criteria. Two main forms are recognized. The postdysentery type follows gastrointestinal infections, most commonly caused by Salmonella, Shigella, Campylobacter, Yersinia, or Clostridium difficile. The venereal type follows genitourinary infections, most often Chlamydia trachomatis and less commonly Neisseria gonorrhoeae. Reactive arthritis has also been described after upper respiratory infections, urinary tract infections, and intravesical BCG therapy for bladder carcinoma. It is more common in males than females, approximately 5:1, and most often occurs in the third decade of life.
Symptoms typically develop within four weeks of the inciting infection but may be delayed up to one year. Urogenital symptoms occur in more than 90% of cases and may include urethritis, cervicitis, or prostatitis. The arthritis is usually asymmetric and polyarticular, most commonly affecting the knees and ankles, but it may also involve fingers, the back, and sacroiliac joints. Achilles tendonitis occurs in approximately 40% of patients, and dactylitis, or “sausage digit,” is present in about 15%. Ophthalmologic involvement occurs in 30–60% of cases. Conjunctivitis is most common and is typically bilateral with mild irritation or mucopurulent discharge. Uveitis and keratitis are less common, usually unilateral, and may cause eye pain, redness, and photophobia.
Mucocutaneous manifestations are more frequent in patients who are HLA-B27 positive. Keratoderma blennorrhagicum presents as erythematous macules and vesicles on the palms and soles that progress to pustules and hyperkeratotic plaques resembling pustular psoriasis. Circinate balanitis occurs in more than half of affected males and presents as plaques or vesicles on the glans penis. Oral lesions, nail dystrophy, and periungual pustules may also be seen. Systemic symptoms such as fever, fatigue, malaise, and weight loss may be present.
The diagnosis is clinical and based on characteristic findings and a recent history of gastrointestinal or genitourinary infection. No laboratory test confirms the diagnosis. Laboratory studies may show leukocytosis, mild anemia, and elevated ESR or CRP. Urinalysis may demonstrate sterile pyuria. Imaging studies are not diagnostic but may be used to exclude other conditions; plain radiographs may show joint effusion. Arthrocentesis should be performed if septic arthritis is a concern. Synovial fluid typically shows leukocytosis with polymorphonuclear predominance, and crystals are absent.
The differential diagnosis includes septic arthritis, gonococcal arthritis, chlamydial urethritis, syphilis, gout, rheumatoid arthritis, pustular psoriasis, Behçet disease, contact dermatitis, and Kawasaki disease in children. Exclusion of life- or limb-threatening conditions such as septic arthritis is essential.
Management in the emergency setting is primarily symptomatic after serious infections have been excluded. Nonsteroidal anti-inflammatory drugs are first-line therapy for arthritis, along with rest, ice, and elevation. The role of antibiotics in reactive arthritis itself is unclear, as studies have not shown consistent long-term benefit once arthritis is established, although the initial infection should be treated if still present. Short courses of systemic corticosteroids may be considered in severe or prolonged cases. Conjunctivitis may be managed with topical agents for symptomatic relief, and severe uveitis requires urgent ophthalmology referral.
Most patients can be managed as outpatients with follow-up through primary care. Severe uveitis warrants ophthalmology follow-up. The course is often prolonged, lasting three to twelve months, and approximately 25% of patients experience recurrent episodes.
A key pitfall is failure to exclude serious conditions such as septic arthritis, gonococcal arthritis, or Kawasaki disease in children. Careful evaluation and appropriate exclusion of emergent diagnoses are critical before attributing symptoms to reactive arthritis.
Reactive arthritis is an inflammatory syndrome classically described by the triad of conjunctivitis, urethritis, and arthritis. Historically referred to as Reiter syndrome, the eponym is no longer favored. The condition is commonly remembered by the phrase “can’t see, can’t pee, can’t climb a tree,” although only about one-third of patients present with the full triad.
The exact incidence is difficult to determine due to the absence of standardized diagnostic criteria. Two main forms are recognized. The postdysentery type follows gastrointestinal infections, most commonly caused by Salmonella, Shigella, Campylobacter, Yersinia, or Clostridium difficile. The venereal type follows genitourinary infections, most often Chlamydia trachomatis and less commonly Neisseria gonorrhoeae. Reactive arthritis has also been described after upper respiratory infections, urinary tract infections, and intravesical BCG therapy for bladder carcinoma. It is more common in males than females, approximately 5:1, and most often occurs in the third decade of life.
Symptoms typically develop within four weeks of the inciting infection but may be delayed up to one year. Urogenital symptoms occur in more than 90% of cases and may include urethritis, cervicitis, or prostatitis. The arthritis is usually asymmetric and polyarticular, most commonly affecting the knees and ankles, but it may also involve fingers, the back, and sacroiliac joints. Achilles tendonitis occurs in approximately 40% of patients, and dactylitis, or “sausage digit,” is present in about 15%. Ophthalmologic involvement occurs in 30–60% of cases. Conjunctivitis is most common and is typically bilateral with mild irritation or mucopurulent discharge. Uveitis and keratitis are less common, usually unilateral, and may cause eye pain, redness, and photophobia.
Mucocutaneous manifestations are more frequent in patients who are HLA-B27 positive. Keratoderma blennorrhagicum presents as erythematous macules and vesicles on the palms and soles that progress to pustules and hyperkeratotic plaques resembling pustular psoriasis. Circinate balanitis occurs in more than half of affected males and presents as plaques or vesicles on the glans penis. Oral lesions, nail dystrophy, and periungual pustules may also be seen. Systemic symptoms such as fever, fatigue, malaise, and weight loss may be present.
The diagnosis is clinical and based on characteristic findings and a recent history of gastrointestinal or genitourinary infection. No laboratory test confirms the diagnosis. Laboratory studies may show leukocytosis, mild anemia, and elevated ESR or CRP. Urinalysis may demonstrate sterile pyuria. Imaging studies are not diagnostic but may be used to exclude other conditions; plain radiographs may show joint effusion. Arthrocentesis should be performed if septic arthritis is a concern. Synovial fluid typically shows leukocytosis with polymorphonuclear predominance, and crystals are absent.
The differential diagnosis includes septic arthritis, gonococcal arthritis, chlamydial urethritis, syphilis, gout, rheumatoid arthritis, pustular psoriasis, Behçet disease, contact dermatitis, and Kawasaki disease in children. Exclusion of life- or limb-threatening conditions such as septic arthritis is essential.
Management in the emergency setting is primarily symptomatic after serious infections have been excluded. Nonsteroidal anti-inflammatory drugs are first-line therapy for arthritis, along with rest, ice, and elevation. The role of antibiotics in reactive arthritis itself is unclear, as studies have not shown consistent long-term benefit once arthritis is established, although the initial infection should be treated if still present. Short courses of systemic corticosteroids may be considered in severe or prolonged cases. Conjunctivitis may be managed with topical agents for symptomatic relief, and severe uveitis requires urgent ophthalmology referral.
Most patients can be managed as outpatients with follow-up through primary care. Severe uveitis warrants ophthalmology follow-up. The course is often prolonged, lasting three to twelve months, and approximately 25% of patients experience recurrent episodes.
A key pitfall is failure to exclude serious conditions such as septic arthritis, gonococcal arthritis, or Kawasaki disease in children. Careful evaluation and appropriate exclusion of emergent diagnoses are critical before attributing symptoms to reactive arthritis.
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