Internal Diseases and Therapy · MU Sofia

41. Reactive arthritis - Rheumatic fever, Reiter’s syndrome, Lyme disease

Covers reactive arthritis, its links to genitourinary and gastrointestinal infections and HLA-B27, and how it differs from Reiter's syndrome, which adds conjunctivitis and urethritis. It then describes the typical joint, enthesal and skin features, including keratoderma blennorrhagicum, followed by investigations and a three-tier management ladder. The note closes with Lyme disease: its tick-borne cause, erythema migrans, arthritis and antibiotic treatment.

Inside: 1 section · 2 labelled pictures · 15 flashcards · 3 min

Topic 41 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 1 section, about 550 words (3 min of reading), with 15 flashcards.

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  1. Reactive arthritis - Rheumatic fever, Reiter’s syndrome, Lyme disease

Reactive arthritis - Rheumatic fever, Reiter’s syndrome, Lyme disease

Reactive arthritis and Reiter’s syndrome

The lead guitarist in the band that is the seronegative arthropathies. Reactive arthritis is an aseptic arthritis that occurs subsequent to an extra-articular infection, commonly GI or GU. If genitourinary, suspect chlamydia trachomatis, if gastrointestinal, suspect salmonella, yersinia, shigella and campylobacter jejuni.

RA is also associated with HLA-B27 mutations, and it carries risk not only for the onset of arthritis but also for axial involvement and chronicity.

Typically, the onset of arthritis occurs 1-3 weeks after the GI or GU infection, although this is not so specific.

I want to mention here that I have in the past used Reiter's syndrome and Reactive arthritis as synonyms which isn’t quite right. Reactive arthritis specifically refers to the articular manifestation that occurs post GI/GU infection, while Reiter's syndrome is the reactive arthritis following GI/GU infection + conjunctivitis and non-gonococcal urethritis (can’t see, can’t pee, can’t climb a tree).

RA often appears with asymmetric oligoarthritis with a predilection for the lower extremities. It may also present with enthesitis (inflammation of the tendon insertion into the bone), with achilles tendonitis or plantar fasciitis.

RA may also appear with skin manifestations, the classic one being keratoderma blennorrhagicum - a painless papulosquamous eruption on the palms or soles, occasionally with nail dystrophy with pitting and onycholysis.

Image: “Feet-Reiters syndrome” by Photo Credit: Content Providers(s): CDC/ Dr. M. F. Rein Transwiki approved by: w:en:User:Dmcdevit, Public domain, via Wikimedia Commons.

Again, this is an immune related disorder where we don’t fully understand pathogenesis, it is assumed to be related to an autoantibody that is triggered by the initial infection that we don’t yet have evidence of.

Investigations in suspected RA should be:

  • Joint aspiration and synovial fluid analysis (rule out crystal deposition and infectious arthritis)
  • Obtain blood tests - look at ESR, CRP and RF
  • Carry out cultures and PCR (look for chlamydia in urine)
  • Obtain radiographs of affected joints.

Management:

  1. 1. NSAIDs
  2. 2. Intra-articular steroids are second line
  3. 3. Antibiotics and DMARDs (methotrexate, sulfasalazine and hydroxychloroquine) are third line

Lyme’s Disease

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