• Clinical science

Reactive arthritis (Reiter syndrome)

Abstract

Reactive arthritis, (formally known as Reiter's syndrome), is an autoimmune condition that occurs after a bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondyloarthritis because of its association with HLA-B27. Reactive arthritis primarily affects young men and usually presents with musculoskeletal or extra‑articular symptoms. The characteristic triad consists of arthritis, conjunctivitis, and urethritis. The diagnosis is based on clinical features such as patient history and physical examination; there are no specific tests for reactive arthritis. Treatment is primarily symptomatic and consists of the administration of NSAIDs, as most patients recover spontaneously.

Epidemiology

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1]

Clinical features

  • Latency period: 1–4 weeks
  • Musculoskeletal symptoms
    • Polyarthritis
      • Acute onset
      • Often asymmetrical with a migratory character
      • Occurs predominantly in the lower extremities
    • Sacroiliitis
    • Enthesitis
    • Dactylitis
  • Extra‑articular symptoms
    • Conjunctivitis or iritis
    • Oral ulcers
    • Dermatologic manifestations; : skin lesions of the glans resembling psoriasis (balanitis circinata; ); hyperkeratinization of the palms and soles (keratoderma blenorrhagicum)
  • Symptoms from preceding infection

The classic triad of reactive arthritis (formerly called Reiter's syndrome) consists of urethritis, conjunctivitis, and arthritis, but it is only present in about a third of cases!

Can't see, can't pee, can't climb a tree!References:[1][2]

Diagnostics

  • Reactive arthritis is a clinical diagnosis that may be supported by diagnostic steps, but there is no confirmatory test.
  • Laboratory tests
    • ESR and CRP
    • Test for potentially positive HLA-B27
    • Consider performing additional tests to confirm a preceding infection
      • Microscopy and culture of synovial fluid
      • Imaging
      • Stool and urine cultures
      • Urethral swab
      • HIV testing in patients with persistent symptoms
  • Arthrocentesis: may be performed to rule out differentials . Findings from synovial fluid analysis include:
    • WBC count: 10,000-40,000/μL
    • Mostly polymorphonuclear leukocytes predominate
    • Gram stain and cultures are negative

References:[1][2][3][4]

Differential diagnoses

Differential diagnoses of infection-associated arthritis
Condition: Septic arthritis Lyme disease Reactive arthritis

At-risk groups

  • People commonly involved in outdoor activities (e.g., hunters, farmers, hikers), especially in summer months
  • Individuals with a recent gastrointestinal or urinary tract infection (usually bacterial)
  • Genetic predisposition and association with HLA-B27 (see seronegative spondyloarthritis)
  • Especially young men

Onset and course

  • Acute course with rapid onset of symptoms
  • Progressive onset that can become chronic
  • Acute onset
  • Typically resolves within 6 months, although 20–30% become chronic
  • Often self-limiting

Clinical features

  • Three stages:

Pattern of disease

  • Primarily monoarthritis, oligoarthritis is possible
  • Migratory asymmetrical polyarthropathy
    • Intermittent or persistent arthritis
    • Generally in large joints (especially knee or elbow)
  • Mono- or oligoarthritis
  • Predominately lower extremities (especially knee)
  • Migratory character if associated with gonococcal infection

References:[5][6][2][7][8][4]

The differential diagnoses listed here are not exhaustive.

Treatment

There is no curative treatment. The goal of treatment is to primarily control symptoms as the disease is usually self-limiting.

  • Arthritis
  • Ongoing infection
    • See bacterial gastrointestinal infections
    • See urethritis
  • Treat extraintestinal manifestations as necessary.

References:[2][4]

Prognosis

  • Resolves spontaneously within a year (80% of cases)
  • High rate of recurrence (15–50% of cases)

References:[4]