Arthritis, reactive

CASES/YEAR
54,000 (US); 1,080,000 (Global)
CATEGORY
Immune-Related
AGENT TYPE
Other
OTHER NAMES
Reactive arthritis (ReA); Reiter's syndrome;
ACUITY
Acute-Moderate
INCUBATION
2-14 days; 2-8 weeks
INITIAL SYMPTOMS
Reiter's syndrome: Triad of joint, eye, and GU inflammation (may not all be evident at the same time); [5MCC-2020]
PRECAUTIONS
COMMENTS
The first episode usually lasts 2 to 6 months. Arthritis usually begins within 4 weeks of the urethritis. The most commonly affected joints are the knees, followed by the ankles and feet. Two thirds of patients develop sacroiliitis, and many develop ankylosing spondylitis. Conjunctivitis and uveitis, if present, usually last for only a few days. Skin diseases include circinate balanitis in 25-40% of patients. Rare complications are pericarditis and myocarditis. [PPID, p. 1355-6]

There are two forms of Reiter's syndrome: sexually transmitted and post-dysentery. Skin/mucous membrane manifestations may include stomatitis, ulcers of the penis, and hyperkeratotic lesions on palms and soles. Complications: recurrence in 5-50%; urethral strictures; cataracts; and ankylosing spondylitis in 30-50% of those HLA-B27 positive. Also pericarditis, murmurs, neuropathy, and meningoencephalitis can occur. In some cases, patients are seriously ill with fever, tachycardia and very tender joints. Chlamydia trachomatis is the usual causal agent in the post-venereal form with symptoms 7-14 days after sexual intercourse. The dysenteric form follows infection by Shigella, Salmonella, Yersinia, and Campylobacter. Reiter's syndrome complicates 1-2% of cases of nongonococcal urethritis. The HLA-B27 antigen is positive in 60-80% of Reiter syndrome cases. [5MCC-2020]

Low grade fever may be present. The sexually-transmitted form usually occurs in 20 to 40 year old males. The eyes are affected with conjunctivitis and sometimes with anterior uveitis. Vesicular skin lesions may resemble pustular psoriasis and become hyperkeratotic and crusted on palms and soles (keratoderma blennorrhagicum). Most cases resolve within 3-4 months. Up to 50% of patients may develop recurrent arthritis, spondylitis, or sacroiliitis. [Merck Manual, p. 314] ReA is uncommon in children. Males and females are affected equally in GI tract form. The GU tract form is more frequent in males. Erythema nodosum is usually associated with Yersinia infection. EKG changes may indicate a sub-clinical carditis. No international standards for tests, but Salmonella and Yersinia usually cause a strong antibody response. Test first morning urine with NAAT for C. trachomatis if GU form suspected. Most genital infections are asymptomatic. Evidence of previous infection can be detected by urogenital or stool samples in only 60% of clinically diagnosed ReA patients. [Hannu2011: PMID 22100285]
DIAGNOSTIC
Clinical (joint, eye and GU inflammation with negative rheumatoid factor); HLA-B27 testing not required; Synovial fluid analysis shows a leucocyte count of 1,000-8,000 cells/mm3 and negative bacterial culture; [5MCC-2020]
SCOPE
Global
SIGNS & SYMPTOMS
  • >fatigue, weakness
  • >fever
  • E stomatitis
  • H anemia
  • H hypergammaglobulinemia
  • H leukocytosis
  • O conjunctivitis, acute
  • S papules or plaques
  • S pustule
  • S rash on palms
  • S skin blister or vesicles
  • S ulcer of skin
  • *arthritis
  • *blindness
  • *cranial neuropathy
  • *encephalitis
  • *erythema nodosum
  • *meningitis
  • *myocarditis
  • *pericarditis
  • *peripheral neuropathy
  • *uveitis
  • *weight loss
ANTIMICROBIC

Yes

VACCINE

No

ENTRY
Sexual Contact
SOURCE
RESERVOIR
RISK FACTORS
TREATMENT
See "Sexually-Associated Reactive Arthritis (SARA)" in ABX Guide.
REFERENCES FOR CASES/YEAR
1. (US) Worldwide incidence = 9-27 cases per 100,000; [Hannu2011: PMID 22100285] Guesstimate: Use 18 cases/100,000 (average of 9-27); 3000 X 18 = 54,000;
2. (Global) Estimate global cases/yr at 20 X US cases/yr = 20 X 54,000;