Reactive Arthritis

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Reactive Arthritis

• Andres Quiceno, MD
• Rheumatology Division
• Presbyterian Hospital of Dallas

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Reactive Arthritis

• 32 y/o WM admitted to the hospital with 2 days of
  acute onset of arthritis in his right knee that
  progressed to the left knee. The day previous to
  the admission, he was evaluated in the ER, and an
  arthrocenthesis was attempted. The patient was
  discharged on Keflex 500 mg QID and Hydrocodone.
• ROS 3 weeks previous to admission he had an
  episode of diarrhea that lasted for 10 days and
  improved after treatment with Cipro.
• Family History Sister with recurrent uveitis.

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Reactive Arthritis

• PE fever 101. Otherwise within normal limits.
• Joint exam tenderness, redness and effusions in
  both knees.
• Labs ESR 60, Synovial fluid showed no crystals
  and Gram stain revealed no organisms. HLA B-27
  positive.
• Patient was started on indomethacin 50 mg PO QID
  with significant improvement of his symptoms.

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Reactive Arthritis

• Reactive Arthritis (ReA) is an infectious
  induced systemic illness characterized by an
  aseptic inflammatory joint involvement occurring
  in a genetically predisposed patient with a
  bacterial infection localized in a distant
  organ/system.

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Reactive Arthritis

• Epidemiology
• ReA is an acute and insidious polyarthritis after
  an enteric and urogenital infections.
• Incidence varies widely (1 to 20).
• Frequency varies from 0 to 15 after infection
  with Salmonella, Shigella, Campylobacter or
  Yersinia.
• HLA-B27 can be present in 72 to 84 of the
  cases.
• Incidence after Chlamydia trachomatis is not well
  known.

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Reactive Arthritis

• ReA can occurs in the absence of HLA-B27, this
  play a very important role.
• HLA-B27 probably works as an antigen presenting
  molecule.
• Comparison of ReA with IBD had suggest a possible
  common antigen associated to the gut flora.
• An ineffective immune response seems to play a
  very important role.
• Th1 cytokines such us IL-12, INF-gamma and
  TNF-alpha are essential for the clearance of
  bacteria.

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Reactive Arthritis

• In patients with ReA, they have an elevated
  production of Th2 cytokines, such us IL-10 and a
  possible decrease production in Th1 cytokines.
• All these factors cause a decrease in the
  effective clearance of bacteria.
• Macrophages, CD4 and CD8 lymphocytes are
  activated in the joints of this patients.
• Some bacterial antigens like heat shock protein
  60 present in Chlamydia and Yersinia.
• Molecular cross reactive has been also associated.

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Reactive Arthritis

• Causative organisms
• Frequent association
• Chlamydial trachomatis
• Ureaplasma urealyticum
• Salmonella enteritidis
• Salmonella typhimurium
• Shigella flexneri
• Shigella dysenteriae
• Campylobacter jejuni
• Yersinia enterocolitica
• Streptococcus SP

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Reactive Arthritis

• Less common association
• Chlamydia pneumoniae
• Neisseria meningitidis serogroup B
• Bacillus cereus
• Pseudomonas
• Clostridium difficile
• Borrelia burgdorferi
• Escherichia coli
• Helicobacter pillory
• Lactobacillus
• Brucella abortus
• Hafnia alvei

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Reactive Arthritis

• Clinical Manifestations
• Postenteric ReA is described equally in men an
  women.
• Postchlamydial is most common in men.
• In patients with postenteric ReA, the episode of
  diarrhea is usually prolonged.
• Arthritis presents usually 2 to 3 weeks after the
  episode of diarrhea.
• Arthritis usually resolves within 6 months, but a
  few patients had recurrences an a minority
  develops a chronic arthritis.

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Reactive Arthritis

• In patients with postchlamydial disease,
  urethritis is usually mild, painless and
  nonpurulent.
• Conjunctivitis is usually observed very early,
  before the onset of arthritis, uveitis is less
  common but occurs in 15 of patients with chronic
  persistent disease.
• Skin manifestations include Keratoderma
  blenorrhagica, Circinate balanitis and oral
  ulcers.
• Less common patients can develop valvulitis,
  rhythm disturbances.

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Reactive Arthritis

• Treatment
• NSAIDS are the first line of treatment.
• In patient with frequent recurrences or chronic
  arthritis benefit from DMARDS such us
  sulfasalazine or methotrexate.
• If there is axial involvement they will benefit
  from TNF-alpha blockers.
• Topical steroids are indicated in conjunctivitis
  and uveitis.
• In monoarthritis steroid injections could be
  beneficial.