Reactive Arthritis

Reactive Arthritis (ReA) (Reiter’s syndrome)

Post-infectious disorder (not a local infection, but a reaction). Classic triad (Reiter – 1916) of arthritis, urethritis and conjunctivitis following infection. Reiter’s syndrome is now not the preferred name (Reiter was involved with Nazi politics and medical experiments).

Syndrome now considered consisting of:
1) Arthritis
2) Urethritis
3) Conjunctivitis
4) Mucocutaneous lesions
However, not all patients will exhibit all of these features.

Usually follows infection with Yersina, Salmonella, Campylobacter (gastrointestinal infections) and Chlamydia (genitourinary infection). A heightened immune reaction then occurs to the triggering infection  increase in IgG/IgA antibodies and an enhanced antigen specific proliferation of synovial fluid lymphocytes.

Clinical features:
M>F. Usually 15 to 35 yrs. Abrupt onset with urethritis is usually first manifestation with low-grade fever. Urethritis in some may be asymptomatic. History should reveal recent infection. Conjunctivitis (usually mild) and arthritis follows urethritis.
Asymmetric arthritis – oligoarticular and usually lower extremity (knees, ankles and MPJ’s) – joints are tender and warm; joint stiffness is early predominant feature.
Some develop mucocutaneous lesions – small mouth ulcers

Involvement of foot:
• Asymmetric involvement of MPJ’s and IPJ’s.
• Achilles tendonitis and plantar fasciitis are common and may be severe (enthesitis).
• Keratoderma blennorrhagia – psoriasis like lesion on sole of foot (in 5-30%) – appears as small reddish to yellow brown vesicles
• X-rays may show calcaneal erosions and ‘fluffy’ spurs; joint space loss, poorly joint defined erosions, periarticular osteoporosis, soft tissue swelling
• “Sausage toe” – toe is swollen (dactylitis) – shows up on bone scan as a ‘hot toe’.
• 50% have some form of polyarthritis in foot joints or heel pain
• Ankle and first metatarsophalangeal joint involvement are the most common joints affected in foot.
• Early reports 54,55 reported exostoses of the calcaneus following gonococcal infection and hereditary syphilis.

Treatment:
Antibiotics; symptomatic (eg NSAID’s); immunosuppressive; corticosteroids
Physical therapy
Eye drops.