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:
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.
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.
Antibiotics; symptomatic (eg NSAID’s); immunosuppressive; corticosteroids