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Reactive arthritis Minor changes. References reduced. 64.
M and Rochelle C Monteiro Reactive arthritis is defined as an episode of peripheral arthritis of more than one month duration occurring in association with conjunctivitis and urethritis and/or cervicitis. It is triggered by an infection most often in the gastrointestinal or urogenital tract. It is also known as Reiter’s syndrome, Feissinger – Leroy’s disease, Brodie’s syndrome and conjunctivo-urethro-synovial syndrome. The term Reactive arthritis was originally introduced to define a sterile joint inflammation during and after infection elsewhere in the body. The definition was later modified since nucleic acids and bacterial antigens were found in the inflamed joints. ² Etiology Reactive arthritis (ReA ) follows infection in the urogenital tract (venereal form) or gastrointestinal tract (dysenteric form).The venereal form follows recent sexual contact, whereas the dysentric form is associated with a wide variety of intestinal pathogens and non-specific diarrheal illnesses. The most common organisms implicated are as follows:
Postdysenteric form: Shigellasonnei ,and Campylobacter jejuni. These organisms are found to be HLAB –27 Individualswith HLA-B27 positivity are strongly predisposed to develop the disease . Postvenereal form: Chlamydia trachomatis .
Some newer organisms have been implicated recently in causation of
reactive arthritis, namely Chlamydia pneumonia, Mycoplasma hominis, Mycoplasma fermentans, Nisseria Gonorrhoea, Borrelia burgdorferi, Clostridium difficile, β-hemolytic streptococci, Propionibacteium acnes, Escherischia coli, Helicobacter pylori, Calmette Guerin bacillus, Brucella abortus, Leptospira yr ema whippeli, Gardnerella vaginalis, Giardia lamblia. ³
Drugs are generally not implicated in the etiology of
reactive arthritis , however a single case of Lithium precipitating pre-existing Re a cti ve arthritis has been described. â´ Pathobiology The prevalence of Re active arthritis is estimated to be 0.1% worldwide. The disease mainly affects people in the 2 nd – 4 th decade of life. Infection occurs 1 –4 weeks following genitourinary infection with a male –female ratio of 9:1. Enteric type has equal incidence in both males and females. â¶ Systemic Features The disease primarily affects the joints, eyes â·, the skin and genitalia. Rarely, patients present with cardiac, renal , and neural abnormalities. Arthritis Articular manifestations are most commonly of an acute, non-destructive oligoarthritis usually affecting the large joints of the lower limbs which persists for 4 –5 months. ‘Sausage digit’ or diffuse swelling of an entire toe/finger occurs in 16% of patients. Enthesitis is another characteristic feature of patients with ReA. It is defined an inflammation of the ligaments and tendons at their site of insertion into the bone. Patients may also develop heel pain and achilles tendonitis. Sacroilitis is another distinctive feature of the disease which results in a low back pain. 8-10 Urethritis Re active arthritis usually follows 1 –3 weeks after an episode of urethritis. Urethritis may occur even in post dysenteric cases. The non specific urethritis presents with mild non-purulent urethral discharge. Hemorrhagic cystitis and prostatitis may develop in few patients. In females, it manifests as cervicitis associated with cervical discharge. Rarely, bleeding and abdominal pain may occur. âµ Mucocutaneous lesions Keratoderma blenorrhagica or Pustulosis palmoplantaris is a specific cutaneous lesion in ReA. Patients present with pustules over the palms and soles which are gradually covered with thick horny crusts. Lesions may coalesce. 1). In addition, small shallow ulcers are seen over the glans and urethral meatus and also the oral cavity. Nail changes are a common finding and include subungual hyperkeratosis, onycholysis, ridging and nail shedding. 10,11
Visceral lesions Visceral involvements mainly include the cardiac, renal and neural system. Cardiovascular manifestations present as conduction delays and aortic disease. Proteinuria, microhematuria, aseptic pyuria, and rarely, glomerulonephritis occur when the renal system is involved. Transient neurologic dysfunction such as cranial or peripheral nerve palsies have been described in some patients. 10
The disease is usually
self limiting. The joint manifestations regress completely withina few months (3 –5 months). Enthesopathy, balanitis and psoriatic lesions may persist even after joint inflammation has subsided. Recurrences are common. Some patients develop chronic polyarthritis, usually HLA B –27 12 Ocular Features Bilateral mucopurulent conjunctivitis is the most common ocular manifestation of ReA that occurs in more than 50% of patients. It is one of the important components of the triad of the disease. Occasionally, the conjunctivitis may be purulent but remains transient, mild and associated with a sterile discharge. It subsides within 1 –4 weeks. Acute anterior uveitits may be found in about one-fifth of cases especially in those who are positive for HLA-B27. 7 Other ocular complications of ReA include keratitis, corneal ulcer with or without hypopyon, episcleritis, scleritis, papilledema, retinal edema, retinal vasculitis and retrobulbar neuritis. ¹³
Vision is usually impaired from corneal scar or recurrent chronic uveitis causing secondary glaucoma, complicated cataract or cystoid
s macular edema. ¹ â´ Laboratory findings in ReA are non-specific and do not usually provide a conclusive diagnosis regarding the etiology. Prognosis Individuals who are HLA B27 9 Treatment Patient education has a major role in patients with Re active arthritis. The chronic relapsing nature of the disease should be explained to the patients for better compliance with therapeutic modalities. Conjunctivitis is usually self-limiting. A slit lamp examination is necessary to rule out uveitis which if present has to be managed with topical corticosteroids, cycloplegics and mydriatics. Keratoderma blenorrhagica is treated using topical steroids and keratolytics. Low potency topical steroids are used in circinate balanitis. 10 Non steroidal anti inflammatory drugs (NSAID ’ s) are highly effective in pain management in patients with Re active arthritis. Intra articular steroids are advocated in oligo/monoarticular disease. The use of systemic steroids has been discouraged except in severe cases where short courses maybe given. 15 Antibiotics are useful in the post venereal form of Re active arthritis. Their role in the post dysenteric form remains controversial. Commonly used antibiotics include erythromycin, ciprofloxacin, tetracycline and doxycycline. 11 In patients who fail to respond to the above mentioned conventional therapy, a more aggressive therapeutic approach is needed. This includes Disease modifying anti rheumatic drugs (DMARD’s). References 1. Fisk PK. Reiter’s disease. British Med J 1982; 284:3. 13 . Kingsley G, Sieper J. Third international workshop on Reactive arthritis 23 -26 September, 1995, Berlin : An overview. Ann Rheum Dis 55:564 – 70. 14 . Kiss S, LetkoE, Qamruddin S et al, Long-term progression, prognosis and treatment of patients with recurrent ocular manifestations of Reiter’s syndrome. Ophthalmology 2003;110::1764 – 9. 15 . Schumacher HR Jr., Reactive arthritis. Rheum Dis Clin North Am 1998; 24:261 -273.
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