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Reactive Arthritis, Emergency Medicine

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Reactive Arthritis, Emergency Medicine

Basics

Description

No specific pre-hospital considerations

Most patients with reactive arthritis can be discharged with follow-up with their primary care provider.

Severe uveitis should be referred to ophthalmology for close follow-up.

With primary care provider. Most cases have a prolonged course (3 " 12 mo), and ’ Ό25% may have recurrent episodes.

Failing to diagnose serious life- or limb-threatening diseases is a pitfall:

  • Syndrome classically includes triad of conjunctivitis, urethritis, arthritis
  • Also known as "Reiters syndrome, "  although the eponym has fallen out of favor:Typically taught as the syndrome of "can't see, can't pee, can't climb a tree " 
  • Typically taught as the syndrome of "can't see, can't pee, can't climb a tree " 

Etiology

  • Exact incidence difficult to determine because of lack of standardized diagnostic criteria
  • 2 main types:Postdysentery:Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficileVenereal:Chlamydia trachomatis, Neisseria gonorrhoeae
  • Also described after upper respiratory infections, UTIs, BCG treatment for bladder carcinoma
  • M > F ( ’ ˆ Ό5:1)
  • Peak onset during 3rd decade
  • Postdysentery:Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficile
  • Venereal:Chlamydia trachomatis, Neisseria gonorrhoeae
  • Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficile
  • Chlamydia trachomatis, Neisseria gonorrhoeae

Diagnosis

Signs and Symptoms

  • Urogenital: Occur in >90% of cases, seen in both forms of disease
  • Arthritis, tendonitis:Typically polyarticular, asymmetricKnees and ankles most commonly affectedMay also affect fingers, back, sacroiliac jointsAchilles tendonitis present in 40% of cases
  • Ophthalmologic: Occur in 30 " “60% of cases:Conjunctivitis is most common:Usually bilateralUveitis, keratitis is less common:Usually unilateralUsually preceded by 1 " “2 days of eye discomfort
  • Mucocutaneous:More common in patients with HLA-B27 positivity
  • Typically polyarticular, asymmetric
  • Knees and ankles most commonly affected
  • May also affect fingers, back, sacroiliac joints
  • Achilles tendonitis present in 40% of cases
  • Conjunctivitis is most common:Usually bilateral
  • Uveitis, keratitis is less common:Usually unilateralUsually preceded by 1 " “2 days of eye discomfort
  • Usually bilateral
  • Usually unilateral
  • Usually preceded by 1 " “2 days of eye discomfort
  • More common in patients with HLA-B27 positivity
  • Symptoms generally within 4 wk of infection, although may be delayed up to 1 yr
  • Diagnosis made by history and physical exam findings
  • Only 1/3 have the complete triad of conjunctivitis, urethritis, arthritis
  • Postdysentery: Usually preceded by symptomatic GI infection, especially in children
  • Venereal: Often follows asymptomatic infection
  • General:May include fever, fatigue, weight loss, malaise
  • Urogenital:UrethritisCervicitisProstatitis
  • Extremities:Swelling, painful range of motion, erythema may all be present.Sausage digit (diffuse swelling of an entire digit) present in ’ ˆ Ό15% of cases
  • Ophthalmologic:Conjunctivitis:Often with mucopurulent dischargeSymptoms range from mild irritation to severe inflammation.Uveitis:Eye pain, redness, photophobia, miosis, blepharospasm
  • Skin/mucosa:Keratoderma blennorrhagicum:Begins as erythematous macules and vesicles on palms and soles, progresses to pustules and dark plaquesSimilar in appearance to pustular psoriasisCircinate balanitis: Present in >50% of males:Plaques, vesicles or papules on glans penisUlcerative vulvitis may be associated with vaginal dischargeNail changes, including nail dystrophy, periungual pustulesOral lesions, include ulcerations, geographic tongue, palatal erosions, usually painless
  • May include fever, fatigue, weight loss, malaise
  • Urethritis
  • Cervicitis
  • Prostatitis
  • Swelling, painful range of motion, erythema may all be present.
  • Sausage digit (diffuse swelling of an entire digit) present in ’ ˆ Ό15% of cases
  • Conjunctivitis:Often with mucopurulent dischargeSymptoms range from mild irritation to severe inflammation.
  • Uveitis:Eye pain, redness, photophobia, miosis, blepharospasm
  • Often with mucopurulent discharge
  • Symptoms range from mild irritation to severe inflammation.
  • Eye pain, redness, photophobia, miosis, blepharospasm
  • Keratoderma blennorrhagicum:Begins as erythematous macules and vesicles on palms and soles, progresses to pustules and dark plaquesSimilar in appearance to pustular psoriasis
  • Circinate balanitis: Present in >50% of males:Plaques, vesicles or papules on glans penis
  • Ulcerative vulvitis may be associated with vaginal discharge
  • Nail changes, including nail dystrophy, periungual pustules
  • Oral lesions, include ulcerations, geographic tongue, palatal erosions, usually painless
  • Begins as erythematous macules and vesicles on palms and soles, progresses to pustules and dark plaques
  • Similar in appearance to pustular psoriasis
  • Plaques, vesicles or papules on glans penis

Essential Workup

  • Clinical diagnosis is based on characteristic physical exam findings and a history of GI illness, sexually transmitted infection or upper respiratory infection.
  • Must exclude other serious time-sensitive diagnoses that require prompt treatment

Diagnosis Tests & Interpretation

  • CBC may show leukocytosis and mild anemia
  • ESR and CRP are usually elevated
  • Urinalysis may show sterile pyuria
  • No radiology exams can confirm the diagnosis
  • Plain x-ray can be considered of affected extremities to exclude other diagnoses:May show swelling around affected joint, indicating joint effusion
  • May show swelling around affected joint, indicating joint effusion
  • Should be performed if septic arthritis is considered
  • Synovial fluid analysis may show leukocytosis, PMN predominance:Crystals not present, and indicate other pathologies (gout, pseudogout)
  • Crystals not present, and indicate other pathologies (gout, pseudogout)

Differential Diagnosis

  • Gonococcal urethritis
  • Chlamydial urethritis
  • Syphilis
  • Gout
  • Gonococcal arthritis
  • Septic arthritis
  • Rheumatoid arthritis
  • Pustular psoriasis
  • Beh ƒ §et disease
  • Contact dermatitis
  • Psoriasis
  • Kawasaki disease (in children)

Treatment

Pre-Hospital

Ed Treatment/Procedures

  • Once other serious infections have been excluded, treatment is symptomatic
  • No consensus about the role of antibiotics
  • Rationale for antibiotic treatment is that reactive arthritis is caused by bacterial infection, which may have long-term viability in synovium (especially Chlamydia):Studies have demonstrated no long-term benefit with doxycycline, ciprofloxacin, azithromycin
  • Short course of systemic corticosteroids may be helpful in severe or prolonged disease
  • Arthritis:Rest, ice, elevationNSAIDs
  • Conjunctivitis:Topical antibiotics may provide symptomatic relief
  • Urethritis:Should be treated if initial infection not recognized or treated
  • Studies have demonstrated no long-term benefit with doxycycline, ciprofloxacin, azithromycin
  • Rest, ice, elevation
  • NSAIDs
  • Topical antibiotics may provide symptomatic relief
  • Should be treated if initial infection not recognized or treated

Medication

Follow-Up

Disposition

Followup Recommendations

Pearls and Pitfalls

  • Septic arthritis
  • Gonococcal arthritis
  • Kawasaki disease

Additional Reading

  • Carter ‚ JD, Hudson ‚ AP. Reactive arthritis: Clinical aspects and medical management. Rheum Dis Clin North Am. 2009;35(1):21 " “44.
  • Wu ‚ IB, Schwartz ‚ RA. Reiters syndrome: The classic triad and more. J Am Acad Dermatol. 2008;59(1):113 " “121.

See Also (Topic, Algorithm, Electronic Media Element)

  • Conjunctivitis
  • Iritis/Uveitis
  • Kawasaki Disease
  • Septic Arthritis
  • Urethritis

Codes

ICD9

  • 099.3 Reiters disease
  • 372.33 Conjunctivitis in mucocutaneous disease
  • 711.10 Arthropathy associated with Reiter's disease and nonspecific urethritis, site unspecified

ICD10

SNOMED

  • 67224007 Reiters disease (disorder)
  • 236690002 Reiter's urethritis (disorder)
  • 403437002 Conjunctivitis due to Reiter's disease