Reactive Arthritis, Emergency Medicine

Basics

Description

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 "

Etiology

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

Diagnosis

Signs and Symptoms

Urogenital: Occur in >90% of cases, seen in both forms of disease
Arthritis, tendonitis:
- Typically polyarticular, asymmetric
- Knees and ankles most commonly affected
- May also affect fingers, back, sacroiliac joints
- Achilles tendonitis present in 40% of cases
Ophthalmologic: Occur in 30 " 60% of cases:
- Conjunctivitis is most common:
  - Usually bilateral
- Uveitis, keratitis is less common:
  - Usually unilateral
  - Usually preceded by 1 " 2 days of eye discomfort
Mucocutaneous:
- More common in patients with HLA-B27 positivity

History

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

Physical Exam

General:
- May include fever, fatigue, weight loss, malaise
Urogenital:
- Urethritis
- Cervicitis
- Prostatitis
Extremities:
- Swelling, painful range of motion, erythema may all be present.
- Sausage digit (diffuse swelling of an entire digit) present in ’ Ό15% of cases
Ophthalmologic:
- Conjunctivitis:
  - Often with mucopurulent discharge
  - Symptoms 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 plaques
  - Similar 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

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

Lab
No lab tests can confirm the diagnosis:

CBC may show leukocytosis and mild anemia
ESR and CRP are usually elevated
Urinalysis may show sterile pyuria

Imaging

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

Diagnostic Procedures/Surgery
Arthrocentesis:

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)

Differential Diagnosis

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

Treatment

Pre-Hospital

No specific pre-hospital considerations

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, elevation
- NSAIDs
Conjunctivitis:
- Topical antibiotics may provide symptomatic relief
Urethritis:
- Should be treated if initial infection not recognized or treated

Medication

No definite role for medication

Follow-Up

Disposition

Admission Criteria
Treatment is generally outpatient, once syndrome is recognized and other diagnoses have been excluded.
Discharge Criteria
Most patients with reactive arthritis can be discharged with follow-up with their primary care provider.
Issues for Referral
Severe uveitis should be referred to ophthalmology for close follow-up.

Followup Recommendations

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

Pearls and Pitfalls

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

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.

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

M02.30 Reiters disease, unspecified site

SNOMED

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

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