Updated: 11/26/2019

Reactive Arthritis

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Snapshot
  • A 32-year-old man presents with redness of the eye as well as discharge. He reports that he experiences pain with urination and stiffness and pain of the knee and ankle. He says that he had a sexually transmitted disease approximately 5 weeks ago but is otherwise healthy. On physical exam there is conjunctivitis, asymmetric oligoarthritis, and discharge from the urethral meatus.
Introduction
  • Clinical definition
    • a systemic inflammatory disorder that results from following an extra-articular infection (e.g., sexually transmitted infection and gastroenteritis)
      • typically results after 1-6 weeks after the infection
      • formerly known as Reiter syndrome
      • classic triad is 
        • urethritis
        • conjunctivitis
        • arthritis
  • Epidemiology
    • demographics
      • age
        • 20-40 years of age
      • sex
        • following a genitourinary infection, it is more common to develop reactive arthritis in men
        • affects men and women equally a gastrointestinal infection
    • risk factors
      • HLA-B27 positivity 
  • Etiology
    • genitourinary pathogens
      • Chlamydia trachomatis
      • Neisseria gonorrhoeae
    • gastrointestinal pathogens
      • Salmonella enteritidis and typhimurium
      • Shigella
      • Yersinia
      • Campylobacter
  • Pathogenesis 
    • unclear
  • Prognosis
    • most cases spontaneously recover
Presentation
  • Symptoms
    • asymmetric joint pain
      • e.g., knee, ankle, and heel
    • eye discomfort
      • in cases of conjunctivitis
  • Physical exam
    • conjunctivitis
    • arthritis 
      • typically an acute and asymmetric oligoarthritis
    • genital involvement
      • circinate balanitis
      • urethritis
      • cervicitis
    • keratoderma blennorrhagicum
Studies
  • Labs
    • complete blood count
      • may demonstrate
        • neutrophillic leukocytosis
    • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
  • Diagnostic criteria
    • a clinical diagnosis
Differential
  • Ankylosing spondylitis
  • Enteropathic arthritis
  • Septic arthritis
  • Gonococcal arthritis
  • Gout
  • Pseudogout
  • Rheumatoid arthritis
Treatment
  • Medical
    • nonsteroidal anti-inflammatory drugs (NSAIDs) 
      • indication
        • drug of choice for acute phase of reactive arthritis 
    • antibiotics
      • indication
        • to treat the underlying genitourinary infection if still present
Complications
  • Cardiac
    • aortitis
      • very rare
 
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Questions (5)
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(M2.RH.17.4686) A 28-year-old man presents with one week of redness and discharge in his eyes, pain and swelling in his left second and third toes, and rash on the soles of his feet. He is sexually active with multiple partners and uses condoms occasionally. He denies any recent travel or illness and does not take any medications. Review of systems is otherwise unremarkable. On physical exam, he has bilateral conjunctivitis, dactylitis of the left second and third toes, and crusty yellow-brown vesicles on his plantar feet. Complete blood count and chemistries are within normal limits. Erythrocyte sedimentation rate (ESR) is 40 mm/h. Toe radiographs demonstrate soft tissue swelling but no fractures. Which diagnostic test should be performed next? Tested Concept

QID: 107415
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Rheumatoid factor

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(0/2)

2

Anti-cyclic citrullinated peptide antibody assay

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(0/2)

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Antinuclear antibody assay

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(0/2)

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HLA-B27

0%

(0/2)

5

Nucleic acid amplification testing for Chlamydia trachomatis

100%

(2/2)

M 6 D

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(M3.RH.16.82) A 32-year-old man comes into your office because of pain in his right knee, left elbow, and left wrist. It started about a week ago but has particularly localized to his wrist. The patient states that he has 2 sexual partners. He states he has also had some white discharge from his penis with pruritis and pain during urination. His temperature is 97.6°F (36.4°C), blood pressure is 124/84 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam reveals pain upon palpation of the patient's left wrist which also appears erythematous and swollen. What is the best next step in management for this patient? Tested Concept

QID: 103023
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Arthrocentesis

25%

(1/4)

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Azithromycin, ceftriaxone, and vancomycin

75%

(3/4)

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Ibuprofen and observation

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Methotrexate

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MRI

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(M3.RH.15.74) A 32-year-old man presents to his physician with a complaint of pain with urination that has developed and persisted over the past 8 days. Upon awakening today, he also noted a clear discharge from his urethra. The patient states he is otherwise healthy. Social history is notable for the patient working at a local farm with livestock. Review of systems is notable for left knee and ankle pain for the past week and worsening of his seasonal allergies with red and itchy eyes. His temperature is 97.7°F (36.5°C), blood pressure is 122/83 mmHg, pulse is 89/min, respirations are 14/min, and oxygen saturation is 98% on room air. Which of the following is likely to be positive in this patient? Tested Concept

QID: 103015
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Anti-CCP

0%

(0/15)

2

Anti-dsDNA

0%

(0/15)

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HLA-B27

27%

(4/15)

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HLA-DR4

73%

(11/15)

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p-ANCA

0%

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(M3.RH.15.66) A 29-year-old man presents to his primary care physician with complaints of pain in his joints. He states it started a few days ago and has persisted since. He states that he is otherwise healthy and is not currently taking any medications. The patient is in the military and is currently in basic training. Review of systems is notable for discomfort with urination. His temperature is 99.0°F (37.2°C), blood pressure is 133/90 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. The knee and ankle joints demonstrate pain with passive range of motion, but there are no signs of erythema, edema, or crepitus. Which of the following is the most likely diagnosis? Tested Concept

QID: 103007
FIGURES:
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Osteoarthritis

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Reactive arthritis

80%

(4/5)

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Rheumatoid arthritis

20%

(1/5)

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Septic arthritis

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(0/5)

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Stress fracture

0%

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M 11 E

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Evidence (5)
Topic COMMENTS (5)
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