Updated: 7/13/2019

Reactive Arthritis

Topic
Review Topic
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Questions
5
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Evidence
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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 antiinflammatory 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)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.RH.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? Review Topic

QID: 103023
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Arthrocentesis

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Azithromycin, ceftriaxone, and vancomycin

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Ibuprofen and observation

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Methotrexate

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MRI

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(M3.RH.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? Review Topic

QID: 103007
FIGURES:
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Osteoarthritis

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Reactive arthritis

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Rheumatoid arthritis

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(1/1)

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Septic arthritis

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Stress fracture

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(M3.RH.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? Review Topic

QID: 103015
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Anti-CCP

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Anti-dsDNA

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HLA-B27

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HLA-DR4

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p-ANCA

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(M2.RH.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? Review Topic

QID: 107415
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Rheumatoid factor

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Anti-cyclic citrullinated peptide antibody assay

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Antinuclear antibody assay

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HLA-B27

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Nucleic acid amplification testing for Chlamydia trachomatis

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