Reactive Arthritis (Reiter Syndrome) Treatment in Singapore

• Reactive arthritis (previously called Reiter syndrome) is a form of reactive, inflammatory arthritis classically associated with urogenital, ocular, mucocutaneous, and musculoskeletal involvement.
• This syndrome is categorized with the group of seronegative arthritides, along with AS, psoriatic arthritis, and enteropathic arthritis.
• Diagnosis often is overlooked because of its variable presentation and the similarities with other seronegative arthritides and with gonococcal arthritis.
• At examination, the classic triad of symptoms-urethritis (or cervicitis in females), conjunctivitis, and arthritis-often is not present or the symptoms of the urethritis or conjunctivitis are mild and not recognized or described by the patient.
• Moreover, cervicitis often is asymptomatic, thus making the probability of missing the diagnosis in females even greater.

• Barrier methods of contraception to prevent transmission of venereal disease
• Proper food handling and preparation to prevent food-borne infection

• HIV
• HLA-B27 haplotype
• Poor hygiene with associated exposure to enteric pathogens
• Increased sexual activity and thus wider exposure to sexually transmitted pathogens
• Geographic location, although this may be related to hygienic conditions and sexual behavior of the population

• The cause of the disease is thought to be an immune response to a sexually transmitted bacterial infection or to bacterial gastroenteritis.
• Most cases are transmitted sexually, as opposed to enterically.
• Organisms that have been associated with the disease include the following:
  • Chlamydia:
    • Chlamydia trachomatis and Chlamydia psittaci
    • Recent evidence shows that Chlamydia pneumoniae may be implicated.
  • Campylobacter fetus or Campylobacter fetus jejuni
  • Salmonella enteritidis, Salmonella heidelberg, or Salmonella paratyphi
  • Shigella flexneri
  • Ureaplasma urealyticum
  • Yersinia enterocolitica or Yersinia pseudotuberculosis
  • Giardia lamblia
  • Cryptosporidium

• The onset of the disease process generally occurs 2-4 weeks after enteric or sexually transmitted infection.
• Urethritis (classic presentation):
  • Often the initial feature of the disease
  • Males experience mild dysuria and/or a mucopurulent urethral discharge.
  • Females may have dysuria, vaginal discharge, with or without purulent cervicitis/vaginitis.
  • Genitourinary symptoms may evolve after sexual or enteric exposure.
• Conjunctivitis in 30-50% of patients:
  • Usually bilateral and can be as mild as onset of crusting of the eyelids each morning
  • As such, often unnoticed by patient and physician
  • Ocular involvement occurs along with urethral involvement, or within a few days of onset.
  • Less commonly seen but much more serious is unilateral, acute uveitis with associated severe ocular erythema and photophobia.
• Articular involvement:
  • Most commonly includes acute oligoarticular arthritis with effusion, marked tenderness, and overlying erythema; a marked blue discoloration also appears sometimes.
  • Pain on active and passive ROM
  • The average number of joints involved is 4:
    • 1 or 2 joints have more severe involvement than do the others.
  • Typically involves lower extremities (knees, ankles, feet) asymmetrically, although upper extremity involvement may be present.
  • Axial involvement, with spondylitis or sacroiliitis:
    • Much more common in the chronic form
  • Rarely involves hip
  • Back pain and buttock pain are common.
• Enthesopathies:
  • An enthesis is an insertion of a tendon or ligament into bone.
  • Very commonly involves the insertion of the Achilles tendon into the calcaneus or the plantar aponeurosis, causing characteristic heel pain
  • Involvement of the extensor hallucis longus or extensor digitorum longus tendons gives rise to sausage toes, a characteristic of reactive or psoriatic arthritis.
  • Although severe, the condition usually lasts only days to weeks before resolving.
• Skin and mucous membrane involvement occur weeks after the inciting infection in 1 of several typical lesions.
  • In keratoderma blennorrhagica, clear vesicles erupt on the palms and soles, then crust, forming hyperkeratotic lesions that look similar to psoriasis.
  • Circinate balanitis is marked by small vesicles about the margins of the glans penis that are painless and self-limited.
  • Small, painless, shallow erosions occur in the buccal mucosa.
  • Fingernails and toenails are opaque and thickened, and can crumble and resemble mycotic infection.

Tests

• The differential diagnosis must include the other seronegative spondyloarthropathies: Psoriatic arthritis; AS; enteropathic arthritis
• Psoriatic arthritis often presents with sausage digits, and enteropathic arthritis may be associated with gastrointestinal symptoms.
• The differential diagnosis also must include gonococcal arthritis, which may present with urethritis and is associated with a positive sexual history.

Special Therapy

Disposition

• The arthritis typically resolves over several months to a year and leaves no disability.
• 15% of patients have chronic disease, typically marked by chronic joint discomfort with occasional exacerbations that are less severe than the initial presentation.
  • Chronic arthritis may lead to permanent joint destruction and deformity.

Miscellaneous

FAQ