Download Reactive Arthritis

Reactive Arthritis
Andres Quiceno, MD
Rheumatology Division
Presbyterian Hospital of Dallas
Reactive Arthritis
 32 y/o WM admitted to the hospital with 2 days of acute
onset of arthritis in his right knee that progressed to the
left knee. The day previous to the admission, he was
evaluated in the ER, and an arthrocenthesis was
attempted. The patient was discharged on Keflex 500
mg QID and Hydrocodone.
 ROS: 3 weeks previous to admission he had an episode
of diarrhea that lasted for 10 days and improved after
treatment with Cipro.
 Family History: Sister with recurrent uveitis.
Reactive Arthritis
 PE: fever 101. Otherwise within normal limits.
 Joint exam: tenderness, redness and effusions in both
knees.
 Labs: ESR 60, Synovial fluid showed no crystals and
Gram stain revealed no organisms. HLA B-27 positive.
 Patient was started on indomethacin 50 mg PO QID with
significant improvement of his symptoms.
Reactive Arthritis
 “Reactive Arthritis (ReA) is an infectious induced
systemic illness characterized by an aseptic
inflammatory joint involvement occurring in a genetically
predisposed patient with a bacterial infection localized in
a distant organ/system”.
Reactive Arthritis
 Epidemiology
 ReA is an acute and insidious polyarthritis after an
enteric and urogenital infections.
 Incidence varies widely (1% to 20%).
 Frequency varies from 0 to 15% after infection with
Salmonella, Shigella, Campylobacter or Yersinia.
 HLA-B27 can be present in 72% to 84% of the cases.
 Incidence after Chlamydia trachomatis is not well
known.
Reactive Arthritis
 ReA can occurs in the absence of HLA-B27, this play a
very important role.
 HLA-B27 probably works as an antigen presenting
molecule.
 Comparison of ReA with IBD had suggest a possible
common antigen associated to the gut flora.
 An ineffective immune response seems to play a very
important role.
 Th1 cytokines such us IL-12, INF-gamma and TNF-alpha
are essential for the clearance of bacteria.
Reactive Arthritis
 In patients with ReA, they have an elevated production
of Th2 cytokines, such us IL-10 and a possible decrease
production in Th1 cytokines.
 All these factors cause a decrease in the effective
clearance of bacteria.
 Macrophages, CD4+ and CD8+ lymphocytes are
activated in the joints of this patients.
 Some bacterial antigens like heat shock protein 60
present in Chlamydia and Yersinia.
 Molecular cross reactive has been also associated.
Reactive Arthritis
 Causative organisms
 Frequent association:









Chlamydial trachomatis
Ureaplasma urealyticum
Salmonella enteritidis
Salmonella typhimurium
Shigella flexneri
Shigella dysenteriae
Campylobacter jejuni
Yersinia enterocolitica
Streptococcus SP
Reactive Arthritis
 Less common association:











Chlamydia pneumoniae
Neisseria meningitidis serogroup B
Bacillus cereus
Pseudomonas
Clostridium difficile
Borrelia burgdorferi
Escherichia coli
Helicobacter pillory
Lactobacillus
Brucella abortus
Hafnia alvei
Reactive Arthritis
 Clinical Manifestations:
 Postenteric ReA is described equally in men an women.
 Postchlamydial is most common in men.
 In patients with postenteric ReA, the episode of diarrhea
is usually prolonged.
 Arthritis presents usually 2 to 3 weeks after the episode
of diarrhea.
 Arthritis usually resolves within 6 months, but a few
patients had recurrences an a minority develops a
chronic arthritis.
Reactive Arthritis
 In patients with postchlamydial disease, urethritis is
usually mild, painless and nonpurulent.
 Conjunctivitis is usually observed very early, before the
onset of arthritis, uveitis is less common but occurs in
15% of patients with chronic persistent disease.
 Skin manifestations include: Keratoderma blenorrhagica,
Circinate balanitis and oral ulcers.
 Less common patients can develop valvulitis, rhythm
disturbances.
Reactive Arthritis
 Treatment:
 NSAIDS are the first line of treatment.
 In patient with frequent recurrences or chronic arthritis
benefit from DMARDS such us sulfasalazine or
methotrexate.
 If there is axial involvement they will benefit from TNFalpha blockers.
 Topical steroids are indicated in conjunctivitis and
uveitis.
 In monoarthritis steroid injections could be beneficial.