Dr.Khudair Al-bedri Consultant Rheumatology & Internal Medicine . Assistant Professor Dr.Khudair Al-bedri Consultant Rheumatology & Internal Medicine .

Reactive Arthritis

Reactive arthritis Reactive arthritis is an acute aseptic arthritis that develops in response to an extra –articular infection ,typically originatingfrom gastrointestinal or genitourinary tract. It is aseronegative spondyloathropathy classically presenting with asymmetrical oligoarthritis, usually in the lower limbs.

Pathophysiology Reactive arthritis is thought to be caused by an infectious trigger usually a bacterial GI or GU infection in genetically individuals. This leads to immune activation and cross-reactivity with self-antigens causing acute inflammation in the affected joint and other tissues approximately 2-6 weeks after the initial infection. GI infection (Salmonella ,Yersinia, Shigella and Campylobacter ). GU infection (Chlamydia).

Pathophysiology As well as inflammation of joints ,inflammation of entheses,axial skeleton,skin,mucous membranes ,GI tract and eyes may also occur. HLA-B27 is positive in most patients and its not only a strong risk factor of reactive arthritis , but it may also predict the severity and chronicity of the disease. 20% of HLA-B27 positive men will develop Reactive Arthritis if they are exposed to an epidemic of Shigella dysentery.

Risk factors for reactive arthritis. Reactive arthritis occurs after exposure to certain GI or GU infections. GI/GU infection There is a 9:1 male : female incidence ratio of Chlamydia –induced reactive arthritis and 1:1 for post-dysentery reactive arthritis. Gender HLA-B27 is positive in approximately 75% of reactive arthritis patients . HLA-B27 Most patients with reactive arthritis are aged 20-40 . Age Reactive arthritis is more common in Caucasians. Ethnicity

ReA, Clinical Features 1 Reactive Arthritis characteristically involves the lower limbs with asymmetrical oligoarthritis, the pattern may be additive. Hip disease is uncommon. Exclusive upper extremities involvement is extremely rare. Dactylitis pattern in the feet is uncommon. Arthritis is sterile synovitis.

ReA, Clinical Features 2 Enthesitis is a characteristic of Reactive Arthritis, Achilles‘ tendonitis and plantar fasciitis are most common sites of involvement, but pain in the iliac crest and ischial tuberosities is also detected. Low back pain and buttock pain reflecting sacroiliitis occurs in up to 50%, but progression to AS is an uncommon and late event & it is strongly associated with HLA-B27.

Clinical Features3 Lower back pain due to sacroiliitis and spondylitis. Reiter’s syndrome –triad of reactive arthritis , conjunctivitis and urethritis .Although rare, it follows a GU or GI infection .

ReA, Extra-atricular Features 1 Extra-articular features can be helpful in establishing the diagnosis particularly in circumstances when it is difficult to identify a triggering infection. Keratoderma blenorrhagicum (15%) is papulosequamous rash most commonly affecting the palms and soles. The lesions can be indistinguishable clinically and histopathologically from pustular psoriasis.

ReA, Extra-atricular Features 2 Nail dystrophy can occur with ReA (Reactive Arthritis), further highlightening the clinical overlap of some features with PsA. Circinate balanitis occurs in (20-50%) of patients and is usually painless. Buccal erosions occurs in (10%) and are usually painless red patches. Oral ulcers on the hard palate or tongue, typically painless. Dysuria and pyuria present clinical features of urethritis. Acute anterior uveitis occurs in 20% of ReA patients, And usually unilateral . Conjunctivitis usually bilateral.

ReA, Clinical Features 3 Google circinate balanitis

ReA, Uncommon Complications Aortic Incompetence. Conductive Defect. Pleuro-pericarditis. Peripheral Neuropathy. Seizures. Amyloidosis.

ReA, Investigations ESR and CRP are raised. RF and ANA are negative. Normochromic normocytic anaemia. Sterile and inflammatory synovitis. Stool culture. Urine culture. Urethral culture. High vaginal swab. Radiological, the most important findings are: Fluffy calcaneal spur. Asymmetrical and unilateral sacroiliac joint involvement.

ReA, Treatment NSAIDS. Local and intra-articular steroid injection. Topical and systemic steroids for anterior uveitis. ReA after 4/52 of treatment without improvement (persistent synovitis): Sulfasalazine and Mehtotrexate are used. Antibiotics for infections. Anti-TNF-a therapy.

ReA, Prognosis The first attack of arthritis is self-limiting with spontaneous remission within 2-4/12 of onset, representing (60%) of patients. 15% of patients of ReA relapse. 15% of patients of ReA continue to a chronic state. 10% of patients develop ankylosing spondylosis. Mortality in ReA results from cardiac complications and amyloidosis.

Arthritis associated with inflammatory bowel disease

Clinical Features 1 Peripheral oligoarthritis is found in 10-20% of patients with IBD (12% in UC and 20% in CD). Enteropathic arhtritis is arthritis of lower limb joints both large & small, asymmetrical, migratory & less often additive. Deformity is rare Peripheral arthritis reflects activity of IBD & subsides with treatment of IBD & colectomy lead to permanent remission of arthritis. HLA-B27 is not associated with CD. IBD = Inflammatory bowel disease UC= Ulcerative colitis CD= Crohn’s disease

Clinical Features 2 Axial involvement (sacroiliac involvement & spondylitis) is found in 10% of patients: Asymptomatic. Males develop complications > females. Does not reflect disease activity. Runs an independent course so may precede bowel and peripheral manifestations. Colectomy does not halt its progression. HLA-B27 association in 50% of patients.

Non-Articular Complications 1 1) Skin lesions (25%): Erythema nodosum: mirrors activity of bowel disease. Pyoderma gangrenosum: is painful deep skin ulceration & is a more serious skin manifestation but it is less common. Recurrent oral ulceration may reflect activity of CD.

Non-Articular Complications 2

Non-Articular Complications 3 2) Anterior uveitis (acute) (11%): Usually unilateral & transient pattern of eye inflammation characteristic of SPA patients. CD may also be associated with granulomatous uveitis that is more chronic. SPA = Sponarthritis

Treatment NSAIDs may exacerbate underlying IBD particularly UC. NSAIDs-related side effect events also mimic flare of IBD & complicate management. Sulfasalazine treats colonic inflammation & peripheral, but not axial, arthritis. Local steroid. Systemic steroid may flare CD. Antitumor necrosis factor: Infliximab affect joints (axial & peripheral) & bowel. Etanercept affects arthritis but not bowel.

Presentation created by Dr. M. Sahib Thank You!