Reactive Arthritis Andres Quiceno, MD Rheumatology Division Presbyterian Hospital of Dallas

Reactive Arthritis z32 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. zROS: 3 weeks previous to admission he had an episode of diarrhea that lasted for 10 days and improved after treatment with Cipro. zFamily History: Sister with recurrent uveitis.

Reactive Arthritis zPE: fever 101. Otherwise within normal limits. zJoint exam: tenderness, redness and effusions in both knees. zLabs: ESR 60, Synovial fluid showed no crystals and Gram stain revealed no organisms. HLA B-27 positive. zPatient was started on indomethacin 50 mg PO QID with significant improvement of his symptoms.

Reactive Arthritis z“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 zEpidemiology zReA is an acute and insidious polyarthritis after an enteric and urogenital infections. zIncidence varies widely (1% to 20%). zFrequency varies from 0 to 15% after infection with Salmonella, Shigella, Campylobacter or Yersinia. zHLA-B27 can be present in 72% to 84% of the cases. zIncidence after Chlamydia trachomatis is not well known.

Reactive Arthritis zReA can occurs in the absence of HLA-B27, this play a very important role. zHLA-B27 probably works as an antigen presenting molecule. zComparison of ReA with IBD had suggest a possible common antigen associated to the gut flora. zAn ineffective immune response seems to play a very important role. zTh1 cytokines such us IL-12, INF-gamma and TNF-alpha are essential for the clearance of bacteria.

Reactive Arthritis zIn patients with ReA, they have an elevated production of Th2 cytokines, such us IL-10 and a possible decrease production in Th1 cytokines. zAll these factors cause a decrease in the effective clearance of bacteria. zMacrophages, CD4+ and CD8+ lymphocytes are activated in the joints of this patients. zSome bacterial antigens like heat shock protein 60 present in Chlamydia and Yersinia. zMolecular cross reactive has been also associated.

Reactive Arthritis zCausative organisms zFrequent association: zChlamydial trachomatis zUreaplasma urealyticum zSalmonella enteritidis zSalmonella typhimurium zShigella flexneri zShigella dysenteriae zCampylobacter jejuni zYersinia enterocolitica zStreptococcus SP

Reactive Arthritis zLess common association: zChlamydia pneumoniae zNeisseria meningitidis serogroup B zBacillus cereus zPseudomonas zClostridium difficile zBorrelia burgdorferi zEscherichia coli zHelicobacter pillory zLactobacillus zBrucella abortus zHafnia alvei

Reactive Arthritis zClinical Manifestations: zPostenteric ReA is described equally in men an women. zPostchlamydial is most common in men. zIn patients with postenteric ReA, the episode of diarrhea is usually prolonged. zArthritis presents usually 2 to 3 weeks after the episode of diarrhea. zArthritis usually resolves within 6 months, but a few patients had recurrences an a minority develops a chronic arthritis.

Reactive Arthritis zIn patients with postchlamydial disease, urethritis is usually mild, painless and nonpurulent. zConjunctivitis is usually observed very early, before the onset of arthritis, uveitis is less common but occurs in 15% of patients with chronic persistent disease. zSkin manifestations include: Keratoderma blenorrhagica, Circinate balanitis and oral ulcers. zLess common patients can develop valvulitis, rhythm disturbances.

Reactive Arthritis zTreatment: zNSAIDS are the first line of treatment. zIn patient with frequent recurrences or chronic arthritis benefit from DMARDS such us sulfasalazine or methotrexate. zIf there is axial involvement they will benefit from TNF- alpha blockers. zTopical steroids are indicated in conjunctivitis and uveitis. zIn monoarthritis steroid injections could be beneficial.