Reiters arthritis

It is a clinical syndrome triggered by a specific etiological agent in a susceptible host following enteric or urogenital infections targeting predominantly HLA-B27 +ve person

It is a triad of Arthritis ,urethritis,and uveitis plus mucocutaneous lesions

History Described by Hans Reiter in 1916

Epidemiology Prevalence world wide Incidence 30-40 /one lack More common in 18-40 yrs of age But all age group can suffer both sex equally affected slightly more common in males. Very severe form seen in patient of AIDS. Family clustering Strongly associated with HLA B27

Prevalence world wide

Incidence 30-40 /one lack

More common in 18-40 yrs of age

But all age group can suffer

both sex equally affected slightly more common in males.

Very severe form seen in patient of AIDS.

Family clustering

Strongly associated with HLA B27

Association of HLA B 27 and Spondyloarthropathies(in whites) -8% General healthy population -50% Acute iritis -70% UnspA -40-50% Psoriatic spA -35-75% Enteropathic spA -70% Juvenile spondyloarthropathy 40-80% ReA -90% Ankylosing spondylitis HLA B 27 prevalence Disease

Pathology Synovial histolgy is similar to inflammatory arthropathies. Enthesitis is very common Microscopic evidence of inflammation is seen colon and Ilium lesion Skin lesions similar to Psoriatic lesions

Synovial histolgy is similar to inflammatory arthropathies.

Enthesitis is very common

Microscopic evidence of inflammation is seen colon and Ilium lesion

Skin lesions similar to Psoriatic lesions

Etiology and pathogenesis Bacteria responsible for triggering disease are Shigella Sonnei Boyedii Flexneri dysenterioe Solmonella Y. Enterocolitica C.Trachomatis Closridium difficle Nesseria Gonorrhoea

Bacteria responsible for triggering disease are

Shigella

Sonnei

Boyedii

Flexneri

dysenterioe

Solmonella

Y. Enterocolitica

C.Trachomatis

Closridium difficle

Nesseria Gonorrhoea

Isolated reports of acute arthritis preceded by even viral and parasitic infection

Immune response inYersinia triggered arthritis Initial, weak IgM-class antibody production Later,strong and persisting IgG and IgA antibody production IgA ab.increases in avidity with time Ab. Are directd against several antigenic epitopes ofYersinia Nonspecific immune complex are always found in serum Specific Ic. Containing Yersinia and anti-Yersinia ab. May be found in se rum and synovial fluid Peripheral T cells shows weak response to Yersinia Tcells in synovial fluid shows vigrous but somewhat nonspecific response

Initial, weak IgM-class antibody production

Later,strong and persisting IgG and IgA antibody production

IgA ab.increases in avidity with time

Ab. Are directd against several antigenic epitopes ofYersinia

Nonspecific immune complex are always found in serum

Specific Ic. Containing Yersinia and anti-Yersinia ab. May be found in se rum and synovial fluid

Peripheral T cells shows weak response to Yersinia

Tcells in synovial fluid shows vigrous but somewhat nonspecific response

In summery advance in molecular research have revealed that an imbalance in inflammation cytokines is central in there pathogenesis

Clinical Features History A vast majority of cases of reactive arthritis are oligosymptomatic, and conjunctivitis or urethritis are present weeks before the patient's first visit A syndrome, with malaise, low-grade fever, and generalized myalgia or headache can be present

History

A vast majority of cases of reactive arthritis are oligosymptomatic, and conjunctivitis or urethritis are present weeks before the patient's first visit

A syndrome, with malaise, low-grade fever, and generalized myalgia or headache can be present

Symptoms of triggering infection would be mild in 9-10 % cases may go unnoticed

Manifestations of the urogenital system Circinate balanitis is characteristic. Circinate balanitis is defined by circinate or gyrate white plaques that grow centrifugally and eventually cover the entire surface of the glans penis. The penile shaft and scrotum can be involved. The lesions become rapidly keratotic in a circumcised penis. Circinate vulvitis is reported in women. Prostatitis, cystitis, and pyelonephritis are rare but possible urogenital manifestations of reactive arthritis. Bartholinitis can be present in women. Proctitis caused by Chlamydia species can occur in both sexes after anal intercourse.

Conjunctivitis Eye involvement is common. Conjunctivitis appears in approximately 50% of patients with reactive arthritis. Conjunctivitis is often bilateral, and it may be overlooked because of its transitory course. An intense red, velvetlike conjunctival injection characterizes the conjunctivitis. Edema and a purulent discharge are not rare in reactive arthritis–associated conjunctivitis.

Other ocular manifestations Iritis, iridocyclitis, and uveitis are seldom reported. Iritis is more common in late recurrent episodes, and it only occurs in 3-8% of patients in the first attack. At clinical examination, redness, pain, impaired vision, and exudation with hypopyon can suggest iritis. Recurrent episodes can lead to pupillary synechia and glaucoma. Keratitis rarely is reported.

Asymmetric Mono or oligoarthritis . Mostly knees,ankles and hips. Shoulders elbow,wrist,and small joints of hands and feet can also get involved Dactilitis is not uncommon Pain in sacroiliac region in late stage.

Asymmetric Mono or oligoarthritis . Mostly knees,ankles and hips.

Shoulders elbow,wrist,and small joints of hands and feet can also get involved

Dactilitis is not uncommon

Pain in sacroiliac region in late stage.

Enthesopathy (ie, inflammation at the tendinous insertion into bone) is common in reactive arthritis and in other seronegative arthritides (eg, plantar fasciitis, digital periostitis, Achilles tendinitis).

Cutaneous and mucus membrane involvement Erythema nodosum Keratoderma blenorrhagicum indistinguisible from psoariasis both clinically and histopathologically. Circinate balanitis ,cystitis and prostatitis

Erythema nodosum

Keratoderma blenorrhagicum indistinguisible from psoariasis both clinically and histopathologically.

Circinate balanitis ,cystitis and prostatitis

GIT Abd. Pain diarrhoea, iliocolonoscopic picture like U.C. or Crohns both micro and macroscopically.

Abd. Pain diarrhoea, iliocolonoscopic picture like U.C. or Crohns both micro and macroscopically.

Investigations ESR CRP CBC LFT RFT RAFactor Urine analysis ECG Joint fluid analysis Cellcount Crystals exlusion Gram stain Bact. Culture Bacterialculture Feces Urine or urethralswab Cervical sample throat Antibody determination at admission HLA B27 After 2-4 weeks Radiographs of affected joints ophthalmologicalexamination

ESR

CRP

CBC

LFT

RFT

RAFactor

Urine analysis

ECG

Joint fluid analysis

Cellcount

Crystals exlusion

Gram stain

Bact. Culture

Bacterialculture

Feces

Urine or urethralswab

Cervical sample

throat

Antibody determination at admission

HLA B27 After 2-4 weeks

Radiographs of affected joints

ophthalmologicalexamination

AIM of treatment Rapid control of inflammation Prevent tissue damage Improve QOL Try to achieve long term remission

Rapid control of inflammation

Prevent tissue damage

Improve QOL

Try to achieve long term remission

Treatment Antibodies if infections still persist Rest NSAIDs Intra-articular corticosteroids Systemic corticosteroids Rarely DMARDs

Antibodies if infections still persist

Rest

NSAIDs

Intra-articular corticosteroids

Systemic corticosteroids

Rarely DMARDs

Summery box Biologic agents are highly effective-modifying medications. currently licenced biologics target TNF α,interleukin-1,Tcell activation and Bcells. Biologic agents improve the s/s and QOL with RA,Crohn’s disease psoriasis and many orphan conditions. Needs vigilance for side effects. Treatment should be commenced early for ultimate outcome.

Biologic agents are highly effective-modifying medications.

currently licenced biologics target TNF α,interleukin-1,Tcell activation and Bcells.

Biologic agents improve the s/s and QOL with RA,Crohn’s disease psoriasis and many orphan conditions.

Needs vigilance for side effects.

Treatment should be commenced early for ultimate outcome.

Prognosis Generally good Urogenital and Eye symptoms can recure Severe destructive disease is rare

Generally good

Urogenital and Eye symptoms can recure

Severe destructive disease is rare