Case history of diagnosis and treatment of a patient with reactive arthritis. Presentation at London South Bank University Bi-annual Non Medical Prescribing Update 15th January 2017

1. The perils of chicken vindaloo
Re-active arthritis
Linda Nazarko
MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN
Consultant Nurse West London Mental Health Trust
Nurse Prescribing; LSBU 15th March 2017

2. Aims and objectives
To be aware of:
 The value of listening to the patient
 The importance of history taking
 The value of physical examination
 How to nail the diagnosis
 How to work within scope of practice
 Determining treatment options
 The value of nurses practicing at advanced
level

3. Clinical presentation
 30 year old single
man
 Had a chicken
vindaloo three
weeks ago, hasn’t
been the same
since.
 Feels as if he’s
been “hit by a
truck”

4. Calgary- Cambridge Model

5. Formulating the diagnosis

6. Medical and social history
 Single, has a steady girl friend planning
to get engaged next year.
 Sharing a flat with a colleague
 Works as a web designer
 Normally fit and well diarrhoea after a
chicken vindaloo. Now settled.
 Did 10 kilometre runs and was training
for the London Marathon.

7. Presenting problems
 Red sore eyes - difficult to read,
bright light hurts & eyes are watering
a lot.
 Stiff sore swollen knees walking is
a struggle, feels like “an old man”
 Dysuria – difficulty passing urine &
painful to pee

8. Mr McKenzie’s perspective
 “ I was fine till I had that vindaloo.
Nobody else was ill but I was the only
one who had chicken”
 “I was fit and healthy and now I feel
like I’ve been hit by a truck”
 “ I don’t think I have an STD Lucy is my
only partner..”

9. Mr McKenzie’s hopes and aspirations
“ I want to know what is wrong with
me and I want to get better”.

10. Physical examination
HENT= normal
Cranial nerves intact
Eyes red and sore, optic discs normal. Examination difficult
Chest clear, heart sounds normal unable to detect any indication of
aortic regurgitation.
Genito-urinary examination - meatal oedema, no discharge, tender
testes.
Mild back pain.
Knees hot, red, swollen and there were small effusions. Observations
of temperature, blood pressure, pulse, respirations, and 02 saturations
were within normal limits. Slightly elevated pulse.
Weight 77kg. BMI 23.

11. Possible red flags
 Anterior Uveitis
 Hot swollen joints with
effusions
 Dysuria and mild meatal
oedema
 Testicular tenderness

12. Differential diagnosis- reactive arthritis
 History and clinical examination suggest that he has re-active
arthritis (ReA) but we need to rule out other possible causes. These
are:
 Gonorrhea with gonococcal arthritis and other types of infectious
urethritis. A urethral swab can be used to check. It’s important to be
aware that gonococcal arthritis does not affect the spine.
 Rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.
Exacerbation of existing ankylosing spondylitis preceded by
diarrhoea is reported to have similar clinical features
 Septic arthritis and pyogenic arthritis can mimic ReA. Septic arthritis
must be ruled out if suspected as failure to treat septic arthritis
appropriately in a timely manner could result in joint destruction

13. What is reactive arthritis?
 Reactive arthritis was describe by Reiter in 1916 and was formerly
known as Reiter’s syndrome. This autoimmune condition can occur
post infection typically genito-urinary infections and gastro-intestinal
infections. It is associated with the HLA-B27 haplotype. This protein
is found on the surface of white blood cells and predisposes to
certain auto-immune diseases.
 It is associated with a number of symptoms including the classic
triad of non-infectious urethritis, arthritis and conjunctivitis.
Around a third of patients demonstrate all three classical features
"can't see, can't pee, can't climb a tree"
 It is underdiagnosed and researched & is thought to affect between
0.6-27 people per 100,000.

14. Diagnosis
 No diagnostic tests to confirm, dx based on history & clinical
examination. Investigations that are often performed are:
 Full blood count & CRP
 Blood, urine and stool and wound cultures to detect any causative
organisms which may require treatment such as gastro-intestinal or
genito-urinal infection.
 Urinalysis
 Human leukocyte antigen (HLA)–B27. On average 75% of people
with ReA are positive to HLA-B27.
 HIV testing. People with HIV are at increased risk of inflammatory
arthritis and ReA and likely to have severe symptoms that require
specific treatment
 Echocardiography. Around 1-2% of people with ReA develop aortic
regurgitation.

15. Treatment options
• To treat triggering infection if
necessary
Antibiotic
• To settle inflammation and treat pain-NSAIDS
• Corticosteroids may be used topically,
intra-articularly and systemically.
Corticosteroids
• May be used when NSAIDs are
ineffective or contraindicated
Disease-modifying anti-
rheumatic drugs
(DMARDs)

16. Treatment
 Antibiotic therapy may be used to treat the
triggering infection
 No specific treatment for ReA
 Management is based on symptom severity.
Standard treatment normally consists of
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Corticosteroids may be used topically, intra-
articularly and systemically. Disease-modifying
anti-rheumatic drugs (DMARDs) – may be used
when NSAIDs are ineffective or contraindicated
 Around 2/3 of patients recover spontaneously
however around 30% develop chronic symptoms.

17. Anterior uveitis.
 “Uveitis is inflammation of the uveal tract,
with or without inflammation of neighbouring
structures”
 Occurs in 12-37% of patients with ReA.
 Is one of the leading causes of preventable
severe visual loss in developed countries

18. Anterior uveitis & conjunctivitis
How to differentiate
Anterior uveitis Conjunctivitis
Red eye Red eye
Pain that worsens when
trying to read
Mucoid discharge
Progressive - occurs over
a few hours/days.
Feeling of grittiness
Blurred vision.
Photophobia.
Excess tear production
Abnormally shaped pupils

19. Diagnosis & treatment of anterior uveitis
 Slit lamp examination of the posterior segment of the eye is required
to check for the presence of posterior uveitis.
 ReA associated uveitis can lead to the adhesion of the iris to the
surface of the lens or vitreous body and the development of angle-
closure glaucoma and blindness.
 Those with suspected uveitis must be referred to an ophthalmologist
within 24 hours, delay in appropriate management can lead to the
development of significant complications and irreversible loss of
vision.
 Management of ocular complications is dependent on the type of
uveitis, whether it is secondary to infection, whether it is likely to
threaten sight and severity of symptoms. Treatment may include
topical, oral and/or intravenous steroid treatment.

20. Scope of practice
 The nurse is required to
work within the limits of
competence and make
a timely and
appropriate referral to
another practitioner
when it is in the best
interests of the
individual requiring care
and treatment

21. Emergency referral
 Mr McKenzie was seen in the emergency
ophthalmic clinic.
 He was treated with oral and topical steroids.

22. Was it the chicken vindaloo?
 Possibly – he may
have developed ReA
following a
campylobacter
infection caused by
eating chicken. He
was positive to HLA-
B27 and genetically
susceptible to ReA

23. Patient progress
 Responded well to oral and
topical steroids.
 Now fully recovered and
running again
 Has decided to stick to
Chinese food when eating out
and to avoid chicken!

24. Take home messages
 ReA can be difficult to diagnose unless clinicians are
alert to its clinical features
 Careful history taking and examination can help ensure
accurate diagnosis
 Most cases resolve spontaneously though causative
infections may require treatment
 Most cases are managed with symptomatic treatment
such as NSAIDS
 Clinicians should be alert to complications, work within
their sphere of competency and refer appropriately.

25. The value of advanced practice
Nurses practicing at advanced level:
 Raise the bar for all nurses
 Are able to see, diagnose and treat
 Are registered, educated and accountable
 Reduce pressures in acute and primary care
 Improve quality of care
So why are physician's assistants being
considered as the solution in primary care?

26. Thank you for listening
Any questions?