The patient presented with acute arthritis in both knees after experiencing diarrhea for 10 days previously. He also had red eyes for a week. Examination found joint tenderness, redness and effusions in both knees. Tests found elevated ESR and CRP but no crystals or organisms in synovial fluid. He was HLA-B27 positive. He was diagnosed with reactive arthritis triggered by a previous enteric infection, as evidenced by his diarrhea, and was started on indomethacin with improvement of symptoms.

1. Presented By: Dr Bushu Harna
Fellow OrthoRheumatology

2.  36 y/o gentleman admitted to the hospital with 2 days of
acute onset of arthritis in his right knee that progressed to
the left knee. The patient was investigated and discharged
on Paracetamol + Ibroprofen TDS. But not responded well.
 Patient had red eyes for past 7 days

3.  Past History: 3 weeks previous to admission he had
an episode of diarrhea that lasted for 10 days and
improved after treatment with Ciprofloxacin.
 Family History: Sister had a similar episode 2 years
back

4. General Examination: fever 1010 F. Otherwise within
normal limits.
Joint exam: tenderness, redness and effusions in both
knees.
Labs: Normal CBC, ESR 60, CRP 32. Synovial fluid
showed no crystals and Gram stain revealed no
organisms.
RA Factor: Negative. HLA B-27 positive.
Eye Examination: Anterior Uvetitis
Patient was started on indomethacin 50 mg PO QID
with significant improvement of his symptoms.

5.  “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”.

6. What’s So Reactive??
to infection
 First described by Hans Reiter in 1916. Also known as
Reiter Syndrome
 Triad: Arthritis, Urethritis, Conjunctivitis
 Name changed to Reactive Arthritis
Postinfectious
arthritis
nongonococca
l
 Aberrant autoimmune resp
uo
rn
et
sh
eritis
conjunctivitis

7. EPIDEMIOLOGY
 Occurs in 20-40 years.
 Begins with an enteric, urogenital or upper respiratory
tract infections.
 M:F::3:1
 Arthritis occurs few days to 6 weeks after infection
 30-70% positive for HLA-B27.
 Incidence more in urethritis, cervicitis and infectious
diarrhea.
 Incidence varies widely (1% to 20%).
 Frequency varies after infection with Salmonella,
Shigella, Campylobacter or Yersinia.

8.  1. Microbes-host interaction.
Components of triggering bacteria includes protein and
nucleic acid. These can be found in the synovium and
circulatory monocytes.

9.  2. Role of immune system
In patients with ReA, they have an elevated production of
Th2 cytokines, such us IL-10 and a possible decrease
production in Th1 cytokines.
Macrophages, CD4+ and CD8+ lymphocytes are
activated in the joints of the patients.
Some bacterial antigens like heat shock protein 60
present in Chlamydia and Yersinia.
Molecular cross reactive has been also associated
 All these factors cause a decrease in the effective
clearance of bacteria.

10. 3. Immunogenetics
HLA-B27 probably works as an antigen presenting
molecule.
Some arthritogenic peptide from chlamydia and yersinia
can be presented by HLA-B27 leading to stimulation of
CD8+ T cells.
 IFN-gamma: low level
 IL-10: High level

11.  Causative organisms
 Chlamydial trachomatis
 Ureaplasma urealyticum
 Salmonella enteritidis
 Salmonella typhimurium
 Shigella flexneri
 Shigella dysenteriae
 Campylobacter jejuni
 Yersinia enterocolitica
 Streptococcus SP
Urethritis
Enteritis

12.  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

13. Clinical Manifestations:
 Infection: History: diarrhea, urethritis, cervicitis,
STDs
 Postenteric ReA is described equally in men an women.
 The episode of diarrhea is usually prolonged.
 Postchlamydial is most common in men.
 In females episodes of cervicitis, vaginitis can precede.

14.  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.

15. Arthritis pattern
 Asymmetric mono or oligo arthritis often of lower
limbs including knees, ankles and feet.
 Musculoskeletal: peripheral arthritis, inflammatory
pain in cervical, thoracic, and lumbar spine
 Sacroilitis
 Enthesitis: plantar facisitis, heel pain, patellar tendon
insertion pain, GT hip pain, base 5th MT, MT head pain
 Sausage digits: IP joints with digital tendonitis and
multiple entheseal lesion

16.  Predictors of more severe disease: hip arthritis,
ESR>30, poor response to NSAIDS, Lumbar spine
stiffness, dactylitis, oligoarthritis, <16 years.
 In HLA-B27 positive patients: more severity and
increased markers like ESR and CRP.

17.  Eye: conjunctivitis, anterior uveitis, episcleritis and
keratitis
 Genitourinary: urethritis, cervicitis, prostatitis,
cystitis, circinate balanitis, salpingo-oophoritis
 Mucosal and skin: mucosal ulcers, keratoderma
blenorrhagica, erythema nodosum
 Cardiac
 Nail changes: onycholysis, subungual keratosis, nail
pits

18.  Mono or oligo arthropathy: RA, AS, Ps arthritis
 Gonococcal arthritis
 Gouty arthritis
 Septic arthritis
 Rheumatic fever
 Tubercular arthritis
 Secondary syphilis
 Rare: IBD, celiac, whipple disease and behcet
disease, immunotherapy related arthropathy

19. Bases on observational data from Germany and Scandinavia
*
 Mono or oligo arthritis
 Exclusion of other diagnosis
Both criteria present: probability is 40%.
 Evidence of previous infection
Then chances are 60%.
 If the bacteria can be culture, then 70%
 If there is history of symptomatic preceding infection with
Chlamdydia trachomatis, then 90%
*Sieper J, Rudwaleit M, Braun J, et al. Diagnosing reactive arthritis: Role of clinical

20. Definitive: Both Major criteria + 1 Minor Criteria
Probable: Both Major criteria

21.  Lab: raised ESR and CRP
 Neutrophilic leukocytosis
 HLA-B27
 Rule out: RF, ANA, Gram staining and culture of the joint
fluid, HIV
 Radiographs: Not required to diagnose. A large bulky
paravertebral area of ossification "floating osteophyte" is often seen.
Early juxta-articular osteoporosis, uniform joint space loss and
fusiform soft tissue swelling.
 Ultrasound
 Scintigraphy
 MRI

22.  Others: ECG, ophthalmological examination, urine
and stool examination, Nucleic acid amplification
tests
 Histopathological dermal features similar to
psoriasis.
 Synovial fluid reveals large macrophages, reiter cell
that have phagocytosed neutrophils, lymphocytes and
plasma cells. Extensive pannus formation is rare.

24.  Goal
1. Decrease pain and inflammation
2. Minimize disability
3. Prevent relapse or progression to chronic disease
 Team effort
 Patient education
 Early diagnosis and treatment

25.  Acute: RICE, NSAIDs, orthotics
 Intra-articular glucocorticoid injection
 Systemic corticosteroids and Topical Steroids
 Antibiotics
 DMARDs: Methotrexate, SSZ
 Anti-TNF agents: Etanercept, Infliximab

26.  It can be self limiting, recurrent or chronic
 Depends on triggering pathogen and genetic
background of the host.
 Chronic arthritis (>6months) occurs in 4-19% patients.
(arthritis caused by salmonella or shigella).
 Chronic relapsing arthritis is seen in 6-8% patients
(induced by salmonella, shigella or chlamydia).

28.  Good history taking: Past history and family
history
 Good General Physical Examination: EYE,
NAIL, SKIN
 Exclude other Spondyloarthropathy
 Involve Physician & Rheumatologist
 NSAIDs, Steroids and DMARDs form the main
basis of treatment.

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