Reactive arthritis is an inflammatory joint arthritis largely characterized by joint inflammation triggered by infection. To date, no diagnostic or classification criteria have been established, but in 2014, the American College of Rheumatology issued general treatment guidelines for the condition which is on the spondyloarthritis spectrum, which includes ankylosing spondylitis, psoriatic arthritis and arthritis associated with inflammatory bowel diseases.
Manuela Di Franco, M.D., of the University of Rome, Italy, outlines the pathogenesis, natural history, prognosis and treatment options in a review article published last month in the journal Clinical and Experimental Rheumatology. In this article, we cover the highlights.
THE PRESENCE OF INFECTION
Reactive arthritis includes any arthritis that is triggered by an infection. In this case, the most common infections include Chlamydia trachomatis and gastro-related infections, including Shigella, Salmonella, Yersinia and Campylobacter.
It is more common in men and in men and women who carry the HLA-B27 gene. It typically presents as sacroiliitis, enthesopathy and asymmetrical oligoarthritis of the lower limbs. But also includes other features often associated with rheumatic conditions, such as urethritis, iritis, conjunctivitis and mucocutaneous lesions (balanitis, keratoderma blenorrhagicum).
There is also “non-classical” reactive arthritis in which infections caused by Borrelia, Brucella, Haemophilus, Leptospira, Mycobacteria, Neisseria, Staphylococcus, Streptococcus, Ureaplasma, BCG and Vibrio spp. These infections can cause polyarticular joint pain, but they are not associated with the HLA-B27 gene.
The most common presentation of reactive arthritis is monoarthritis or asymmetric oligoarthritis of the lower extremities. Typically, the symptoms start days to weeks following the primary infection.
While large joints are most often involved, the small joints of the hands can be affected too. The presence of plantar fasciitis or Achilles’ tendon enthesitis should raise the suspicion for reactive arthritis. Axial involvement is more common in HLA-B27 positive patients.
Extra articular involvement including uveitis may also be present. Skin and mucous membrane inflammation are more rare and cardiac involvement even more so.
Because of the broad spectrum of clinical manifestations, developing a validated set of diagnostic criteria is difficult for reactive arthritis.
Reactive arthritis carries a good prognosis and a self-limiting course with full recovery in three to five months. A smaller portion of reactive arthritis patients will develop a chronic course with symptoms for more than six months.
A small portion of reactive arthritis patients will go on to develop ankylosing spondylitis or radiological sacroiliitis. Clinicians should identify those with chronic symptoms early and institute aggressive treatment to prevent debilitating manifestations.
Poor prognostic signs include specific infections, HLA-B27 positivity, positive family history for spondyloarthritis or ankylosing spondylitis, and the presence of chronic gut inflammation. Salmonella induced reactive arthritis has been associated with a chronic course, as has Yersinia and Shigella triggered disease.
Data suggest that the prognosis is better for enteroarthritis than Chlamydia-induced reactive arthritis. The frequency of HLA-B27 among reactive arthritis patients ranges from 30-80 percent, and HLA-B27 carriers are more likely affected by severe disease, with frequent spine involvement, extra-articular features and a chronic course of arthritis.
Persistent gut inflammation appears to play a significant role in determining the course and prognosis of reactive arthritis.
See “Treatment” on next page…