Reactive Arthritis: Clinical Aspects and Medical Management
Section snippets
History of reactive arthritis
Considering the many terms and eponyms used in the literature to describe this condition, a brief review of the history of ReA is warranted. Although many attribute the earliest description of ReA to Hans Reiter in 1916, when he described the clinical triad of arthritis, nongonococcal urethritis, and conjunctivitis in a German soldier after an episode of bloody diarrhea,4 the syndrome also was described by two French physicians (Fiessinger and Leroy) in that same year.5 Therefore, it often was
Epidemiology
The lack of a disease definition or specific diagnostic criteria for ReA makes epidemiologic studies problematic.19, 20 An epidemiologic discussion of ReA not only should include the typical analyses of incidence and prevalence but also an analysis of attack rate, which is of equal importance. Because only a percentage of subjects exposed to the known causative organisms of ReA develop the disease, the attack rate refers to that percentage. The incidence, prevalence, and attack rate of ReA vary
Clinical features
The clinical features of ReA are well described and generally congruent for the postvenereal and the postenteric forms. The acute and chronic symptoms can include articular, tendon, mucosal, cutaneous, ocular, and occasionally cardiac manifestations (Table 1) or systemic features (fever, malaise, and weight loss); the latter usually are confined to the acute stage. Symptoms typically start within 1 to 4 weeks of the initial infection. As in the case of chlamydiae, however, the inciting
Triggering microbes
The triggering microbes of ReA are gram-negative bacteria with a lipopolysaccharide (LPS) component of their cell walls. All of these bacteria, or their bacterial products, have been demonstrated in the synovial tissue or fluid of patients who have ReA. This has been demonstrated in several studies involving many different laboratories.48, 49, 50, 51, 52, 53, 54, 55, 56 It is apparent that the entire bacteria or bacterial components traffic to the joints of patients who have ReA. Once these
Triggering Microbes Persist
The triggering microbes and their associated molecular biology in relation to arthritis, specifically ReA, are discussed elsewhere in this issue in the article by Gerard and colleagues. A brief review is warranted. PCR technology occasionally has demonstrated the presence of chromosomal DNA from the known triggers in the synovial tissue of patients who have the postdysentery form of ReA.48, 52, 53, 54 Recent studies from many laboratories have demonstrated that Ct and Cpn, such as Mycobacterium
Diagnostic tests
There are diagnostic criteria available, but these are broad and rely on clinical symptoms only. The American College of Rheumatology criteria, published in 1981, require the presence of a peripheral arthritis occurring in association with urethritis or cervicitis.2 The Third International Workshop on Reactive Arthritis in 1995 requires a peripheral arthritis with sacroiliac involvement and a preceding gastrointestinal or genitourinary infection.3 The current American College of Rheumatology
Nonsteroidal Anti-Inflammatory Drugs
A breadth of clinical experience suggests that nonsteroidal anti-inflammatory drugs (NSAIDs) help with the inflammatory arthritis associated with ReA, but there are no well-designed prospective trials analyzing their efficacy for this indication. Although helpful for the articular symptoms, they are not believed efficacious for the potential extra-articular symptoms of ReA. Data suggest that continuous use of NSAIDs might reduce radiographic progression for other types of SpAs, in particular
Summary
Although environmental exposures have been implicated as potential causes for nearly all chronic diseases, ReA is one of the few with a known bacterial trigger. This insight into disease initiation has led to significant advances in the pathophysiology of this condition. As disease pathophysiology often stays one step ahead of science, however, many of the mysteries that surrounded ReA remain unsolved, including the clinical implications of bacterial persistence. In similar fashion, HLA-B27 is
References (146)
Christopher Columbus: the first case of Reiter's disease in the old world?
Lancet
(1980)- et al.
Declining use of the eponym “Reiter's Syndrome” in the medical literature, 1998–2003
J Am Acad Dermatol
(2005) - et al.
Reactive arthritis: newer developments
Rheum Dis Clin North Am
(2003) Reactive arthritis: defined etiologies, emerging pathophysiology, and unresolved treatment
Infect Dis Clin North Am
(2006)- et al.
Walkerton Health Study Investigators. A gradient of acute gastroenteritis was characterized, to assess risk of long-term health sequelae after drinking bacterial-contaminated water
J Clin Epidemiol
(2006) - et al.
Screening for chlamydial infection
Am J Prev Med
(2001) A review on infection with Chlamydia trachomatis
Best Pract Res Clin Obstet Gynaecol
(2006)- et al.
Chlamydia pneumoniae present in the human synovium are viable and metabolically active
Microb Pathog
(2000) - et al.
Detection of Chlamydia trachomatis DNA in joints of reactive arthritis patients by polymerase chain reaction
Lancet
(1992) - et al.
Chlamydia and Reiter's syndrome (reactive arthritis)
Rheum Dis Clin North Am
(1992)
Reactive arthritis following an outbreak of Salmonella Bovismorbificans infection
J Infect
Campylobacter reactive arthritis: a systematic review
Semin Arthritis Rheum
Differential expression of three Chlamydia trachomatis hsp60-encoding genes in active vs. persistent infections
Microb Pathog
Apolipoprotein E4 enhances attachment of Chlamydophila (Chlamydia) pneumoniae elementary bodies to host cells
Microb Pathog
Reiter's syndrome and reactive arthritis
J Am Osteopath
Reiter's syndrome: evaluation of preliminary criteria for definite disease
Arthritis Rheum
Third International Workshop on Reactive Arthritis. 23–26 September 1995, Berlin, Germany
Ann Rheum Dis
Uber eine bisher unerkannate Spirochateninfektion (Spirochetosis arthritica)
Dtsch Med Wochenschr
Contribution a l'etude d'une epidemie de dysenterie dans le somme
Bull Mem Soc Med Hop Paris
Hippocratic writing
Reiter's syndrome
De l'arthrite dysenterique
Arch Med Gen Trop
Observation sur une metastase de gonorrhee
Ann Soc Med Prat de Montpellier
Pathological and surgical observations on diseases of the joints
Arthropaties recidivantes amythrophie generalize troubles trophiques multiples. D'origine blennofthalmique
Bull Mem Soc Med Hop Paris
On gonorrhoeal rheumatism. On gonorrhoeal ophthalmia
Lancet
Syndrome of unknown aetiology characterized by urethritis, conjunctivitis, and arthritis (so-called Reiter's Disease)
Trans Assoc Am Physicians
Should a war criminal be rewarded with eponymous distinction? The double life of Hans Reiter (1881–1969)
J Clin Rheumatol
Retraction of the suggestion to use the term “Reiter's syndrome” sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation
Arthritis Rheum
On the difficulties of establishing a consensus on the definition of and diagnostic investigations of reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3–6, 1999
J Rheumatol
Epidemiology of Reiter's syndrome in Rochester, Minnesota 1950-1980
Arthritis Rheum
Ten-year follow-up study on patients with Yersinia arthritis
Arthritis Rheum
Reactive arthritis (Reiter's syndrome)
Am Fam Physician
A comparison of self-reported joint symptoms following infection with different enteric pathogens: effect of HLA-B27
J Rheumatol
Reactive arthritis following culture-confirmed infections with bacterial enteric pathogens in Minnesota and Oregon: a population-based study
Ann Rheum Dis
Chlamydia trachomatis infections: progress and problems
J Infect Dis
Chlamydia pneumonia as a cause of reactive arthritis
Br J Rheumatol
Chlamydia pneumonia—a new causitive agent of reactive arthritis and undifferentiated oligoarthritis
Ann Rheum Dis
Chlamydia pneumoniae as a triggering infection in reactive arthritis
Rheumatology (Oxford)
Low incidence of reactive arthritis in children following a salmonella outbreak
Ann Rheum Dis
An outbreak of Campylobacter enteritis—a rheumatological followup survey
J Rheumatol
Reactive arthritis and Reiter's syndrome following and outbreak of gastroenteritis caused by Salmonella enteritidis
Clin Infect Dis
Symptomatic acute reactive arthritis after an outbreak of salmonella
J Rheumatol
Reactive arthritis in patients attending and urban sexually transmitted disease clinic
Arthritis Rheum
Human chlamydial infections: persistence, prevalence, and prospects for the future
Nat Sci et Soc
Estimated incidence and prevalence of genital Chlamydia trachomatis infections in the United States, 1996
Sex Transm Dis
Trends in incidence and morality in rheumatoid arthritis in Rochester, Minnesota, over a forty-year period
Arthritis Rheum
Annual incidence of inflammatory joint disease in a population based study in southern Sweden
Ann Rheum Dis
Change in the epidemiology of Reiter's syndrome (reactive arthritis) in the post-AIDS era? An analysis of cases appearing in the Greek Army
J Rheumatol
Cited by (165)
Man With Hip Pain
2022, Journal of Emergency MedicineCitation Excerpt :Genitourinary (C. trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, Neisseria gonorrhoeae) and gastrointestinal infections (Salmonella enterica, Shigella, Campylobacter jejuni, Yersinia) are the most commonly discovered etiologies (1,2). Human leukocyte antigen (HLA)-B27 plays an important role in disease severity and progression (3). Reactive arthritis most commonly presents with oligoarthritis, but also can present with polyarthritis or monoarthritis (4).
Comparison of immune checkpoint inhibitor-induced arthritis and reactive arthritis to inform therapeutic strategy
2022, Biomedicine and PharmacotherapyCutaneous manifestation of reactive arthritis
2020, Joint Bone SpineDiagnostic considerations in the clinical management of sudden swelling of the knee: a case report and review of the literature
2024, Journal of Medical Case ReportsImmunologic derangement caused by intestinal dysbiosis and stress is the intrinsic basis of reactive arthritis
2024, Zeitschrift fur RheumatologieReactive arthritis following COVID-19 current evidence, diagnosis, and management strategies
2023, Journal of Orthopaedic Surgery and Research