Reactive arthritis is one of the seronegative spondyloarthropathies, so called because serum rheumatoid factor is not present in these forms of inflammatory arthritis. Its characteristic clinical course consists of urethritis, conjunctivitis, and arthritis. Hans Reiter was a Nazi war criminal, and many believe that he should no longer be given name recognition to designate this syndrome. Reactive arthritis is an asymmetric polyarthritis that affects mainly the lower extremities and is associated with one or more of the following:

• Urethritis
• Cervicitis
• Dysentery
• Inflammatory eye disease
• Mucocutaneous lesions

Reiter disease

Reiter syndrome

Seronegative spondyloarthropathy

• Polyarthritis:
  1. Affecting the knee and ankle
  2. Commonly asymmetric
• Heel pain and Achilles tendinitis, especially at the insertion of the Achilles tendon
• Plantar fasciitis
• Large effusions
• Dactylitis, or “sausage toe”
• Urethritis
• Uveitis or conjunctivitis; uveitis can progress to blindness without treatment
• Keratoderma blennorrhagicum, circinate balanitis:
  1. Hyperkeratotic lesions on soles of the feet (Fig. E1), toes, penis (Fig. E2), hands
  2. Closely resembles psoriasis
• Aortic regurgitation similar to that seen in ankylosing spondylitis

• Epidemic Reiter syndrome after outbreaks of dysentery has been well described.
• Genetically susceptible HLA-B27 individuals are at risk for developing reactive arthritis after infection with certain pathogens:
  1. Salmonella
  2. Shigella
  3. Yersinia enterocolitica
  4. Campylobacter jejuni
  5. Chlamydia trachomatis
• Symptom complex indistinguishable from reactive arthritis has been described in association with HIV infection.

• Ankylosing spondylitis
• Psoriatic arthritis
• Rheumatoid arthritis
• Gonococcal arthritis-tenosynovitis
• Rheumatic fever
• Serum sickness
• Gout
• Chronic mucocutaneous candidiasis

• X-ray examination of affected joints
• Synovial fluid examination and culture
• Careful examination of eyes and skin
• Cultures for gonococcus (urethral, cervical, stool)

• Elevated but nonspecific erythrocyte sedimentation rate
• No specific laboratory tests to diagnose reactive arthritis
• Do not use HLA-B27 testing as a diagnostic tool, as only positive in 30% to 50% of patients

Plain radiographs:

• Juxtaarticular osteopenia of affected joints
• Erosions and joint space narrowing in more advanced disease
• Periostitis and reactive new bone formation at the insertions of the Achilles tendon and the plantar fascia
• Sacroiliitis:
  1. Unilateral or bilateral
  2. Indistinguishable from ankylosing spondylitis
• Vertebral bridging osteophytes

Physical therapy to maintain range of motion of the spine and other joints

• Flares treated with NSAIDs such as indomethacin (25 to 50 mg by mouth [PO] tid). Refractory cases can be treated with methotrexate or infliximab.
• Mucocutaneous lesions are visually self-limited and clear with topical corticosteroids. Acitretin or cyclosporine can be used for refractory skin lesions.
• Enteric or urethral infection should be treated with appropriate antibiotic coverage.
• Uveitis should be treated with steroid eye drops in consultation with an ophthalmologist.
• Achilles tendinitis and plantar fasciitis should be treated with injections of methylprednisolone (40 to 80 mg).
• Sulfasalazine (500 to 1000 mg PO bid, then titrate up to maximum 3 g/day) may be effective.
• Careful monitoring for the following is essential:
  1. GI toxicity
  2. Hypersensitivity
  3. Bone marrow suppression
• Persistent and uncontrolled disease should be managed with cytotoxic drugs (methotrexate, azathioprine) in consultation with a rheumatologist.
• The role of tumor necrosis factor alpha inhibitors in therapy is evolving, but agents such as etanercept for 6 mo, adalimumab, or infliximab have been shown to be helpful in small studies.

Chronic disease is best managed by a team approach with the collaboration of a rheumatologist or other experienced physician and physical therapist.

• Recurrences are frequent, even with treatment.
• Long-term sequelae:
  1. Persistent polyarthritis
  2. Chronic back pain
  3. Heel pain
  4. Progressive iridocyclitis
  5. Aortic regurgitation

• To ophthalmologist if uveitis is suspected
• To rheumatologist if arthritis and tendinitis fail to improve rapidly after a course of NSAIDs

• Infection with HIV is associated with particularly severe cases of reactive arthritis.
• HIV testing is recommended, especially if risk factors such as unprotected sexual activity or intravenous drug use are identified.
• The role of antibiotics seems useful in Chlamydia-triggered arthritis, but the role of antibiotics in arthritis triggered by enteric pathogens is less clear.
• It has been suggested that altered microbiota may result in aberrant immune responses to gut flora, gut dysbiosis, inflammation, and thus to spondylarthritis.

Reiter Syndrome (Patient Information)