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A. Properties

  1. Transient, non-infectious Arthritis
  2. Associated with HLA-B27 (37X risk increase in persons with B27)
  3. Most commonly follows Chlamydia trachomatis
  4. Also Occurs with Bacterial Enteritis
    1. Salmonella ssp [2]
    2. Shigella ssp
    3. Yersinia enterocolitica [3] and Y pseudotuberculosis
    4. Campylobacter jejuni
    5. Clostridium difficile [4]
  5. May follow intravesicular (bladder) injection of bacille Calmette-Guerin (BCG)
  6. Symptoms
    1. Duration of mainly peripheral arthritis typically 4-5 months
    2. ~65% of patients have persistent (usually mild) symptoms for ~1 year
    3. Resolution of enteritis does not necessarily correlate with arthritis symptoms
    4. Recurrent attacks most common in patients with chlamydial associated disease

B. Post-Salmonella Arthritis [2]

  1. Food poisoning episode with 423 subjects studied in Ontario in 1984
  2. ~6% of affected persons developed post-infectious arthritis (reactive arthritis)
  3. Arthritis resolved within 4 months in 1/3 of the affected patients
  4. Objective joint changes in sacroiliac, knees, hands in 37% of arthritis patients after 5 years
  5. Joints Involved: Low Back > Knee > Elbow = Shoulders > Hands > Heel Pain
  6. IgA anti-lipopolysaccharide Ab titer correlated with severity and duration of disease

C. C. Difficle Associated Arthritis [4]

  1. Usually occurs 1-2 weeks after onset of enteric infection
  2. Causes an asymmetric polyarthritis which may be migratory
  3. Usually involves large joints, but wrist and fingers may be involved
  4. Synovial fluid shows WBC 2-70K/µL, mainly neutrophils
  5. About 60% of patients are positive for HLA-B27
  6. Treat with antibiotics and glucocorticoids or NSAIDs, ± sulfasalazine
  7. Usually the arthritis is self limited with treatment

D. Reiter's Syndrome [1,3]

  1. Components
    1. Urethritis
    2. Arthritis
    3. Conjunctivitis ~40%
    4. Other: Balanitis, Keratoderma blenorrhagica [9], vulvitis, acute iritis
    5. Unusual for all major components to be present in single patient
  2. Occurrance
    1. Male >> Female
    2. Mean age ~27 years
    3. >50% of patients have >1 episode
  3. Ankylosing spondylitis may occur, especially in HLA-B27+ patients
  4. Risks for chronic arthritis
    1. Balanitis at onset
    2. Chronic synovitis and Ankylosing Spondylitis (AS) are risks
    3. HLA-B27+ is risk for AS and chronic synovitis

E. HLA-B27 Association

  1. Strongest in patients who develop back and SI joint pain
  2. Not related to development of distal extremity arthritis
  3. Overall, ~65% of patients with reactive arthritis are HLA-B27+

F. Diagnosis

  1. ESR increase (usually >40mm/hr)
  2. Cultures of urethra, throat, stool, blood
    1. Chlamydia trachomatis is highly associated with Reiter's Syndrome
    2. Rule out bacterial infection: Salmonella , Shigella ssp, Yersinia, Campylobacter
  3. Plain Radiographs - erosions can occur, sacroiliac joint fusion, others
  4. Complete blood count usually unremarkable unless severe active infection present
  5. HLA-B27 typing may be performed

G. Treatment

  1. Similar for reactive arthritis and Reiter's Syndrome
  2. Non-Steroidal Antiinflammatory Drugs (NSAIDs)
    1. Full doses of potent agents usually required for one month
    2. For example, indomethicin 25-50mg po qid may be used
    3. Cox-2 selective inhibitors may be tried if standard NSAIDs not tolerated
  3. Sulfasalazine [5]
    1. Gradual increasing dose to 2000-3000mg / day, divided bid to tid
    2. Appears to be effective in patients who have failed NSAIDs [6]
    3. May be particularly useful in patients with gastrointestinal inflammation
  4. Antibiotic Therapy
    1. Lymecycline (tetracycline) for 3 months of reported efficacy in decreasing symptoms duration in Chalmydial disease [7]
    2. Doxycycline for 1-3 months is now recommended in patients with Chlamydial disease
    3. Patient contacts should be treated as carriers for infection
  5. Glucocorticoids
    1. Caution if enteritis associated (may worsen carrier state or infection)
    2. HIV test should precede use in most patients
    3. Local injection is often beneficial

References

  1. Khan MA. 2002. Ann Intern Med. 136(12):896 abstract
  2. Thomson GTD, et al. 1995. Am J Med. 98(1):13 abstract
  3. Granfors K, Jalkanen S, von Essen R, et al. 1989. NEJM. 320:216 abstract
  4. Schmerling RH and Caliendo AM. 1998. NEJM. 338(25):1830 (Case Record)
  5. Clegg DO, Reda DJ, Weisman MH, et al. 1996. Arthritis Rheum. 39(12):2021 abstract
  6. Leirisalo-Repo M, et al. 1994. Arthritis Rheum. 37(1):23 abstract
  7. Lauhio A, et al. 1991. Arthritis Rheum. 34:6 abstract
  8. Rosen T. 2003. JAMA. 290(8):1001 abstract
  9. Tonna I and Laing RB. 2008. NEJM. 358(20):2160 abstract