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The arthritis is most commonly asymmetric and frequently involves the large weight-bearing joints (chiefly the knee and ankle); sacroiliitis or ankylosing spondylitis is observed in at least 20% of patients, especially after frequent recurrences Systemic symptoms including fever and weight loss are common at the onset of disease The mucocutaneous lesions may include balanitis, stomatitis, and keratoderma blennorrhagicum, indistinguishable from pustular psoriasis Involvement of the fingernails in Reiter s syndrome may also mimic psoriatic changes Carditis and aortic regurgitation may occur While most signs of the disease disappear within days or weeks, the arthritis may persist for several months or even years Recurrences involving any combination of the clinical manifestations are common and are sometimes followed by permanent sequelae, especially in the joints
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Radiographic signs of permanent or progressive joint disease may be seen in the sacroiliac as well as the peripheral joints
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REACTIVE ARTHRITIS
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Fifty to 80 percent of patients are HLA-B27-positive Oligoarthritis, conjunctivitis, urethritis, and mouth ulcers most common features Usually follows dysentery or a sexually transmitted infection
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Reactive arthritis (formerly called Reiter s syndrome) is a clinical tetrad of urethritis, conjunctivitis (or, less commonly, uveitis), mucocutaneous lesions, and aseptic arthritis It occurs most commonly in young men, is associated with HLA-B27 in 80% of white patients and 50 60% of blacks, and often follows infection (see above)
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Gonococcal arthritis can initially mimic reactive arthritis, but the marked improvement after 24 48 hours of antibiotic administration and the culture results distinguish the two disorders Rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis must also be considered By causing similar oral, ocular, and joint lesions, Beh et s disease may also mimic reactive arthritis The oral lesions of reactive arthritis, however, are typically painless, in contrast to those of Beh et s The association of reactive arthritis and HIV has been debated, but evidence now indicates that it is equally common in sexually active men regardless of HIV status
Treatment
NSAIDs have been the mainstay of therapy Antibiotics given at the time of a nongonococcal sexually transmitted infection reduce the chance that the individual will develop this disorder Unfortunately, once reactive arthritis has developed, antibiotics do not alleviate symptoms Patients who fail NSAIDs and tetracycline may respond to sulfasalazine, 1000 mg orally twice daily, or to methotrexate, 75 20 mg orally per week Anti-TNF agents (etanercept, infliximab, adalimumab), which are effective in ankylosing spondylitis, may be effective for treating reactive arthritis that is refractory to more conventional therapies
Putschy N et al Comparing 10-day and 4-month doxycycline courses for treatment of Chlamydia trachomatis-reactive arthritis: a prospective, double-blind trial Ann Rheum Dis 2006 Nov;65(11):1521 4 [PMID: 17038453]
Clinical Findings
A Symptoms and Signs
Most cases of reactive arthritis develop within days or weeks after either a dysenteric infection (with Shigella, Salmonella, Yersinia, Campylobacter) or a sexually transmitted infection (with Chlamydia trachomatis or perhaps Ureaplasma urealyticum) Whether the inciting infection is sexually transmitted or dysenteric does not affect the subsequent manifestations but does influence the gender ratio: The ratio is 1:1 after enteric infections but 9:1 with male predominance after sexually transmitted infections Although affected joints are culture-negative, fragments of putative organisms have been identified by polymerase chain reaction studies on synovial fluid The exact role of infection remains unclear
ARTHRITIS & INFLAMMATORY INTESTINAL DISEASES
One-fifth of patients with inflammatory bowel disease have arthritis, making it second only to anemia as the most common extraintestinal manifestation Arthritis compli-
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Methicillin-resistant S aureus (MRSA) and group B streptococcus have become increasing frequent and important causes of septic arthritis Gram-negative septic arthritis causes about 10% of cases and is especially common in injection drug users and in other immunocompromised persons Escherichia coli and Pseudomonas aeruginosa are the most common gram-negative isolates in adults The widespread use of arthroscopy and prosthetic joint surgery has also increased the frequency of septic arthritis In the latter conditions, Staphylococcus epidermidis is the usual offending organism Pathologic changes include varying degrees of acute inflammation, with synovitis, effusion, abscess formation in synovial or subchondral tissues, and, if treatment is not adequate, articular destruction
cates Crohn s disease somewhat more frequently than it does ulcerative colitis In both diseases, two distinct forms of arthritis occur The first is peripheral arthritis usually a nondeforming asymmetric oligoarthritis of large joints in which the activity of the joint disease parallels that of the bowel disease The arthritis usually begins months to years after the bowel disease, but occasionally the joint symptoms develop earlier and may be prominent enough to cause the patient to overlook intestinal symptoms The second form of arthritis is a spondylitis that is indistinguishable by symptoms or x-ray from ankylosing spondylitis and follows a course independent of the bowel disease About 50% of these patients are HLA-B27-positive Controlling the intestinal inflammation usually eliminates the peripheral arthritis The spondylitis often requires NSAIDs, which need to be used cautiously since these agents may activate the bowel disease in a few patients Range-of-motion exercises as prescribed for ankylosing spondylitis can be helpful About two-thirds of patients with Whipple s disease experience arthralgia or arthritis, most often an episodic, large-joint polyarthritis The arthritis usually precedes the gastrointestinal manifestations by years In fact, the arthritis resolves as the diarrhea develops Thus, Whipple s disease should be considered in the differential diagnosis of unexplained episodic arthritis
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