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REACTIVE ARTHRITIS

REACTIVE ARTHRITIS. Definition. A form of peripheral arthritis often accompanied by one or more extra-articular manifestation , shortly after infection of genitourinary or gastrointestinal infection. Epidemiology. After venereal infection m/F=7-9/1

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REACTIVE ARTHRITIS

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  1. REACTIVE ARTHRITIS

  2. Definition A form of peripheral arthritis often accompanied by one or more extra-articular manifestation , shortly after infection of genitourinary or gastrointestinal infection.

  3. Epidemiology After venereal infection m/F=7-9/1 After GI infection M/f=1 Prevalence 1/10000 4.6/100000 in chlamydia 5/100000 in enteric infection

  4. Pathogenesis Altered mucosal permeability ,abnormality in GI tract, increased titer of IgA during active phase CD8 T-cell antigen recognition in association with HLA-B27 Increased chemotaxis and phagocytosis in neutrophils and monocytes Bacterial LSP and HSP Ag in synovial leukocytes and peripheral blood leukocytes in long term Involvement of CD4 T-Cell (TH2)

  5. Etiology Urogenital infection Chlaymedia trachomatis, less common C. pneumoniae, C. psittaci, ureaplasma urealyticum GI infection Salmonella typhimurium, less common S. paratyphi, S. enteridis, S. heidelberg Yersinia enterocolitica, and less common Y. pseudotuberculosis

  6. Articular Manifestation Additive, asymmetric and oligoarticular arthritis. Involvement of upper limbs more than upper Only upper limb involvement is rare Hip disease is uncommon Occasionally sternoclavicular, shoulder and TMJ affected Joints are swollen, painful, warm and erythematous

  7. Monarthritis of Knee Joint

  8. Articular Manifestation (continued) Sausage digits or dactylitis in toe or digital finger Enthesitis in plantar fascia, achilles tendon, ischial tuberositis, iliac crest, tibial tuberositis and ribs Low back pain in 50%, sacroiliitis in X-Ray 20%, progression to As 10%

  9. Heels Tendinitis

  10. Sausage Digits

  11. Sausage Digits

  12. Inflammatory Back Pain At least 3 months’ duration Onset before 45 years of age Insidious onset Improved by exercise Associated with morning stiffness

  13. Extra-Articular Manifestation Keratoderma blennorrhagicum:Papulosquamous skin rash most common on the soles or palms, early lesion pustular and then become scaly and hyperkeratotic, this is a form of pustular psoriasis Nail changes: Thickened and opaque toe and fingernails, absent pitting

  14. Foot, Rash, Pustules

  15. Keratoderma Blennorrhagica Pustules  Hyperkeratotic Indistinguishable from psoriasis Usually soles and palms May affect any area

  16. Nail Dystrophy and Arthritis Thick, opaque Resembling mycotic infection No pitting

  17. Extra-Articular Manifestation (continued) Circinate balanaitis: Characteristic lesion in glans or shaft of penis, in circumcised men, rash is dry plaque like hyperkeratotic and in un circumcised men shallow and moist ulcer Oral ulcer: Shallow and painless Weight loss and cachexia: occur in some patients

  18. Balanaitis Circinata

  19. Palate Erosion

  20. Tongue Erosion

  21. Extra-Articular Manifestation (continued) Eye lesion: Acute anterior uveitis at any time during course of disease in 20% Chronic uveitis and visual loss in few patients Aortitis: 1-2% in longstanding disease, AI, heart block Amyloidosis, Ig A nephropathy Neurologic complication: peripheral neuropathies, encephalopathy, transverse myelitis

  22. Conjunctivitis

  23. Conjunctivitis

  24. Classification Criteria in spondyloarthropathyESSG 1991 1-Inflammatory spinal pain 2-Synovitis, asymmetric in lower limbs Plus any one of following features 1-Positive family history of AS, psoriasis, ReA, IBD 2-Psoriasis 3-IBD 4-Nongonococcal urethritis or cervicitis or acute diarrhea in one month ago 5- Alternate buttock pain 6-Enthesopathy Sensetivity=77%, specificity=89% When Sacroiliitis is also present Sensetivity=86%, specificity=87%

  25. Classification CriteriaAmor 1990 A:Cinical symptom or past history (9 item,16 points) B: Radiologic finding (3 points) C: Genetic background (2 points) D: Response to treatment (2 points) Spondyloarthropathy is considered if sum of points is 6 or more

  26. Diagnostic Strategy for Spondyloarthropathy Features Probability Inflammatory low back pain or 14% oligoarthritis of lower extremity Plus Additional features from 30-70% Amor or ESSG criteria Plus HLA-B27, sacroiliitis, or both 95%

  27. Diagnostic Criteria in Reactive Arthritis No validated criteria for diagnosis or classification of Reactive Arthritis 3rd International workshop on reactive Arthritis in 1996 1-An acute inflammatory arthritis ,Inflammatory low back pain, or enthesitis 2-Evidence of an infection preceding this condition by 4 to 8 weeks

  28. Diagnostic Strategy in Reactive Arthritis Features Probability Inflammatory low back pain or oligoarthritis of lower extremity Plus Symptoms of preceding acute symptomatic 30-50% urethritis, cervicitis, or enteritis Plus Positive bacterial recognition test 70-80% Plus Positive HLA-B27 >80%

  29. Laboratory Features Mild anemia, leukocytosis, thrombocytosis Acute phase reactant Negative RF and ANA HLA-B27 in 65-75% Inflammatory synovial fluid, Reiter’s cell (large mononuclear cell that ingested PMN) Urine sample or genital swab for culture or PCR, stool culture in enteric infection PCR to detection of bacterial RNA or DNA

  30. Radiographic Manifestation No abnormality in early disease except soft tissue swelling Fluffy periosteal reaction on the calcaneous New bone formation and periostitis, pencil –in cup Sacroiliitis often unilateral, asymmetrical syndesmophytes

  31. Foot, Plantar Periosteitis Periosteal reaction Bony erosion Plantar / Achilles tendon or other symptomatic sites

  32. Sacroiliitis

  33. Management First line of treatment NSAID’s, improvement after 2 weeks, however ESR and CRP elevated for long time Local steroid injection into the joints or enthes, systemic use no effective topical therapy in uveitis Antibiotic therapy? Indicated in chlamydial conjunctivitis and urethritis (treatment of partner), non significant improvement in long term outcome

  34. Management (continued) Failure to NSAID”s, sulfasalazine 2 gram daily ,maximum 3 gram, if not affected after 4 months discontinued Methotrexate if not effect after 6 months discontinued Biologic agent, Infliximab, Enbrel

  35. Clinical course and prognosis Self-limited course in 3-12 MO. 15% relapse (reinfection?) 15% chronic, destructive, disabling arthritis and enthesitis

  36. Predictors of Poor Outcome in reactive Arthritis Hip arthritis Higher ESR Poor efficacy of NSAID’s Limitation of lumbar axis Sausage finger/toe Oligoarthritis Onset at the age of 16 years

  37. Ethiology, Uncommon Infection Bacterial Streptococcal (group A, G) Clostridium difficile Propionibacterium and corynebacterium acne Staphylococcus ureus (Toxic shock arthritis) Spirochetal Borrelia burgdorferi (lyme disease) Viral HIV? Mycobacterial tuberculosis and avium intracellulare (poncet’”s disease) Parasitic Giardia lamblia, strongyloides stercoralis, cryptosporidium, Ascaris lumbricoides, Taenia saginata, Filaria

  38. Poststreptococcal Reactive Arthritis In comparison to rheumatic fever Short latent period 1-2 weeks (2-3 weeks in acute rheumatic fever) No evidence of carditis Extra-articular manifestation such as tenosynovitis and renal abnormalities were seen Poor response to NSAID”s Course is often benign with a good outcome

  39. Poncet”s Disease Sterile mono or polyarthritis in setting of active pulmonary or extra-pulmonary tuberculosis Joint swelling resolve in days to months often without radiographic changes Treatment of tuberculosis resolve arthritis

  40. Reactive Arthritis and AIDS Severe chronic asymmetric oligoarthritis Prominent enthesitis and extra-articular features More rapid progression and deformities HLA-B27 in 75% of cases Rarely associated with uveitis or axial disease Poorly responsive to standard NSAID therapy Don’t use of MTX or others cytotoxic agents

  41. SAPHO SyndromeSynovitis, Acne, pusulosis, hyperostosis, osteitis Early erosive and late hyperostotic changes in anterior chest wall joints or axial skeleton Chronic pustular skin lesions; acne fulminans, acne congolobata, pustular psoriasis Lack of association with HLA-B27 Parallel course of skin and skeletal abnormalities

  42. SAPHO Skeletal Involvement Anterior chest wall: sternoclavicular, manubriosternal, sternocostal Axial skeleton Peripheral joints Spondylodiscitis, vertebral sclerosis, bony ankylosis, Sacroiliitis, marginal syndesmophytes, paravertebral ossification Hyperostosis of axial skeleton (DISH, SPA, Fluorosis, retinoid therapy, Ochronosis, Hypoprathyroidism)

  43. SAPHO Comparison to SPA Predominant involvement of chest wall joints Less frequent sacroiliitis Lack of association with HLA-B27 F=M Absence of extra-articular manifestation

  44. SAPHO: TREATMENT Treatment of skeletel lesions is difficult Treatment of pustular skin lesions AB, NSAID’s, oral or intraarticular corticosteroides

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