Reiters arthritis

It is a clinical syndrome triggered by a specific etiological agent in a

susceptible host following enteric or urogenital infections targeting

predominantly HLA-B27 +ve person

It is a triad of Arthritis ,urethritis,and uveitis plus mucocutaneous lesions

History

Described by Hans Reiter in 1916

EpidemiologyPrevalence world wideIncidence 30-40 /one lackMore common in 18-40 yrs of ageBut all age group can sufferboth sex equally affected slightly more common in males.Very severe form seen in patient of AIDS.Family clusteringStrongly associated with HLA B27

Association of HLA B 27 and Spondyloarthropathies(in whites)

-8%General healthy population

-50%Acute iritis

-70%UnspA

-40-50%Psoriatic spA

-35-75%Enteropathic spA

-70%Juvenile spondyloarthropathy

40-80%ReA

-90%Ankylosing spondylitis

HLA B 27 prevalenceDisease

Pathology•Synovial histolgy is similar to inflammatory arthropathies.•Enthesitis is very common

•Microscopic evidence of inflammation is seen colon and Ilium lesion

•Skin lesions similar to Psoriatic lesions

Etiology and pathogenesis

Bacteria responsible for triggering disease are Shigella

Sonnei Boyedii Flexneri dysenterioe

Solmonella Y. Enterocolitica C.Trachomatis Closridium difficle Nesseria Gonorrhoea

Isolated reports of acute arthritis preceded by even viral and

parasitic infection

Immune response inYersinia triggered arthritis

Initial, weak IgM-class antibody productionLater,strong and persisting IgG and IgA antibody productionIgA ab.increases in avidity with timeAb. Are directd against several antigenic epitopes ofYersiniaNonspecific immune complex are always found in serumSpecific Ic. Containing Yersinia and anti-Yersinia ab. May be found in se rum and synovial fluidPeripheral T cells shows weak response to YersiniaTcells in synovial fluid shows vigrous but somewhat nonspecific response

In summery advance in molecular research have revealed that an

imbalance in inflammation cytokines is central in there pathogenesis

Clinical Features History

A vast majority of cases of reactive arthritis are oligosymptomatic, and conjunctivitis or urethritis are present weeks before the patient's first visit

A syndrome, with malaise, low-grade fever, and generalized myalgia or headache can be present

Symptoms of triggering infection would be mild in 9-10 % cases may go

unnoticed

Manifestations of the urogenital system

Circinate balanitis is characteristic. Circinate balanitis is defined by circinate or gyrate white plaques that grow centrifugally and

eventually cover the entire surface of the glans penis. The penile shaft and scrotum can be involved. The lesions become rapidly

keratotic in a circumcised penis. Circinate vulvitis is reported in women.

Prostatitis, cystitis, and pyelonephritis are rare but possible urogenital manifestations of reactive arthritis.

Bartholinitis can be present in women. Proctitis caused by Chlamydia species can occur in both sexes

after anal intercourse.

Conjunctivitis

Eye involvement is common. Conjunctivitis appears in approximately 50% of patients with

reactive arthritis. Conjunctivitis is often bilateral, and it may be overlooked because

of its transitory course. An intense red, velvetlike conjunctival injection characterizes the

conjunctivitis. Edema and a purulent discharge are not rare in reactive arthritis–

associated conjunctivitis.

Other ocular manifestations Iritis, iridocyclitis, and uveitis are seldom reported.

Iritis is more common in late recurrent episodes, and it only occurs in 3-8% of patients in the first attack.

At clinical examination, redness, pain, impaired vision, and exudation with hypopyon can suggest iritis.

Recurrent episodes can lead to pupillary synechia and glaucoma. Keratitis rarely is reported.

Asymmetric Mono or oligoarthritis . Mostly knees,ankles and hips.Shoulders elbow,wrist,and small joints of hands and feet can also get involvedDactilitis is not uncommonPain in sacroiliac region in late stage.

Enthesopathy (ie, inflammation at the tendinous insertion into bone) is common in reactive arthritis and in other seronegative

arthritides (eg, plantar fasciitis, digital periostitis, Achilles tendinitis).

Cutaneous and mucus membrane involvement

Erythema nodosumKeratoderma blenorrhagicum

indistinguisible from psoariasis both clinically and histopathologically.

Circinate balanitis ,cystitis and prostatitis

GIT

Abd. Pain diarrhoea, iliocolonoscopic picture like U.C. or Crohns both micro and macroscopically.

InvestigationsESRCRPCBCLFTRFTRAFactorUrine analysisECGJoint fluid analysis Cellcount Crystals exlusion Gram stain Bact. Culture

Bacterialculture Feces Urine or urethralswab Cervical sample throat

Antibody determination at admissionHLA B27 After 2-4 weeksRadiographs of affected jointsophthalmologicalexamination

AIM of treatment

Rapid control of inflammationPrevent tissue damageImprove QOLTry to achieve long term remission

Treatment

Antibodies if infections still persistRestNSAIDsIntra-articular corticosteroidsSystemic corticosteroidsRarely DMARDs

Summery boxBiologic agents are highly effective-modifying medications.currently licenced biologics target TNFα,interleukin-1,Tcell activation and Bcells.Biologic agents improve the s/s and QOL with RA,Crohn’s disease psoriasis and many orphan conditions.Needs vigilance for side effects.Treatment should be commenced early for ultimate outcome.

PrognosisGenerally goodUrogenital and Eye symptoms can recureSevere destructive disease is rare