19th January 2024

Presentation

Reactive arthritis generally develops around 2-4 weeks after an infection; however, in 10% of patients, no symptomatic infection is identified. The onset is usually acute, and systemic features such as fever, weight loss and fatigue may be present.

• Classic triad: urethritis, conjunctivitis, arthritis = Reiter’s syndrome.
• Peripheral arthritis:
  • Usually asymmetrical
  • Predominantly affects large joints in the lower limbs
  • Usually oligoarticular – affects less than 6 joints
  • Tends to present as tender, swollen, stiff joints, usually in the morning

• Axial arthritis:
  • Sacroiliitis and inflammation in the lumbosacral spine occurs commonly
  • May present as lower back pain and stiffness, particularly in the morning and after periods of inactivity – symptoms are generally alleviated with exercise
• Enthesitis
  • Achilles tendonitis, which presents as heel pain and plantar fasciitis can occur
• Dactylitis
• Skin manifestations:
  • Erythema nodosum (palpable, tender, erythematous subcutaneous nodules)
  • Circinate balanitis (painless ulcers and plaque-like lesions on the shaft or glans of the penis)
  • Keratoderma blennorrhagicum (vesicles which can develop into plaque-like or pustular lesions, most commonly on the palms and soles of the feet)
  • Dystrophic nail changes
• Mucous membrane involvement:
  • Mouth ulcers – usually superficial and painless
  • Genital ulcers
  • Cystitis
  • Prostatitis
• Ocular manifestations:
  • Conjunctivitis – can present with eye erythema, tearing and purulent discharge
  • Anterior uveitis (iritis) – associated with HLA B27 positivity. Can present with pain, erythema and photophobia
  • Episcleritis
  • Keratitis
  • Corneal ulcerations
• Gastrointestinal manifestations:
  • Some patients may have intermittent symptoms of abdominal pain and diarrhoea
• Cardiovascular manifestations:
  • Aortitis – can occur with or without aortic regurgitation and may precipitate heart failure
  • Cardiac conduction defects leading to arrhythmias

Image Source: Wikimedia Commons (2022). Swollen eye with conjunctivitis, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Swollen_eye_with_conjunctivitis.jpg (Accessed: 30 June 2021).

Image Source: Wikimedia Commons (2022). Keratoderma blennorrhagic, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Keratoderma_blennorrhagica.jpg (Accessed: 30 June 2021).