Reactive arthritis

Classification according to ICD-10
M02.1	Postenteritic Arthritis
M02.3	Reiter's disease
M02.8	other reactive arthritis
M02.9	Reactive arthritis, unspecified
ICD-10 online (WHO version 2019)

The reactive or post-infectious arthritis (abbreviated ReA ), and Reiter's disease called, is a flammable - rheumatic disease is selected from the group of spondyloarthritides . As a result of an infection , especially of the intestines or the urethra with bacteria , joints or other structures become inflamed without being infected themselves. According to the Berlin doctor Hans Reiter , who first described the symptoms of the disease in the First World War in 1916, the four main symptoms are

1. Inflammation of the joints ( arthritis ),
2. Inflammation of the urethra ( urethritis )
3. Eye inflammation ( conjunctivitis / uveitis ) and
4. typical skin symptoms (rider dermatosis)

as the Reiter Tetrad , the first three of which are called the Reiter Trias . If at least three of these symptoms are present in a patient, one speaks of Reiter's syndrome (from which Christopher Columbus possibly suffered, whose doctor reported arthritis and eye changes in the discoverer); however, this occurs only in every third reactive arthritis.

Epidemiology

Young white men with a peak age of 20 to 30 (up to 45) years are mainly affected. The incidence of this worldwide occurring disease is 3.5 per 100,000 men under 50 years of age, in Western countries around 4–5 per 100,000. The gender ratio is inconsistent in the literature: according to the AWMF guideline, m: w = 3: 1, according to the German Rheuma League, m: w = 1: 1. A chronic course occurs in approx. 20% of the cases.

etiology

If synovial fluid is obtained from affected joints, no reproductive pathogens can be detected, but some antigens , DNA or RNA from pathogens can be detected. In the case of infection with chlamydia, it has been demonstrated that inactivated bacteria persist within cells. Reactive arthritis is therefore considered an autoimmune disease . Apparently the infection triggers a reaction of the immune system that is directed against the own body.

According to the underlying infection, two groups can be formed:

• Posturethritic reactive arthritis: Infection of the urethra ( urethritis ) by Neisseria gonorrhoeae (=  gonorrhea ), Chlamydia trachomatis Serovar D – K, Mycoplasma genitalium or Ureaplasma urealyticum . In these cases, the infection is usually sexually transmitted ( sexually acquired reactive arthritis , SARA).
• Postenteritic reactive arthritis: Infection of the intestine ( enteritis ) by Salmonella (Salmonella enteritidis, Salmonella typhimurium), Shigella (Shigella flexneri, Shigella dysenteriae), Yersinia enterocolitica , Campylobacter fetus or other pathogens.

Since the symptoms of the previous disease urethritis or enteritis are often weak and fleeting, it can only be estimated that about 3% of all chlamydial infections and about every third chlamydial urethritis result in Reiter's syndrome.

The HLA-B27 cell characteristic ( HLA class I ) is detected in the blood in 60 to 80% of the sick people ; the disease obviously has a genetic component.

Symptoms

The symptoms of reactive arthritis usually appear 2 to 6 weeks after the infection, which is often not noticed by the patient. The main initial symptoms include possible fever and fatigue:

• Inflammation of the urethra without pathogen infection (sterile urethritis ) or inflammation of the cervix ( cervicitis ) with mucous or purulent discharge , rarely inflammation of the prostate ( prostatitis ) or urinary bladder inflammation ( cystitis ).
• Inflammation of the conjunctiva ( conjunctivitis ). Inflammation of the iris ( iridocyclitis ) can occur as a complication and lead to permanent damage.
• Joint inflammation ( arthritis ): reddening and warming of one or more joints ( monarthritis or oligoarthritis , mostly asymmetrical) mainly of the large joints of the legs ( knee joint , ankle joint ), often associated with pronounced joint effusions that can tie the patient to the bed. If the arms are affected, the small joints are more likely to be affected. Inflammation of the vertebral arch joints and the sacroiliac joint are also possible, which results in the symptoms of inflammatory back pain .
• Again, inflammation of the Achilles tendon (lover's heel) or the plantar fascia on the heel bone is common .

Skin changes of the feet

• Diverse skin changes, which in their entirety enable the fastest diagnosis.
  • Usually begins with sterile pustules appearing in groups on an erythematous base on the palms of the hands and soles of the feet ( [1] ), whereby the vesicles soon burst and a so-called keratoderma blenorrhagicum forms.
  • Psoriasis-like foci, which arise particularly above the joints (thus differential diagnosis: psoriatic arthritis ), but in principle can occur anywhere ( [2] )
  • Superficial ulcers of the oral mucosa
  • Changes similar to a lingua geographica (map tongue)
  • Balanitis circinata on the glans penis (glans) and foreskin
  • Erythema nodosum also rarely occurs
  • Nail changes such as subungual keratoses , onycholysis and onychodystrophy are possible.

After 3–12 months (weeks to years), relapses can occur in up to 15% of patients . Also in 15% the disease can take a chronic course and lead to joint destruction.

diagnosis

• Anamnesis of a previous infection (often not effective)
• The laboratory examination of the blood shows unspecific changes: signs of inflammation; antinuclear antibodies and rheumatoid factors are absent. It therefore primarily serves to substantiate suspicions by excluding other causes.
• The detection of HLA-B27 further corroborates the suspected diagnosis , but is by no means conclusive in individual cases , since around 8% of the healthy population also have this characteristic.
• A urethral swab or cervical swab with an examination for chlamydia and mycoplasma should also be performed in patients who are symptom-free. The corresponding detection is carried out by means of pathogen culture or PCR . Chlamydia serology alone is not effective . In contrast, a titer determination of the Salmonella, Campylobacter and Yersinia antibodies is indicated in all cases.
• X-rays and magnetic resonance imaging of the affected joints

In the frequent detection of HLA-B27, in the distribution pattern of the inflamed joints, in the involvement of the eyes and tendon attachments, and possibly in the skin manifestations, reactive arthritis resembles other spondyloarthritis such as ankylosing spondylitis , psoriatic arthritis or enteropathic arthritis . If the infection is not remembered and can no longer be detected, chronic reactive arthritis can be difficult to distinguish from these related diagnoses.

Differential diagnosis

In addition to the already mentioned psoriasis arthropathica, other manifestations of psoriasis such as

• Psoriasis vulgaris both in the predominantly large-spotted and predominantly small-spotted form, pustular psoriasis type Barber-Koenigsbeck, isolated psoriasis palmaris et plantaris as well as psoriasis inversa
• Sexually transmitted diseases such as secondary syphilis , gonorrhea , gonorrhea arthritis , chlamydial urethritis
• Chronic polyarthritis , recurrent polychondritis
• Fungal diseases ( tinea manus , tinea pedis )
• Behçet's disease , circinate erosive balanitis
• Acrodermatitis continua suppurativa Hallopeau

treatment

For rapid relief of inflammatory joint problems, the symptomatic administration of NSAIDs along with local anti-inflammatory measures (such as cold applications) is recommended . In addition, the elimination of the causative infection through appropriate antibiotic therapy is desirable, although a benefit has only been proven in the urogenital form (infection with Chlamydia trachomatis). Antibiotics are therefore rarely used - since usually no pathogens can be detected. If they are proven, however, treatment of the sexual partner (s) is also necessary.

If the disease progresses seriously and several joints are involved, especially if iridocyclitis occurs, corticosteroids must be used to avoid permanent changes.

Immunosuppressants such as methotrexate and sulfasalazine are only used in chronic cases .

literature

• Wolfgang Miehle: Joint and spinal rheumatism. Eular Verlag, Basel 1987, ISBN 3-7177-0133-9 , p. 43.

Web links

• Pictures of the diagnosis 'Reiter's disease'

Individual evidence

1. ↑ ^{a b c d e} Gerd Herold and colleagues: Internal Medicine 2017 . Self-published, Cologne 2016, ISBN 978-3-9814660-6-5 , p. 669 .
2. ↑ Wolfgang Miehle: Joint and spinal rheumatism. Eular Verlag, Basel 1987, ISBN 3-7177-0133-9 , p. 11.
3. ↑ See also www.abendblatt.de: Columbus suffered from Reiter's syndrome .

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !