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Reactive arthritis

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Reactive arthritis (ReA) can be defined as the development of sterile inflammatory arthritis as a sequel to remote infection, often in the gastrointestinal or urogenital tract. Although no generally agreed-upon diagnostic criteria exist, the diagnosis is mainly clinical, and based on acute oligoarticular arthritis of larger joints developing within 2–4 weeks of the preceding infection. According to population-based studies, the annual incidence of ReA is 0.6–27/100 000. In addition to the typical clinical picture, the diagnosis of ReA relies on the diagnosis of the triggering infection. Human leucocyte antigen (HLA)-B27 should not be used as a diagnostic tool for a diagnosis of acute ReA. In the case of established ReA, prolonged treatment of Chlamydia-induced ReA may be of benefit, not only in the case of acute ReA but also in those with chronic ReA or spondylarthropathy with evidence of persisting chlamydia antigens in the body. In other forms of ReA, there is no confirmed evidence in favour of antibiotic therapy to shorten the duration of acute arthritis. The outcome and prognosis of ReA are best known for enteric ReA, whereas studies dealing with the long-term outcome of ReA attributable to Chlamydia trachomatis are lacking.

Section snippets

Incidence

Most cases of ReA arise sporadically. Single-source epidemics, in which patients with joint symptoms during and/or after the infection have been traced with questionnaires and/or with clinical investigations, have been reported in association with different gastrointestinal microbes (Table 3, Table 4). In these studies, estimates of the incidence of ReA and frequency with which it occurs following an episode of infection depend, in large part, on how ReA is defined and on the epidemiologic

Clinical picture

There is usually an interval of 1–2 weeks from the start of infection to the onset of musculoskeletal symptoms; in Chlamydia infection, the interval can extend up to 4 weeks. The triggering infection can also be asymptomatic, which can hamper the diagnosis. The ReA patients are usually young adults, with a mean age of nearly 30–40 years. The disease is uncommon in children [32], [40], [41]. Male and female patients have similar risk for the development of ReA induced by gastrointestinal

Investigation

In addition to the typical clinical picture, the diagnosis of ReA relies on the diagnosis of the triggering infection. During the acute phase of enteric infections, isolation is usually possible from the stools. However, by the time arthritic complications appear, the patient may have already recovered from the gastroenteritis and the microbe may no longer be detectable in the faeces. Therefore, the laboratory diagnosis of ReA is often dependent on the detection of specific antibodies in the

Is it necessary to test for HLA-B27?

Nearly 90% of patients with ankylosing spondylitis (AS) carry antigen HLA-B27. Several early studies investigating this connection in ReA patients reported a high frequency (nearly 60–80%) also with this antigen. These figures were founded on hospital-based series, including the most severe cases [47]. In outbreak studies or in epidemiological surveys at population level, only a slight or no increased frequency of HLA-B27 has been reported [20].

In 2002, Sieper et al. published calculations of

Treatment – experience and evidence

First, the treatment of ReA with respect to treatment of the triggering infection and treatment of acute arthritis is discussed. Then, effect of antimicrobial therapy on acute arthritis will be discussed, followed by considering effects of disease modifying antirheumatic drugs (DMARDs) and biologicals. Finally, some novel insights are addressed.

What is the long-term outcome?

The average duration of acute ReA is 3–5 months. Clinically, the duration of arthritis for >6 months is regarded as a sign of development of chronicity.

We summarised the long-term outcome of enteric ReA in this journal in 2006 [7]. Since then, no new clinical studies dealing with this issue have been published. Two older studies have assessed the long-term prognosis of Salmonella-triggered ReA [51], [61]. In an American study with 5 years’ follow-up, one-third of the patients had fully

Acknowledgements

Professor Marjatta Leirisalo-Repo is acknowledged for critically reading the manuscript.

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