Diagnostic Criteria for Reiter´s Syndrome or Reactive Arthritides (ReA)

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Reactive arthritis (ReA) is an inflammatory arthritis that arises after certain types of gastrointestinal or genitourinary infections. It belongs to the group of arthritidies known as the spondyloarthropathies (SpAs). The classic syndrome is a triad of symptoms, including the urethra, conjunctiva, and synovium; however, the majority of patients do not present with this classic triad. In general, there are two forms of ReA, postvenereal (Chlamydia trachomatis [Ct]) and postdysentery (Salmonella, Shigella, Campylobacter, and Yersinia), but several other bacteria have been implicated as potential causes.
 There are diagnostic criteria available, but these are broad and rely on clinical symptoms only. The American College of Rheumatology criteria, published in 1981, require the presence of a peripheral arthritis occurring in association with urethritis or cervicitis.
The Third International Workshop on Reactive Arthritis in 1995 requires a peripheral arthritis with sacroiliac involvement and a preceding gastrointestinal or genitourinary infection.
The current American College of Rheumatology definition might be too limited in scope and the latter’s reliance on a preceding infection could lead to underdiagnosis.
The traditional disease definition also suggests that ReA represents a sterile inflammatory arthritis.
Clinical manifestations of reactive arthritis
A- Acute symptoms
  • Articular
  1. Most commonly present with oligoarthritis but also can present with polyarthritis or monoarthritis
    1. Axial
      1. Frequently involved
        1. Sacroiliac joints
        2. Lumbar spine
      2. Occasionally involved
        1. Thoracic spine (usually seen in chronic ReA)
        2. Cervical spine (usually seen in chronic ReA)
        3. Cartilagenous joints (symphysis pubis; sternoclavicular and costosternal joints)
    2. Peripheral
      1. Frequently involved
        1. Large joints of the lower extremities (especially knees)
    3. Dactylitis (sausage digit): Very specific for a spondyloarthropathy
  • Enthesitis
    1. Hallmark feature
    2. Transitional zone where collagenous structures, such as tendons and ligaments, insert into bone
    3. Inflammation causes collagen fibers to undergo metaplasia forming fibrous bone
    4. Chronic enthesitis leads to radiographic findings
      1. Plantar or Achilles spurs
      2. Periostitis
      3. Nonmarginal syndesmophytes
      4. Syndesmoses of the sacroiliac joints
  • Mucosal
    1. Oral ulcers (generally painless)
    2. Sterile dysuria (occurs with both postvenereal and postdysentery forms)
  • Cutaneous
    1. Keratoderma blenorrhagicum
      1. Pustular or plaque-like rash on the soles or palms
        1. Grossly and histologically indistguishable from pustular psoriasis
      2. Also can involve nails (onycholysis, subungual keratosis, or nail pits), scalp, extremities
    2. Circinate balanitis
      1. Erythema or plaque-like lesions on the shaft or glans of penis
  • Ocular
    1. Conjunctivitis: typically during acute stages only
    2. Anterior uveitis (iritis): often recurrent
    3. Rarely described: scleritis, pars planitis, iridocyclitis, and others
  • Cardiac
    1. Pericarditis (uncommon)
B- Chronic symptoms (>6 months)
  • Articular
    1. Axial
      1. Sacroiliac joints
      2. Lumbar spine
      3. Thoracic spine
      4. Cervical spine
    2. Cartilagenous joints (symphysis pubis; sternoclavicular joints)
    3. Peripheral: Large joints of the lower extremities (especially knees)
    4. Dactylitis (sausage digit): Very specific for a spondyloarthropathy
  • Enthesitis
    1. Chronic inflammation can cause collagen fibers to undergo metaplasia forming fibrous bone
    2. Chronic enthesitis leads to radiographic findings
      1. Plantar/Achilles spurs
      2. Periostitis
      3. Nonmarginal syndesmophytes
      4. Syndesmoses of the sacroiliac joints
  • Mucosal
    1. Sterile dysuria
  • Cutaneous
    1. Keratoderma blennorrhagicum
    2. Circinate balanitis
  • Ocular
    1. Anterior uveitis (iritis): often recurrent
    2. Rarely described: scleritis, pars planitis, iridocyclitis, and others
  • Cardiac
    1. Aortic regurgitation
    2. Valvular pathologies
References
  1. Braun J, Kingsley G, van der Heijde D, et al. On the difficulties of establishing a consensus on the definition of and diagnostic investigations for reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3-6, 1999. J. Rheumatol. 2000;27(9):2185-92. [Medline]
  2. Willkens RF, Arnett FC, Bitter T, et al. Reiter’s syndrome: evaluation of preliminary criteria for definite disease. Arthritis Rheum 1981;24:844–9. [Medline]
  3. Carter JD, Hudson AP. Reactive arthritis: clinical aspects and medical management. Rheum Dis Clin North Am. 2009 Feb;35(1):21-44. [Medline]
  4. Parker CT, Thomas D. Reiter’s syndrome and reactive arthritis. J Am Osteopath 2000;100(2):101–4. [Medline]
Created: Mar 11, 2011.