Добре дошли в сайта на д-р Севдалина Ламбова, дм, ревматолог




Reactive arthritis

            Reactive arthritides are a heterogeneous group of inflammatory joint diseases, which are linked to a preceding infection and the causative organism can not be detected in the joint. They are referred to the group of seronegative spondyloarthropathies. They include a wide range of inflammatory joint conditions of postviral and postbacterial arthritides. Common triggers of reactive arthritis are Chlamydia trachomatis, Salmonella, Campylobacter, Yersinia, Shigella flexneri. The form of reactive arthritis, which follows genitourinary and gastrointestinal infection and is characterized with the clinical triad of arthritis, conjunctivitis, urethritis/cervicitis or gastroenterocolitis is termed Reiter-Leroy syndrome. The mean common frequency of reactive arthritis from different triggering microbes is thought to be 100-200 per 100 000. The factors, which influence the pathogenesis are the characteristic structural and functional features of the infecting agent, the genetic background (mainly HLA B 27 positivity) and the immune response of the host organism.


            The joint inflammation in Reiter-Leroy syndrome manifests usually as asymmetric oligoarthritis with a tendency to affect predominantly the large joints of the lower extremities. Dactylitis (diffuse swelling of fingers and toes, that exceeds the contour of the joints) may develop, which is a characteristic feature of the whole group of spondyloarthropathies. Low back pain or buttock pain may develop in the context of acute sacroiliitis. The joint inflammation is generally most severe in the first few weeks. In a part of the cases, symptoms may persist for several months. In another subgroup of patients, the joint inflammation has a recurrent course with remission and exacerbations. A history for a preceding infection (dysuria, discharge or diarrhoea) has to be specifically sought as there is usually an interval between the symptoms of infection and reactive arthritis and the patient may not consider an association between the clinical events. Of note, in a part of the cases, the infection is asymptomatic. Specific clinical signs of Reiter-Leroy syndrome are extraarticular features, which may direct the clinician to the proper diagnosis. The inflammation of ligamentous and tendinous insertions to the bone (enthesitis) is a characteristic features of the diseases as a member of spondyloarthropathies group. The commonest sites of enthesitis are the insertion of Achilles tendon, plantar fascia, clinically manifested with pain at the posterior side of the ankle joint, heel pain and local oedema in a part of the cases. A number of mucous pathologic changes may be observed such as conjunctivitis, oral ulcers, lesions of genital mucosae.


            Laboratory and instrumental investigations

            In acute Reiter-Leroy syndrome, there is evidence of a major inflammatory response with elevated erythrocyte sedimentation rate (ESR) and CRP values. The tests for rheumatoid factor and antinuclear antibodies are classically negative. By definition the causative microorganism is not isolated from the affected joints, but they may be detected from different cultures. Thus, microbiological testing from different sites of potential infection is obligatory such as stool, swabs from the genitourinary tract and sterile urine.


            Joint X-rays, joint ultrasonography and magnetic resonance imaging may be used for the detection of inflammatory changes of musculoskeletal system e. g., arthritis, enthesitis, sacroiliitis.


            In 80% of the cases symptoms resolve completely within the first year. In HLA-B27 positive patients, the prognosis may be less favourable, the course more severe and require hospitalization in a proportion of the cases. The remaining proportion of the patients may have a chronic course with recurrent attacks of joint inflammation. Advice for adequate protection from further infection is needed.


            The treatment includes nonsteroidal anti-inflammatory drugs, antibiotics, oral or intraarticular corticosteroids, and in a proportion of patients disease modifying antirheumatic drugs. The precise therapeutic regimen should be recommended by rheumatologist in every individual case.


                                                                                  Dr Sevdalina Lambova, MD, PhD