Reactive Arthritis

Basic Information

  • Classically occurs 1 to 4 weeks after genitourinary Chlamydia infection
    • “Can’t see (conjunctivitis), can’t pee (urethritis), can’t climb a tree (arthritis)”
      • Previously known as Reiter syndrome
    • In children, most commonly occurs 1 to 4 weeks after bacterial gastroenteritis (Yersinia, Salmonella, Shigella, Campylobacter)
    • Symptoms are due to an immunologic response to preceding infection
      • Occurs most frequently in those who are human leukocyte antigen (HLA)-B27 positive and thus is considered to be a subset of the spondyloarthropathies

Clinical Presentation

  • History
    • Preceding diarrheal or genitourinary infection
    • Chlamydia infection is typically asymptomatic, so a history of dysuria and urethral or vaginal discharge may not be elicited
    • Low-grade fever can be present at onset of arthritis
  • Physical signs
    • Asymmetric oligoarticular arthritis of the lower extremities, usually markedly painful
      • Unlike juvenile idiopathic arthritis (JIA), overlying erythema is common
    • Conjunctivitis in both Chlamydia and gastroenteritis-associated reactive arthritis may be purulent
    • Skin lesions are occasionally seen with Chlamydia-associated reactive arthritis:
      • Keratoderma blenorrhagicum (scaly psoriasis-like eruption on the feet)
      • Circinate balanitis (painless, shallow ulcers on the glans penis)
      • Erythema nodosum

Diagnosis and Evaluation

  • If reactive arthritis is suspected, documentation of a preceding infection is helpful but not always possible:
    1. Stool cultures for enteric organisms
    2. Urethral swab for polymerase chain reaction (PCR) to detect Chlamydia
  • Synovial fluid is inflammatory (∼20,000 white blood cells [WBCs]), but cultures are negative
    • Chlamydial antigens or nucleic acids may be detectable in synovial fluid
  • Urethral and conjunctival cultures are sterile
  • Other laboratory studies can support the diagnosis but are not specific:
    • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and mild leukocytosis with neutrophil predominance


  • ▪Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line
    • Chlamydia should be treated, but symptoms may not improve with antibiotics alone
  • Usually self-limited and resolves within 6 to 12 weeks, but may last up to 6 months
    • Referral to rheumatology is required for persistent symptoms

1 Comment

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