Reactive arthritis - Symptoms

One of the most prominent representatives of reactive arthritis is Reiter's syndrome or urethro-oculosynovial syndrome.

Reiter's syndrome is an inflammatory process that develops in chronological connection with an infection of the genitourinary tract or intestines and is manifested by the classic triad of symptoms - urethritis, conjunctivitis, arthritis.

Reiter's syndrome most often begins with symptoms of urogenital tract damage 2-4 weeks after an intestinal infection or suspected infection with chlamydia or intestinal bacteria. Later, symptoms of eye and joint damage are added.

Urogenital tract lesions are characterized by the erasure of the clinical picture. Boys develop balanitis, infected adhesions, phimosis, girls - vulvitis, vulvovaginitis, leuko- and microhematuria, cystitis. Urogenital tract lesions may precede the development of articular syndrome by several months.

Eye damage - conjunctivitis, often catarrhal, mild, short-lived, but prone to recurrence. In yersiniosis reactive arthritis, conjunctivitis can be purulent, severe. Acute iridocyclitis, threatening blindness, develops in 30% of patients. Eye damage can also precede the development of articular syndrome by several months or years.

Lesions of the musculoskeletal system - limited asymmetric, mono-, oligo- and, less frequently, polyarthritis. The process mainly involves the joints of the legs, with the most frequent lesions of the knee, ankle joints, metatarsophalangeal, proximal and distal interphalangeal joints of the toes.

Arthritis may begin acutely, with pronounced exudative changes. Some patients develop a fever, up to febrile levels.

Exudative arthritis in Reiter's disease of chlamydial etiology occurs without pain, stiffness, pronounced dysfunction, with a large amount of synovial fluid, continuously recurring. Joint damage is characterized by a long-term absence of destructive changes, despite recurrent synovitis. The development of tenosynovitis and bursitis, Achilles bursitis, unilateral damage to the sternoclavicular joint is characteristic.

Typical for reactive arthritis is damage to the first toe, the formation of a “sausage-shaped” deformation of the toes due to severe swelling and hyperemia of the affected toe.

Some patients develop enthesitis and enthesopathies (pain and tenderness on palpation at the sites of tendon attachment to bones). Enthesopathies are most often determined along the spinous processes of the vertebrae, iliac crests, at the sites of sacroiliac joint projection, at the site of the Achilles tendon attachment to the calcaneal tuberosity, and at the site of attachment of the plantar aponeurosis to the calcaneal tuberosity. Patients with reactive arthritis are characterized by heel pain (talalgia), pain, stiffness, and limited mobility in the cervical and lumbar spine, and iliosacral joints. These clinical symptoms are typical of adolescent boys with HLA-B27; there is a high risk of developing juvenile spondyloarthritis.

With a protracted (6-12 months) or chronic (more than 12 months) course of the disease, the nature of the joint syndrome changes, the number of affected joints increases, arthritis becomes more symmetrical, and the joints of the upper limbs and spine are more often involved.

The symptoms of Reiter's syndrome are not chronologically related to each other, which complicates diagnosis. Sometimes, even with a thorough examination, it is not possible to identify signs of one of the symptoms (urethritis or conjunctivitis), which makes it necessary to regard the disease as incomplete Reiter's syndrome. In addition to the classic triad of symptoms, Reiter's disease often reveals lesions of the skin and mucous membranes. They are manifested by keratoderma of the palms and feet, psoriasis-like rashes, trophic changes in the nails. Children also develop erosions of the oral mucosa such as stomatitis or glossitis, often clinically unmanifested and remaining unnoticed. Other extra-articular manifestations: lymphadenopathy, less often hepatosplenomegaly, myopericarditis, aortitis.

Postenterocolitic reactive arthritis is more acute and aggressive than reactive arthritis associated with chlamydial infection. In postenterocolitic reactive arthritis, there is a more obvious chronological connection with a previous intestinal infection. The disease occurs with pronounced symptoms of intoxication, fever, acute joint syndrome, and high laboratory activity indicators.

Diagnostic criteria for postenterocolitic arthritis:

• development of arthritis 1-4 weeks after diarrhea;
• predominantly acute nature of joint damage (swelling, increased local temperature, redness of the skin over the joints, sharp pain when moving;
• asymmetrical joint damage;
• predominant damage to large joints (knees, ankles);
• oligo-, polyarthritis;
• possible bursitis, tendovaginitis;
• significant changes in laboratory parameters;
• increased titers of antibodies to pathogens of intestinal infections and antigenemia;
• torpidity of the joint syndrome, chronicity of the process;
• HLA-B27 in 60-80% of patients.

In some cases, reactive arthritis occurs without distinct extra-articular manifestations related to the symptom complex of Reiter's syndrome (conjunctivitis, urethritis, keratoderma). In such cases, the leading clinical picture is the joint syndrome, characterized by predominantly asymmetrical damage to the joints of the lower extremities. Mono- and oligoarthritis predominate in terms of the number of affected joints. In general, the nature and course of arthritis are similar to Reiter's syndrome. Reactive arthritis is characterized by damage to the first toe, the formation of a "sausage-shaped" deformity of the toes. Some patients may develop enthesitis and enthesopathies. Regardless of the presence of extra-articular manifestations, these children have a high risk of developing juvenile spondyloarthritis.

In the absence of a complete clinical picture of Reiter's syndrome (even with a characteristic joint syndrome), the diagnosis of reactive arthritis presents significant difficulties. Characteristic mono- or oligoarthritis with predominant damage to the joints of the legs, pronounced exudation; associated with a previous intestinal or genitourinary infection or serological markers of these infections allows us to classify the disease as probable reactive arthritis.

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