Artritis reactiva diapos, Esquemas y mapas conceptuales de Reumatología

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Andres Quiceno, MD

Rheumatology Division

Presbyterian Hospital of Dallas

 (^) 32 y/o WM admitted to the hospital with 2 days of acute onset of arthritis in his right knee that progressed to the left knee. The day previous to the admission, he was evaluated in the ER, and an arthrocenthesis was attempted. The patient was discharged on Keflex 500 mg QID and Hydrocodone.  (^) ROS: 3 weeks previous to admission he had an episode of diarrhea that lasted for 10 days and improved after treatment with Cipro.  (^) Family History: Sister with recurrent uveitis.

 “Reactive Arthritis (ReA) is an infectious induced

systemic illness characterized by an aseptic

inflammatory joint involvement occurring in a

genetically predisposed patient with a bacterial

infection localized in a distant organ/system”.

 (^) Epidemiology  (^) ReA is an acute and insidious polyarthritis after an enteric and urogenital infections.  (^) Incidence varies widely (1% to 20%).  (^) Frequency varies from 0 to 15% after infection with Salmonella, Shigella, Campylobacter or Yersinia.  (^) HLA-B27 can be present in 72% to 84% of the cases.  (^) Incidence after Chlamydia trachomatis is not well known.

 (^) In patients with ReA, they have an elevated production of Th2 cytokines, such us IL-10 and a possible decrease production in Th1 cytokines.  (^) All these factors cause a decrease in the effective clearance of bacteria.  (^) Macrophages, CD4+ and CD8+ lymphocytes are activated in the joints of this patients.  (^) Some bacterial antigens like heat shock protein 60 present in Chlamydia and Yersinia.  (^) Molecular cross reactive has been also associated.

 Causative organisms

 Frequent association:

 (^) Chlamydial trachomatis  (^) Ureaplasma urealyticum  (^) Salmonella enteritidis  (^) Salmonella typhimurium  (^) Shigella flexneri  (^) Shigella dysenteriae  (^) Campylobacter jejuni  (^) Yersinia enterocolitica  (^) Streptococcus SP

 (^) Clinical Manifestations:  (^) Postenteric ReA is described equally in men an women.  (^) Postchlamydial is most common in men.  (^) In patients with postenteric ReA, the episode of diarrhea is usually prolonged.  (^) Arthritis presents usually 2 to 3 weeks after the episode of diarrhea.  (^) Arthritis usually resolves within 6 months, but a few patients had recurrences an a minority develops a chronic arthritis.

 In patients with postchlamydial disease, urethritis

is usually mild, painless and nonpurulent.

 Conjunctivitis is usually observed very early,

before the onset of arthritis, uveitis is less

common but occurs in 15% of patients with

chronic persistent disease.

 Skin manifestations include: Keratoderma

blenorrhagica, Circinate balanitis and oral ulcers.

 Less common patients can develop valvulitis,

rhythm disturbances.

 (^) Treatment:  (^) NSAIDS are the first line of treatment.  (^) In patient with frequent recurrences or chronic arthritis benefit from DMARDS such us sulfasalazine or methotrexate.  (^) If there is axial involvement they will benefit from TNF-alpha blockers.  (^) Topical steroids are indicated in conjunctivitis and uveitis.  (^) In monoarthritis steroid injections could be beneficial.