Integrated clinical assessment

Reactive arthritis:

Follow-up Questions/Answers

What do you think the most likely diagnosis is here, and can you offer me a
differential diagnosis as well?
o This gentleman has presented with an acute history of oligoarthritis that has been
predated by a diarrhoeal illness about 3–4 weeks ago.
o My top differential would be reactive arthritis.
o My differential would include a first presentation of rheumatoid arthritis.
o Given the family history of psoriatic disease, I would consider psoriatic arthritis.
o I feel that, given the examination, a septic knee or an episode of gout is less likely.

You mentioned diarrhoeal illness as a potential trigger for his reactive arthritis. Can
you tell me about the potential triggers for reactive arthritis?

o Diarrhoeal illnesses principally caused by Salmonella, is particularly common, as

are streptococcal infections.
o Sexually transmitted infections can be a precipitant to reactive arthritis,
particularly Chlamydia.
What about a gonococcal infection?
o Whilst Gonococcus can cause reactive arthritis, it is more likely to cause a septic
joint.
How would you investigate this gentleman?
o I would not expect X-rays to be of any help.
o I would do some blood tests.
o I would like to check the inflammatory markers to get an idea of the active
inflammation ongoing, so a CRP (C-reactive protein) and ESR (erythrocyte
sedimentation rate).
o I would do U&Es (urea and electrolytes) to make sure the kidney function is okay
given his use of NSAIDs (non-steroidal anti-inflammatory drugs).
o I would also do a rheumatoid factor, an anti-CCP *(cyclic citrullinated peptides)
antibody, and if they were borderline, we could consider looking at HLA (human
leukocyte antigen)-B27.
Did you think he had an effusion?
o I did not, but if there was an effusion present, then I would like to do an
aspiration, send that for culture and sensitivity, cytology and for crystals.
Integrated clinical assessment

Reactive arthritis:

Key Words and Phrases

This gentleman has a classic history of reactive arthritis. He has symptoms of

asymmetrical oligoarthritis preceded by a diarrhoeal illness.

However, you do have to consider other differential diagnoses, such as first presentation
of rheumatoid arthritis, other spondyloarthritidies, such as psoriatic arthropathy if he
had a personal or family history of psoriasis, and you could consider gout, meniscal lesion
or septic arthritis, but I agree with the candidate with this history and examination that
these are all less likely.

Good candidates will know that Gonococcus causes septic arthritis (and so the patients
typically present with purulent urethral discharge and concurrent joint pain and also
fever) while Chlamydia, Salmonella, Campylobacter and Streptococcus are the classic
causes of reactive arthritis – the joint symptoms usually post-date the initial infection by
some weeks (typically 4–8).

Candidates should examine the patient, specifically examining the knees and ankles to
assess for the presence of a hot/swollen joint, plus any effusion. The joint examination
should include inspection, palpation, and an assessment of range of movement.

Appropriate investigations would include Blood tests for urate, CRP, ESR, full blood
count (FBC), rheumatoid factor (RF) and CCP antibody.

You could consider HLA-B27 testing, it’s positive in up to 50% patients with reactive
arthritis.

If there are any suspicions of a sexually transmitted infection, then urine and genital
swab testing for Gonnorhoea and Chlamydia in particular would be indicated.

There are no specific findings on plain X-rays in reactive arthritis that can confirm the
diagnosis, so these would not be helpful.

If there was any effusion, then joint aspiration would be appropriate for cell count,
crystals, culture, and sensitivity.

Rheumatology referral is appropriate here.

Acute management of reactive arthritis would be with simple analgesics, NSAIDs unless
contraindicated. The condition is usually self-limiting. Most patients will not require
steroids or disease-modifying antirheumatic agents to control inflammation or to
prevent erosive joint changes.