Alright, so let's review a few
key points in our case
that will help to highlight some key points
about reactive arthritis.
First of all, we see that she had left knee,
left ankle and several toes
were involved and that is pretty typical
of reactive arthritis.
You're going to see Oligoarticular arthritis
of the lower extremities
sometimes called additive
because from one day to the next, a new
joint is added to the list.
Secondly, we talked about the fact that
the sole of her left foot
is indicative of plantar
A brief sidebar comment about how to
manage plantar fasciitis.
We typically use night splints which basically lock
your heel into a dorsiflex position
so that the plantar fascia doesn't
Heel stretching exercises can be helpful
NSAIDs as needed
occasionally we also do direct
into the plantar fascia insertion
at the calcaneal tubercle.
Next up the fact that her
aunt has psoriasis,
this is a Family of diseases and so if
you have family members
who have these diseases you're
certainly more likely to be
carrying the HLA b 27
So that is relevant piece
of family history.
Low back pain, as I mentioned,
Spondylosis refers to disease
of the spine,
you're going to see some evidence
of low back pain
pretty much universally amongst
these four conditions.
In addition, the evidence
with pain radiating into the buttocks
would be supportive.
Now, this episode of diarrhea
You may remember that more
often than not
when we think of reactive
We're thinking about a preceding
genital urinary infection
in particular chlamydia. However,
it's been shown that
in addition to those genital urinary sexually
that can precipitate
a lot of the time it's actually a proceeding
in particular Shigella, Campylobacter,
Salmonella and Yersinia
So oftentimes, you'll see that a patient had
simply a diarrheal episode
a few weeks before the onset of their
reactive arthritis picture.
That being said, as we've
inflammatory bowel disease related Spondyloarthritis
is also a possibility.
These symptoms could be the harbinger of the
future development of IBD.
So that's something to
keep in mind.
Just to highlight the commonly involved
sites or reactive arthritis
we've talked about the knees,
the ankles, the toes,
and highlighted in the red circles there
on the top is where
the Achilles tendon would insert
into the calcaneus.
In the bottom circle, is where the plantar fascia
inserts into the calcaneus tubercle.
Other associated findings that you might
see with reactive arthritis
of course, just like all the Spondyloarthritides, you can
see Uveitis and conjunctivitis
genital urinary symptoms like urethritis
and Cervicitis are common
especially if chlamydia was the preceding infection
that led to reactive arthritis.
Remember the old adage, reactive
arthritis was can't see,
can't pee, can't climb a tree,
referring to the Uveitis,
the urethritis and the arthritis that goes
along with reactive arthritis.
Next up is the dermatologic
We've talked about aphthous
ulcers in the mouth.
Then the other two, there are these
kind of rare birds
that we do see associated the
there's Keratoderma blennorrhagicum which
is a desquamating lesion
that you'll find on the sole of the feet and
then Circinate Balanitis
which has these roundish lesions that are
appearing on the tip of the penis.
Okay, now that we've made this diagnosis,
how are we going to manage it?
You want to check HIV, and that's
for two reasons.
Number one, if you think that person had a sexually
transmitted infection with chlamydia
it's just good practice to check all of the
sexually transmitted infections.
But more importantly, there's a really
high association between
being HIV positive and developing
So it's worth just being thorough. Next up like
all the Spondyloarthritides,
NSAIDs are going to be your
first line management
glucocorticoids can be used as needed.
And then worst case scenario
you can add on some of the non-biologic disease
modifying anti rheumatic drugs as well.
It is preceded by a genital urinary or
about one to four weeks prior to
all the other symptoms.
It's an acute, asymmetric, additive,
look for disease of the eyes, the joints,
the skin, urethritis and other
It is a seronegative
that is the rheumatoid factor
should be negative
you will see some nonspecific
and of course it is associated with
the HLA b 27 Allele.
Lastly NSAIDs and
are your first line treatments
for this condition.