Management of Reiter Syndrome (Reactive Arthritis)
The management of Reiter syndrome (reactive arthritis) should focus on treating the underlying infection, controlling inflammation with NSAIDs as first-line therapy, and using disease-modifying agents for persistent symptoms, while incorporating exercise and physical therapy for optimal outcomes.
Definition and Etiology
Reactive arthritis (formerly known as Reiter syndrome) is an inflammatory spondyloarthropathy that typically follows a urogenital or gastrointestinal infection, characterized by the classic triad of:
- Conjunctivitis
- Urethritis
- Arthritis
The condition most commonly affects young men, with an estimated frequency of 3.5-5 per 100,000 in the United States 1. It is associated with HLA-B27 genotype in over two-thirds of patients 2.
Diagnostic Approach
When evaluating a patient with suspected reactive arthritis:
Identify the triggering infection:
- Genitourinary infections (most commonly Chlamydia trachomatis)
- Gastrointestinal infections (certain strains of Salmonella or Shigella)
- Consider HIV testing as reactive arthritis may be the first manifestation of HIV infection 2
Clinical presentation:
- Inflammatory arthritis (typically asymmetric, affecting lower limbs)
- Urethritis
- Conjunctivitis
- Dermatologic manifestations (keratoderma blennorrhagicum, circinate balanitis, nail changes)
- Oral lesions
Laboratory testing:
- Inflammatory markers (ESR, CRP)
- HLA-B27 testing
- Joint fluid analysis to rule out septic arthritis
- Specific testing for triggering infections
Treatment Algorithm
1. Treat the Underlying Infection
For genitourinary infections (particularly Chlamydia):
- Doxycycline 100 mg twice daily for 7-10 days 2
- Early antibiotic treatment may shorten the course or prevent the onset of arthritis
For enteric infections:
- Antibiotics have not been shown to be effective for reactive arthritis following Salmonella or Shigella infections 2
2. Control Inflammation and Symptoms
First-line therapy:
- High-dose NSAIDs (e.g., indomethacin 25-50 mg 3-4 times daily) 2
- Continue until symptoms resolve, typically 4-6 weeks
For inadequate response to NSAIDs:
- Intra-articular corticosteroid injections for large joint involvement 2
- Consider systemic corticosteroids for severe symptoms (prednisone 0.5-1 mg/kg/day with gradual taper)
3. For Persistent Symptoms (>3-6 months)
Disease-modifying antirheumatic drugs (DMARDs):
- Methotrexate (7.5-15 mg weekly, escalating to 20-25 mg) 3
- Sulfasalazine (2-3 g daily in divided doses)
For refractory cases:
- Consider biologic agents (TNF inhibitors) based on principles similar to those for rheumatoid arthritis management 4
4. Non-pharmacological Interventions
- Exercise and physical therapy to maintain joint function and muscle strength 4
- Occupational therapy for adaptive devices if needed
- Self-management programs to improve coping with pain and disability 4
Monitoring and Follow-up
- Regular assessment of disease activity every 1-3 months during active disease 4
- Monitor for complications and extra-articular manifestations
- Adjust therapy if no improvement after 3 months or if target not reached by 6 months 4
Prognosis
- Variable course: 15-20% of patients may develop severe chronic sequelae 5
- Most patients recover completely within 3-12 months
- Recurrences may occur in 15-50% of cases
- HIV-positive patients may have more severe and persistent disease 5
Special Considerations
- In pregnancy: NSAIDs should be avoided in the third trimester; consult with rheumatologist for alternative treatments
- Comorbidities: Assess and manage cardiovascular risk factors
- Chronic disease: Consider multidisciplinary approach involving rheumatology, ophthalmology, and urology as needed
Early recognition and appropriate management are crucial to prevent progression to chronic destructive arthritis and improve long-term outcomes 1.