What is the treatment and management approach for a young to middle-aged adult with Reiter's syndrome (reactive arthritis) and a history of recent bacterial infection?

Treatment and Management of Reiter's Syndrome (Reactive Arthritis)

Begin treatment with NSAIDs as first-line therapy for all patients with Reiter's syndrome, add doxycycline 100 mg orally twice daily for 7 days if Chlamydia trachomatis infection is documented or suspected, and escalate to DMARDs for persistent symptoms beyond 4-6 weeks. 1

Initial Assessment and Diagnosis

Before initiating treatment, confirm the diagnosis by identifying:

• Classic triad: Conjunctivitis, urethritis, and arthritis occurring 1-6 weeks after urogenital or gastrointestinal infection 2, 3
• Asymmetric oligoarthritis predominantly affecting lower extremity large joints (knees, ankles) 4
• Preceding infection: Urogenital (77.5% of cases, most commonly Chlamydia trachomatis) or enteric (16.5% of cases, Salmonella or Shigella) 5, 4
• HLA-B27 positivity: Present in 67-83% of patients, indicating genetic susceptibility 3, 5, 4

First-Line Treatment: NSAIDs

Initiate high-dose potent NSAIDs immediately as the cornerstone of initial management for all patients 1, 5. This addresses the inflammatory arthritis that dominates the clinical picture and provides symptomatic relief.

Antibiotic Therapy

For urogenital Chlamydia trachomatis infection:

• Prescribe doxycycline 100 mg orally twice daily for 7 days 1
• This may shorten the disease course or prevent arthritis onset 1, 5
• Treat even if the acute infection has resolved, as the organism may persist 5

For enteric infections (Salmonella, Shigella):

• Do not use antibiotics, as they have not been shown to be effective for post-enteric reactive arthritis 5

Management of Specific Manifestations

Ocular involvement (conjunctivitis):

• Treat with artificial tears containing methylcellulose or hyaluronate 1
• Avoid anticholinergic medications as they worsen sicca symptoms 1
• Monitor for uveitis, which requires ophthalmologic consultation 2

Large joint involvement:

• Consider intra-articular corticosteroid injections for persistent monoarticular or oligoarticular disease 5
• This provides targeted relief without systemic corticosteroid exposure

Escalation to DMARDs

For persistent symptoms beyond 4-6 weeks despite NSAIDs:

• Initiate disease-modifying antirheumatic drugs (DMARDs) 1
• This prevents progression to chronic destructive arthritis, which occurs in 15-20% of patients 2

Corticosteroid Use: Exercise Caution

Minimize systemic corticosteroid use:

• Use only at the minimum effective dose and duration 1
• Overuse leads to significant side effects without clear benefit in reactive arthritis 1
• Reserve for severe systemic manifestations or when other therapies fail

Special Considerations

HIV-positive patients:

• Treatment is more difficult with variable response 2
• Screen young men presenting with reactive arthritis for HIV, as this may be the first manifestation 5

Chronic or recurrent disease (occurs in ~60% of patients):

• Chronic form affects 28.5% of patients, recurrent form affects 31% 4
• These patients require long-term DMARD therapy to prevent joint destruction 1
• Monitor for extra-articular complications including cardiac involvement 3

Common Pitfalls to Avoid

• Do not delay antibiotic treatment if Chlamydia infection is suspected—waiting for culture results may allow arthritis to develop 5
• Do not use antibiotics for post-enteric reactive arthritis—this is ineffective and contributes to resistance 5
• Do not rely solely on NSAIDs for patients with persistent symptoms beyond 4-6 weeks—early DMARD initiation prevents chronic sequelae 1, 2
• Do not overlook dermatologic manifestations (keratoderma blennorrhagicum, circinate balanitis) which confirm the diagnosis 2