Working Diagnosis:
Reactive Arthritis (ReA)

Treatment:
On the day of initial presentation, patient received therapeutic bilateral trapezius trigger point injections with lidocaine and betamethasone. He was advised to continue Nsaid therapy and physical therapy with focus on rotational maneuvers of the cervical spine.

Patient followed up 2 weeks later, at which time he had complete resolution of the right knee pain and significant improvement in left hip pain and limp. His neck stiffness/pain continued without improvement. He also had developed some intermittent eye irritation and dryness. At initial follow up we also had the results from our laboratory investigation showing positive HLA-B27 and moderate elevations in ESR and CRP. This prompted us to seriously consider the diagnosis of reactive arthritis. Patient's previous salmonella infection, subsequent development of polyarticular arthralgias, and now with left eye irritation supported our diagnosis.

Outcome:
Patient continues to follow up in clinic regularly; at one month follow up, the patient had further improvement in his hip pain with some mild improvement in neck pain. Patient was next prescribed an oral prednisone taper for 8 days. He continued with scheduled physical therapy appointments.

At six week follow up, the patient's only remaining symptom was neck stiffness and neck pain. He has no neurological/radicular symptoms. The patient is currently awaiting referral to a PM&R specialist for therapeutic facet injections. As our primary diagnosis is reactive arthritis continued discussion in regards to the self-limiting nature of disease and continued symptomatic treatment remain mainstay.

Author's Comments:
Reactive arthritis is a systemic inflammatory arthritis often in response to recent genitourinary or
gastrointestinal infection. Most common pathogens include Chlamydia trachomatis, Salmonella, Shigella flexneri, Campylobacter jejuni, and Yersinia. Less common include Neisseria gonorrhoeae, Clostridium difficile, and E. Coli.

Typically, patients present with acute onset oligo arthritis mainly affecting the lower extremities, sacroiliac joint, and the lumbar spine. In rare instances as in the case above, the cervical spine may become involved. Classically reactive arthritis joint pain is nocturnal early morning stiffness, isometric and affecting weight-bearing joints. 30% of patients can suffer from plantar fasciitis or Achilles tendinitis.

Human Leukocyte-Antigen B27 is estimated to be present in 30% to 50% of patients with reactive arthritis, which may correlate with disease severity but is not by itself diagnostic. A combination of elevated CRP and positive HLA-B27 carries a 69% sensitivity in 93.6% specificity to the diagnosis of reactive arthritis.

Reactive arthritis treatment begins with treating the preceding infection. Symptomatic relief and
prevention of chronic complications are the mainstay of treatment including nonsteroidal anti-inflammatory drugs, intra-articular or local glucocorticoids; Systemic glucocorticoids are generally limited for severe polyarthritis, cardiac, and/or ocular involvement. This disorder is self-limiting with resolution occurring in weeks to months. Reoccurrences happen in reported 25 - 50% of cases, especially in patients who are HLA B-27 positive. Of the patients w/ ReA, 30-50% of them can progress into long-term arthritis or other joint abnormalities.

Editor's Comments:
Reactive arthritis is a is a seronegative spondyloarthropathy. Flares of this condition typically follow a genitourinary or gastrointestinal infection and typically presents with acute oligoarthritis involving the lower extremities, sacroiliac joint, and the spine. Patients typically report symptoms of pain in multiple joint, dry/irritated eyes and urinary discomfort. During the history, it is important to gain insight in to recent infections that involved in the genitourinary and gastrointestinal tracks. Common bacteria associated with Reactive Arthritis are: mycoplasma, yersinia ,salmonella, shigella, chlamydia, and campylobacter.

The physical examination typically demonstrates arthritis, conjunctivitis and urethritis Diagnostic testing includes the collection of inflammatory markers, Erythrocyte sedimentation rate, C-reactive protein, a Urinalysis and Human leukocyte antigen B27. Both the erythrocyte sedimentation rate, C-reactive protein are typically elevated and patients are Human leukocyte antigen B27 positive in 75% of the cases. A combination of elevated C-reactive protein and positive Human leukocyte antigen B27 carry a 69% sensitivity and 93.6% specificity for this condition. Most cases are self-limited with treatment for reactive arthritis, centered on symptomatic relief by utilizing Non-steroidal anti-inflammatory drugs and physical therapy. Glucorticoids can be used in recalcitrant cases. Antibiotic therapy is indicated when an active infection is identified. Severe cases can result in complications that include aortic insufficiency, arrhythmia, and polyarthritis.

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