Reactive arthritis and post-infectious inflammatory syndromes

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Target exams

Red flags

• A child with an acute swollen joint and a fever is septic arthritis until proven otherwise, and the Kocher criteria, the blood cultures and the joint aspirate must come before the label of reactive arthritis is applied
• A child with the asymmetric arthritis after a group A streptococcal infection needs the echocardiogram to exclude the subclinical carditis of the acute rheumatic fever, because a missed carditis may scar the mitral valve
• A child on the anti-tumour-necrosis-factor biologic with a fever has a serious infection until proven otherwise, because the blockade masks the signs and the empiric antibiotics come before the cultures return
• The red eye in a child with the post-infectious arthritis may be the acute anterior uveitis that scars the sight, and the slit-lamp and the urgent ophthalmology referral are non-negotiable

Life stages

Care settings

Clinical exam formats

Board mappings

• Defines reactive arthritis as a sterile inflammatory arthritis arising one to four weeks after a distant infection of the genitourinary or gastrointestinal tract, and distinguishes it from septic arthritis by the asymptomatic interval and the absence of organisms in the joint
• Names the classic Reiter triad of arthritis, conjunctivitis or uveitis, and urethritis, while recognising that the full triad is uncommon in children and that the term is now discouraged in favour of reactive arthritis
• Identifies the HLA-B27 association and the asymmetric lower-limb oligoarthritis with enthesitis as the clinical signature, and lists Salmonella, Shigella, Campylobacter, Yersinia and Chlamydia as the classic triggers
• Distinguishes post-streptococcal reactive arthritis from acute rheumatic fever by the latency under ten days, the additive rather than migratory pattern, the persistence beyond the non-steroidal anti-inflammatory drug course, the prominent enthesitis, and the absence of carditis
• Applies the 2015 revised Jones criteria for acute rheumatic fever, including the low-risk and moderate-or-high-risk population splits, the echocardiographic subclinical carditis criterion, and the monoarthritis allowance in high-risk populations
• Coordinates the stepwise management from the exclusion of septic arthritis through the non-steroidal anti-inflammatory drugs and the intra-articular corticosteroid to the disease-modifying drugs for persistent disease, with the treatment of the triggering infection and the partner notification
• A child with an acute swollen joint and fever is septic arthritis until proven otherwise, and the Kocher criteria, the blood cultures and the joint aspirate must come before the label of reactive arthritis is applied
• Naproxen at ten milligrams per kilogram per day in two divided doses or ibuprofen at thirty milligrams per kilogram per day in three divided doses is the first-line treatment for reactive arthritis, with the intra-articular triamcinolone hexacetonide for the persistent monoarthritis or oligoarthritis
• A child with post-streptococcal reactive arthritis needs the echocardiogram to exclude the subclinical carditis of acute rheumatic fever, and the penicillin prophylaxis decision is guided by the carditis and the risk of recurrence
• Examines the child with the suspected reactive arthritis systematically, looking for the enthesitis at the Achilles tendon and the plantar fascia, the dactylitis, the conjunctivitis or uveitis, and the cutaneous stigmata of keratoderma blennorrhagicum and circinate balanitis
• Counsels the family on the self-limiting nature of most reactive arthritis, the importance of treating the triggering infection and the Chlamydia contact tracing, the rheumatology referral for the persistent disease, and the safety-net for the red flags of sepsis and uveitis
• Synthesises the differential between the reactive arthritis, the post-streptococcal reactive arthritis, the acute rheumatic fever, the enthesitis-related juvenile idiopathic arthritis and the periodic fever syndromes, and defends each with the discriminating features
• Level 1: Recognition of the asymmetric oligoarthritis one to four weeks after the gastrointestinal or genitourinary infection, the exclusion of the septic arthritis, and the HLA-B27 association
• Level 2: Application of the post-streptococcal reactive arthritis and acute rheumatic fever distinction with the 2015 Jones criteria, and the stepwise management from the non-steroidal anti-inflammatory drugs through the intra-articular corticosteroid
• Level 3: Coordination of the multidisciplinary care for the persistent disease, the disease-modifying and biologic escalation, the uveitis screening, and the differentiation from the autoinflammatory syndromes
• The classic triggers of reactive arthritis in Salmonella, Shigella, Campylobacter, Yersinia and Chlamydia, the one-to-four-week latency, and the HLA-B27 association with the asymmetric lower-limb oligoarthritis and the enthesitis
• The distinction of the post-streptococcal reactive arthritis from the acute rheumatic fever, the 2015 revised Jones criteria with the population-risk splits and the echocardiographic carditis, and the role of the antibiotic prophylaxis
• The Reiter triad and its limitations, the keratoderma blennorrhagicum and the circinate balanitis, and the naproxen and ibuprofen first-line treatment with the intra-articular corticosteroid and the disease-modifying escalation
• Structured musculoskeletal examination of the child using the look-feel-move-measure approach, with the specific search for the enthesitis, the dactylitis and the sacroiliac tenderness
• Recognition of the conjunctivitis and the uveitis, the cutaneous stigmata, and the post-infectious timeline that anchors the reactive arthritis diagnosis
• Communication of the diagnosis, the self-limiting prognosis, the treatment of the trigger and the contact tracing, and the rheumatology referral plan to the child and the family
• Reactive arthritis as the sterile arthritis one to four weeks after the gastrointestinal or genitourinary infection, presenting with the asymmetric lower-limb oligoarthritis and the enthesitis in the HLA-B27-positive child
• The diagnostic pathway of the exclusion of the septic arthritis, the stool and urine and throat cultures, and the differentiation from the post-streptococcal reactive arthritis and the acute rheumatic fever
• The stepwise treatment from the non-steroidal anti-inflammatory drugs through the intra-articular corticosteroid to the disease-modifying drugs, with the treatment of the triggering infection
• Recognition of the reactive arthritis in the child with the acute asymmetric arthritis following the gastrointestinal or genitourinary infection, and the exclusion of the septic arthritis as the first priority
• Application of the 2015 Jones criteria for the acute rheumatic fever and the distinction from the post-streptococcal reactive arthritis, with the echocardiogram to exclude the carditis
• Coordination of the multidisciplinary treatment and the uveitis surveillance, with the rheumatology referral for the persistent or the refractory disease
• Canadian approach to the child with the post-infectious arthritis, the exclusion of the septic arthritis and the osteomyelitis, and the recognition of the reactive arthritis and the enthesitis-related spectrum
• The HLA-B27 association and the trigger organisms, and the 2015 Jones criteria for the acute rheumatic fever with the carditis as the hallmark
• The stepwise treatment and the surveillance, the transition, and the differentiation from the periodic fever and the autoinflammatory syndromes