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At the heart of general practice since 1960

Sexual health update

Sexually acquired reactive arthritis

Dr Neil Lazaro advises on diagnosis and management of this condition

Which organisms?

• Chlamydia (up to 70 per cent of cases)

• Gonorrhoea (up to 16 per cent)

• Others unknown

Which patients?

• It is diagnosed in men 10 times more than in women

• Under-recognition in women may be a problem

• If a patient has the HLA B27 gene they have a 50 times increased susceptibility

Clinical features

History

• Ask about past or family history of spondyloarthritis or iritis

• Sexual contact, usually with a new

partner, within three months prior to the onset of the arthritis

• If there is gut infection look for GI trigger as well as STI trigger

Symptoms

• Systemic symptoms of malaise, fever,

fatigue in about 10 per cent

• Onset of arthritis within 30 days of sex in most patients (average of 14 days' interval between the onset of GU symptoms and the arthritis)

• Recent history of urethral discharge and dysuria

• Pain (with or without swelling and stiffness) at one or more (usually less than six) joints

• Joints tend to be knees and feet

• Pain and stiffness at entheses in 20 per cent of patients (especially posterior and plantar aspects of heels)

• Low back pain and stiffness (10 per cent get sacroiliitis during acute episode)

• Irritable eyes with or without drop in

visual acuity, redness or photophobia

– Up to 50 per cent get conjunctivitis

– Up to 10 per cent get iritis

Signs

• Genital infection (urethritis, cervicitis, epididymitis, etc)

• Arthritis (one to five joints, usually

asymmetrical distribution, upper limb

involvement is rare if no psoriasis)

• Enthesopathy (especially at tendon

attachments to calcaneum)

• Tenosynovitis (especially at fingers)

• Pain on direct sacral pressure (but beware pre-existing back pain)

• Pain and redness of eye (this is usually conjunctivitis, but rarely iritis – refer for slit lamp examination to differentiate)

• Psoriasiform skin lesions

– typical plaque or guttate skin lesions

– pustules on soles (keratoderma blennorrhagicum)

• Mucous membrane lesions (geographical tongue, circinate balanitis)

• Heart lesions (usually asymptomatic) – for example, pericarditis

• Renal pathology (usually asymptomatic proteinuria, hence need for dipstick)

Complications

• SARA is usually self-limiting (average

duration five months)

• 50 per cent will get recurrent episodes

• 17 per cent get chronic symptoms

• May get erosive damage to joints causing locomotor disability

• Complications are usually due to aggressive arthritis and are more likely if HLA B27 is positive

• Acute anterior uveitis can cause cataracts and blindness – rare but important to

detect early; get an ophthamology opinion if worried

Diagnosis

Be aware when faced with

• Urethritis in a man (ask about joint pain/sore eyes)

• Cervicitis in a female

• Skin and joint symptoms and signs as above (ask about urethritis)

Management

Symptoms are self-limiting in most cases but:

• Check FBC, ESR or C-reactive protein, and urinalysis. FBC helps to exclude septic arthritis, sickle cell and bleeding diatheses, which can all present with swollen joints

• Consider stool culture

• Refer for STI screen even if there are no symptoms (the patient could have asymptomatic chlamydia)

• Refer for ophthamology opinion if there are eye symptoms

• Consider X-rays of affected joints

• Consider testing for HLA B27 (usually done by blood transfusion labs)

• General advice – to rest and take NSAIDs

• Liaise with relevant specialty early.

Involve rheumatologist/GUM clinic/dermatologists/ophthalmology as necessary.

This article is based on Sexually Transmitted Infections in Primary Care by Dr Neil Lazaro, published by the RCGP sex, drugs and

HIV task group and the British Association

for Sexual Health and HIV.

See www.rcgp.org.uk/PDF/clinspec_STI_ in_primary_care_NLazaro.pdf

Neil Lazaro is a GP hospital practitioner in GU medicine in Lancaster, a member of the RCGP sex, drugs and HIV task group and he also sits

on the BASHH clinical effectiveness group

Acknowledgments to Dr Elizabeth Carlin, a GUM consultant in Nottingham, for extra advice on this article.

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