Reactive Arthritis Imaging

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Reiter syndrome was originally defined as a triad of arthritis, conjunctivitis, and urethritis. Hans Reiter first reported this triad of symptoms in 1916, and Bauer and Engelman formally described it as a syndrome in 1942.

A term frequently associated with Reiter syndrome is reactive arthritis. Ahvonen and coworkers introduced this term in 1969. Reactive arthritis is used to describe an acute arthritis complicating an infection elsewhere in the body in which the infecting organism cannot be cultured from the joint fluid or synovium. ^{[1, 2]}

Approximately 80% of patients are positive for the histocompatibility antigen called human leukocyte antigen (HLA)-B27; therefore, reactive arthritis is strongly associated with HLA-B27. Reiter syndrome is now thought to be only 1 clinical manifestation of reactive arthritis. Because of its association with HLA-B27 and its clinical overlap with ankylosing spondylitis and psoriatic arthritis, reactive arthritis and Reiter syndrome are classified as types of seronegative (for rheumatoid factor) spondyloarthropathy. ^{[3, 4]}

Radiography is most important imaging technique for the detection of Reiter syndrome. Computed tomography (CT) can demonstrate small structural alterations of cortical and spongy bone, and magnetic resonance imaging (MRI) can identify bone marrow edema. ^[5]

Images of reactive arthritis are provided below:

Radiographs are a reliable means of diagnosing Reiter syndrome, particularly if the typical clinical features are present.

In early stage, radiographs are normal. The synovial joint, symphyses, and entheses are affected. An asymmetrical distribution with predominant involvement of lower extremities is seen.

The general radiographic changes are similar to those of psoriatic arthritis, but the characteristic sites of abnormality are the small joints of the foot, the calcaneus, the ankle, the knee, and the sacroiliac joint. Nonspecific soft-tissue swelling is frequently seen in the toes and fingers, resulting in sausage-shaped digits.

Periarticular osteoporosis is seen with acute episode of arthritis. Diffuse loss of the articular space is characteristic and frequently affects the small joints of the foot, hand, wrist, knee, and ankle. Bone erosions may also occur at these joints, resulting in sacroiliitis. Erosions initially occur at the joint margins and later progress to involve subchondral bone in the central portion.

Bone proliferation is characteristic of all seronegative spondyloarthropathies and is the most helpful radiographic feature in distinguishing these conditions from rheumatoid arthritis. Linear and fluffy periosteal bone proliferations are common in Reiter syndrome, especially in the calcaneus; knee; and metacarpal, metatarsal, and phalangeal shafts. A second variety of bone proliferation occurs at the sites of tendon and ligament attachments to the bone.

Intra-articular bony ankylosis is seen in small joints of hands and feet but is less common than it is in ankylosing spondylitis and psoriatic arthritis.

Radiographs of the foot show asymmetrical involvement of the metatarsophalangeal and interphalangeal joints. Any joint may be affected; the joints of the great toe are commonly involved, as shown in the image below.

Calcaneal enthesopathy is characteristic of Reiter syndrome and occurs in 25-50% of cases. The posterior and plantar aspects of the bone are affected, as shown in the image below. Bilateral changes are common.

Radiographic findings are seen in 30-50% of patients. Changes include soft-tissue swelling, linear or fluffy periostitis of the distal tibial and fibular diaphyses and metaphysis, and articular space loss and marginal erosions.

Knee changes are seen in 25-50% of patients. The most common abnormality is joint effusion.

Changes in the upper extremity are seen in 10-30% of cases. Abnormalities of the proximal interphalangeal joint are more common than changes in the metacarpophalangeal and distal interphalangeal joints. Involvement of the wrist is usually asymmetrical. Erosion of the metacarpal heads is demonstrated in the image below. ^[6]

Osseous erosions and adjacent bony proliferation at the manubriosternal joints are seen in Reiter disease and may be associated with local pain and tenderness. Similar changes are seen at the symphysis pubis.

Patients with Reiter disease often have condylar erosions that cause pain and dysfunction in the temporomandibular joints. These abnormalities can be demonstrated by plain radiography. When the radiographs are inconclusive, the changes can be depicted by magnetic resonance imaging (MRI) or computed tomography (CT) scanning. ^{[6, 7]}

Sacroiliitis is common in Reiter syndrome; while it is seen in only 5-10% of patients with acute disease, it is present in 40-60% of patients with chronic, severe disease. If supplemented with radionuclide investigation, sacroiliitis is found in 60-75% of patients.

Bilateral, asymmetrical changes, demonstrated in the image below, are most typical. Less commonly, unilateral abnormalities of the sacroiliac joint are seen in Reiter syndrome, particularly early in the disease process.

Spinal changes are less common than the other changes in Reiter disease and are seen less often than in ankylosing spondylitis and psoriatic arthritis. An early finding in Reiter syndrome is the appearance of paravertebral syndesmophytes about the lower 3 thoracic and upper 3 lumbar vertebrae, as shown in the image below.

Sacroiliitis is demonstrable on CT scanning earlier than on plain radiography. Early sacroiliitis manifests with small joint erosions and irregularities in the articular surfaces of the sacroiliac joint, as shown in the image below. Unilateral or asymmetrical involvement of the sacroiliac joints is also common. Enthesopathies are also demonstrable.

The high radiation dose to the patient makes CT an unattractive modality for screening large areas of the body in cases of suspected Reiter disease, but CT is useful in localized evaluations or in determining the extent of complications, such as bony ankylosis, when plain radiographs are inconclusive.

CT is also useful in interventions, such as CT-guided injections of the sacroiliac joint (shown in the image below), and in the management of chronic, severe sacroiliac joint pain.

CT is a reliable means of establishing diagnosis of sacroiliitis and in demonstrating enthesopathies. However, the findings are generally nonspecific and should be correlated with the clinical picture.

In Reiter disease, MRI reveals the extent of the process; the presence of bursitis and tenosynovitis, especially in the peroneal, anterior tibial, and posterior tibial tendons; and the presence of complications, such as synovial cysts. Erosive arthritis and synovitis may develop in the hands and wrists.

Synovitis and tenosynovitis are hypointense on T1-weighted images and hyperintense on T2-weighted, spin-echo images. These appearances reflect the water content of the affected areas. Short-tau inversion recovery (STIR) images reveal strong hyperintensity in the affected joints and adjacent marrow, as well as in sites of enthesitis, as shown in the images below.

MRI has extremely high sensitivity for active Reiter disease but low specificity. Correlation with clinical and radiographic findings is usually necessary to differentiate Reiter disease from other seronegative arthropathies.

Plantar fasciitis is the most common cause of inferior heel pain, and Reiter disease is one of the causes of plantar fasciitis.

High-resolution ultrasonography reveals decreased echogenicity and increased thickness of the plantar fascia (normal thickness, 3-4 mm).

In addition to Reiter disease, a variety of rheumatologic conditions can cause plantar fasciitis. Examples include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and gout. The ultrasonographic findings of these conditions are identical. These other disease should be considered in the differential diagnosis and excluded with clinical history taking and other means.

Bone scintigraphy with bone-seeking radiopharmaceutical agents allows the early detection of Reiter syndrome and provides accurate details about the extent of the disease. The distribution of abnormal radionuclide accumulation parallels that obtained by radiographic examination and may occur before radiographic and clinical alterations are apparent.

Asymmetrical involvement of lower extremity is usually seen. Increasing radioactivity related to the plantar and posterior aspects of the calcaneus is observed.

Scintigraphy provides high sensitivity but low specificity for the diagnosis of sacroiliitis.

The interpretation of scintigraphic abnormalities at sacroiliac joints is difficult, because prominent uptake at this site is a normal finding.

Abnormal radionuclide uptake in the sacroiliac joint and other locations may not be specific for Reiter syndrome. Other seronegative spondyloarthropathies, such as psoriatic arthritis, may have similar findings.

Moorthy LN, Gaur S, Peterson MG, Landa YF, Tandon M, Lehman TJ. Poststreptococcal reactive arthritis in children: a retrospective study. Clin Pediatr (Phila). 2009 Mar. 48(2):174-82. [Medline].

El-Khoury GY, Kathol MH, Brandser EA. Seronegative spondyloarthropathies. Radiol Clin North Am. 1996 Mar. 34(2):343-57, xi. [Medline].

Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. 2009 Apr. 44(4):309-15. [Medline].

Selmi C, Gershwin ME. Diagnosis and classification of reactive arthritis. Autoimmun Rev. 2014 Apr-May. 13 (4-5):546-9. [Medline].

Paparo F, Revelli M, Semprini A, Camellino D, Garlaschi A, Cimmino MA, et al. Seronegative spondyloarthropathies: what radiologists should know. Radiol Med. 2014 Mar. 119 (3):156-63. [Medline].

Jevtic V, Watt I, Rozman B. Distinctive radiological features of small hand joints in rheumatoid arthritis and seronegative spondyloarthritis demonstrated by contrast-enhanced (Gd-DTPA) magnetic resonance imaging. Skeletal Radiol. 1995 Jul. 24(5):351-5. [Medline].

Kononen M, Kovero O, Wenneberg B, Konttinen YT. Radiographic signs in the temporomandibular joint in Reiter’s disease. J Orofac Pain. 2002. 16(2):143-7. [Medline].

Aminzadeh Z, Fadaeian A. Reactive arthritis induced by bacterial vaginosis: prevention with an effective treatment. Int J Prev Med. 2013 Jul. 4(7):841-4. [Medline]. [Full Text].

Chrisment D, Machelart I, Wirth G, Lazaro E, Greib C, Pellegrin JL, et al. Reactive arthritis associated with Mycoplasma genitalium urethritis. Diagn Microbiol Infect Dis. 2013 Nov. 77(3):278-9. [Medline].

Kaarela K, Jäntti JK, Kotaniemi KM. Similarity between chronic reactive arthritis and ankylosing spondylitis. A 32-35-year follow-up study. Clin Exp Rheumatol. 2009 Mar-Apr. 27(2):325-8. [Medline].

Singh M, Ganguli NK, Singh H, Deodhar SD, Sethi S, Sharma M. Role of 30 kDa antigen of enteric bacterial pathogens as a possible arthritogenic factor in post-dysenteric reactive arthritis. Indian J Pathol Microbiol. 2013 Jul-Sep. 56(3):231-7. [Medline].

Anil Kumar Aribandi, MBBS, MD, MRCP Specialist Registrar, Department of Hematology, Manchester Royal Infirmary, UK

Disclosure: Nothing to disclose.

Oludare Adetokunbo Demuren, MD, FRCR Consulting Staff, Department of Radiology, Colchester General Hospital

Oludare Adetokunbo Demuren, MD, FRCR is a member of the following medical societies: Royal College of Radiologists

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Theodore E Keats, MD Professor, Departments of Radiology and Orthopedics, University of Virginia School of Medicine

Disclosure: Nothing to disclose.

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Amilcare Gentili, MD Professor of Clinical Radiology, University of California, San Diego, School of Medicine; Consulting Staff, Department of Radiology, Thornton Hospital; Chief of Radiology, San Diego Veterans Affairs Healthcare System

Amilcare Gentili, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Reactive Arthritis Imaging

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