What are the signs and symptoms of human leukocyte antigen (HLA) B27–associated reactive arthritis?

Updated: Apr 09, 2021
  • Author: Huy D Nguyen, MD, MBA; Chief Editor: Andrew A Dahl, MD, FACS  more...
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The syndrome usually begins with urethritis followed by conjunctivitis and rheumatological findings. Arthritis begins within 1 month of infection in 80% of patients. It is usually acute, asymmetric, and oligoarticular and predominantly involves the joints of the lower extremities (eg, knees, ankles, feet, wrists). The arthritis is usually quite painful. Dactylitis or sausage digit is a diffuse swelling of a solitary finger or toe. This is a distinct feature of both reactive arthritis and psoriatic arthritis. Plantar fasciitis and Achilles tendonitis also are common. Sacroiliitis is present in as many as 70% of patients. The eye is involved in 20% of patients, most commonly manifesting as papillary and mucopurulent conjunctivitis that is usually minimal and lasts for only a few days or weeks. 

Reactive arthritis. Involvement of knee (left) and Reactive arthritis. Involvement of knee (left) and conjunctivitis (right). Courtesy of Paul Dieppe, BSc, MD, FRCP, FFPHM.

Punctate and subepithelial keratitis may occur rarely, leading to permanent corneal scars. Acute nongranulomatous iritis occurs in 10% of these patients and may become bilateral and chronic. Mucocutaneous lesions are common and appear in the mouth and palate and on the glans penis and palms and soles.

In addition to the Reiter triad, two other mucocutaneous conditions are part of the major diagnostic criteria for reactive arthritis, according to the American Rheumatological Association (ARA) guidelines: (1) keratoderma blennorrhagicum, a scaly, erythematous, irritating disorder of the palms and soles of the feet, and (2) circinate balanitis, a persistent, scaly, erythematous circumferential rash of the distal penis. Keratoderma blennorrhagicum may resemble pustular psoriasis, which can make it difficult to distinguish between these two seronegative arthropathies. Minor diagnostic criteria of reactive arthritis include sacroiliitis, plantar fasciitis, Achilles tendonitis, nail bed pitting, palatal ulcers, and tongue ulcers.

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