GPAtlas🧭 When to suspect
Reactive arthritis (ReA) is a sterile, culture-negative inflammatory arthritis triggered by an infection at a distant site. It is a peripheral form of spondyloarthritis (SpA) and is associated with human leukocyte antigen B27 (HLA-B27). Suspect it in an acute, asymmetric oligoarthritis (a few joints), predominantly of the lower limbs (knees, ankles, feet), developing 1–4 weeks after a gastrointestinal or genitourinary infection.
Two trigger patterns are recognised: post-enteric ReA, after a diarrhoeal illness, and sexually acquired reactive arthritis (SARA), after a sexually transmitted infection (STI). The classic triad of arthritis, urethritis and conjunctivitis is present in only a minority – most patients do not have all three, so its absence does not exclude the diagnosis.
The two priorities in primary care are to recognise the post-infective pattern and to never miss septic arthritis or sight-threatening anterior uveitis, both of which can masquerade as, or complicate, reactive arthritis.
| Post-enteric reactive arthritis | Sexually acquired reactive arthritis (SARA) |
|---|---|
|
• Pathogens: Campylobacter, Salmonella, Shigella, Yersinia |
• Pathogens: Chlamydia trachomatis (commonest); also Neisseria gonorrhoeae, Mycoplasma genitalium |
|
• Preceding illness: diarrhoea ± vomiting, typically 1–4 weeks earlier |
• Preceding illness: urethritis / cervicitis – dysuria, discharge; recent new or unprotected sexual contact |
|
• Who: men and women affected roughly equally |
• Who: more common in young men (up to around 9:1) |
|
🧠 Clinical pearl Do not wait for the full triad. Most patients never develop arthritis, urethritis and conjunctivitis together, and the eponym Reiter's syndrome has been abandoned (Reiter was a convicted war criminal). Consider reactive arthritis in any acute lower-limb oligoarthritis following a recent gut or genital infection – even with a single extra-articular clue such as heel pain or a red eye. |
Source: NICE NG65 · BASHH SARA 2021
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