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Reactive arthritis

What is Reactive Arthritis?

Reactive arthritis, formerly known as Reiter’s syndrome, is an inflammatory form of arthritis that occurs as a reaction after an infection in another part of the body. The inciting infection usually is in either the urogenital tract (bladder, vagina or urethra) or the intestinal tract (called enteric reactive arthritis). Although the bacteria do not migrate to other parts of the body, they do set off a reaction in different parts of the body. The three classic symptoms of reactive arthritis are inflammation of the eyes (conjunctivitis), inflammation of the urinary tract (urethritis) and inflammation of the joints (arthritis).

The symptoms of reactive arthritis usually last three to 12 months. Many affected individuals have mild or absent conjunctivitis and urethritis with only a couple swollen and painful joints. However, some people may have an acute, severe bout of reactive arthritis that can seriously limit their activities.

Medications are available that can reduce the pain and inflammation of the eyes, urinary tract and joints. Most people with reactive arthritis have no long-term damage to their eyes or joints.

What causes it?

The bacterium most often associated with reactive arthritis isChlamydia trachomatis, commonly known as Chlamydia, which is usually acquired through sexual contact. Chlamydiainfections often have no symptoms; if symptoms do occur, they include pain during urination and a discharge from the penis or vagina.

Bacteria in the digestive tract that may trigger reactive arthritis include Salmonella, Shigella, Yersinia and Campylobacter. These infections cause severe diarrhea with blood and mucus in the stools. People may become infected after eating or handling improperly prepared food, or through contact with the feces of an infected person.

Why some people who are infected with these bacteria develop reactive arthritis and some don’t is not known. Having the genetic factor HLA-B27 increases a person’s chance of developing the disease. HLA-B27 is associated with a whole group of rheumatic diseases known as the seronegative sponlyloarthropathies, including ankylosing spondylitis, psoriatic arthritis, the arthritis of inflammatory bowel disease, the undifferentiated spondyloarthropathies, as well as reactive arthritis.

What are the symptoms/effects?

Reactive arthritis typically begins two to four weeks after a venereal infection or intestinal infection. Urethritis usually is the first symptom but may frequently be absent in women. This is accompanied or followed by conjunctivitis. Arthritis is usually the last symptom to appear.

Most people will recover from the initial flare of symptoms and be able to return to normal activities after three to six months. For these people, mild symptoms of arthritis may last for up to 12 months. Some reactive arthritis patients will have a relapse of symptoms at some point after the initial flare has disappeared. About 20 percent of people with the disease will develop chronic arthritis.

Following is a list of symptoms for reactive arthritis by body part.

  • Urogenital symptoms: Inflammation in the urogenital tract occurs in both postvenereal and postenteric (intestinal) forms of the disease.
  • Urethritis: Men may notice an increased need to urinate, a burning sensation when urinating and a fluid discharge from the penis. Women may notice a burning sensation during urination.
  • Prostatitis: Some men may develop inflammation of the prostate gland.
  • Cervicitis: Some women may develop inflammation of the cervix.
  • Salpingitis: Some women may develop inflammation of the fallopian tubes.
  • Vulvovaginitis: Some women may develop inflammation of the vulva and vagina.
  • Eye symptoms: Not all people with reactive arthritis will have eye problems, or they may be mild and go unnoticed.
  • Conjunctivitis: Inflammation of the mucous membrane that protects the eye will cause redness, a burning sensation and crusting in the morning.
  • Anterior uveitis (iritis): Inflammation of the interior portion of the eye that includes the iris results in redness, pain, blurred vision and sensitivity to light.
  • Musculoskeletal symptoms: Joint symptoms typically appear last, after urinary and eye symptoms have subsided.
  • Arthritis: Knees, ankles and small joints of the feet become inflamed more commonly than do joints of the wrists, elbows or hands. The average number of involved joints is four, and they are not affected symmetrically – meaning that different joints on each side of the body are affected. Joints become swollen, warm, tender and painful when moved. When fingers or toes are involved, they may become diffusely swollen and are often called “sausage digits.”
  • Enthesitis: Inflammation at sites where tendons, ligaments or fascia attach to bone is common in reactive arthritis. Especially common and debilitating is heel pain brought on by the inflammation of the attachment points of the plantar fascia and the Achilles tendon.
  • Sacroiliitis: Low back and buttock pain often occur in people with reactive arthritis, but only about 20 percent have inflammation of the sacroiliac joint that can be seen by X-ray. Approximately 10 percent of reactive arthritis patients will progress to having ankylosing spondylitis.
  • Skin symptoms: Several rashes and skin lesions are highly associated with reactive arthritis.
  • Keratoderma blennorrhagicum: About 20 to 25 percent of people with reactive arthritis develop a rash or raised, waxy bumps on the soles or palms. These lesions eventually will grow together to form large scaly patches that look like psoriasis.
  • Circinate balanitis: About 25 percent of men with reactive arthritis develop shallow, painless lesions on the penis. The nature of these lesions is different on circumcised (moist, shallow ulcers with a wavy or indented margin) and uncircumcised (dry, plaque-like lesions resembling psoriasis) penises.
  • Oral ulcers: About 15 percent of patients have shallow, painless lesions on the tongue or hard palate.

How is it diagnosed?

There is no one single test that your doctor can give to determine whether you have reactive arthritis. By listening to your description of symptoms, by asking you questions and by running a few laboratory tests, your doctor can make a clinical diagnosis.

  • Medical history: Your doctor may look for clues about possible infections you may have had; you may be asked about fever, vomiting, bloody diarrhea, painful urination and changes in sexual partners. You may be asked about mild symptoms of reactive arthritis, such as crusty eyes in the morning.
  • Physical exam: During a physical exam, your doctor will look for evidence of reactive arthritis, as well as evidence of other causes of your symptoms. Some examples include eye inflammation, discharge from your penis or vagina, skin rashes or lesions, oral ulcers, joint inflammation and heel pain.
  • Laboratory tests: Your doctor may run some tests to rule out other possible causes of your symptoms and some tests to help positively diagnose reactive arthritis.
  • Sedimentation rate or C-reactive protein: These tests indicate whether inflammation is present somewhere in the body. Reactive arthritis, as well as several other diseases, will increase your sedimentation rate or C-reactive protein level.
  • Rheumatoid factor (RF): Serum RF is usually negative in patients with reactive arthritis.
  • Antinuclear antibody (ANA): Antinuclear antibodies are usually not detected in patients with reactive arthritis.
  • HLA-B27: Being positive for this genetic factor can increase the likelihood of a reactive arthritis diagnosis.
  • Chlamydia: Cells from the urethra in men and cervix in women will be tested for chlamydia. Tests for the presence of bacteria associated with reactive arthritis may be performed, including urine studies to detect chlamydia.
  • Synovial fluid: A small amount of fluid may be taken from an inflamed joint with a needle to rule out an infection in the joint.
  • X-rays: Some signs of reactive arthritis can be seen on X-ray; likewise, other causes of arthritis can be ruled out.

What are the treatment options?

Although there is no cure for reactive arthritis, treatment can relieve the symptoms.

  • Antibiotics: If the infection is still active, antibiotics to eliminate the bacterial infection that triggered reactive arthritis may be prescribed.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Traditional NSAIDs, such as ibuprofen (Advil), naproxen sodium (Aleve) or indomethacin (Indocin), or COX-2 inhibitors, such as celecoxib (Celebrex), can relieve the pain and inflammation of reactive arthritis.
  • Corticosteroid injections: Injections of corticosteroids directly into affected joints can relieve severe inflammation.
  • Topical corticosteroids: Corticosteroid creams or lotions can be applied to skin lesions.
  • DMARDs: Severe or persistent joint symptoms may require treatment with medicine that reduce joint inflammation that may lead to persistent pain and joint damage, such as sulfasalazine (Azulfidine) or methotrexate (Rheumatrex).
  • TNF inhibitors: If other treatments do not control reactive arthritis, your doctor may prescribe a TNF inhibitor (etanercept [Enbrel] or infliximab [Remicade]).
  • Joint protection: During the acute stage of reactive arthritis, your joints may need to be protected and their use limited.
  • Exercise: Strengthening and range-of-motion exercises will improve joint function once the initial bout of severe inflammation has subsided.

Who is at risk?/How can I prevent it?

Reactive arthritis is most common among white men aged 20 to 40 years. Men are nine times more likely to develop reactive arthritis after venereally acquired infections; however men and women are equally as likely to develop the disease after an intestinal infection. Women generally have milder symptoms than men.