Reactive Arthritis

Reactive arthritis is a form of arthritis, or joint inflammation, that occurs as a "reaction" to an infection elsewhere in the body. Inflammation is a reaction of tissues to injury or disease and is characterized by swelling, redness, heat, and pain. Reactive arthritis is associated with two other symptoms: redness and inflammation of the eyes (conjunctivitis) and inflammation of the urinary tract (urethritis). These symptoms may occur alone, together, or not at all.

Reactive arthritis is also known as Reiter's syndrome or seronegative spondyloarthropathy. The seronegative spondyloarthropathies are a group of disorders that can cause inflammation throughout the body, especially in the spine. Examples of other disorders in this group include psoriatic arthritis, ankylosing spondylitis, and the kind of arthritis that sometimes accompanies inflammatory bowel disease.

In many patients, reactive arthritis is triggered by a sexually transmitted infection in the urogenital tract (the bladder, the urethra, or, the vagina). This form of the disorder is sometimes called genitourinary or urogenital reactive arthritis. Another form of reactive arthritis is caused by an infection in the intestinal tract resulting from eating food or handling substances that are contaminated with bacteria. This form of arthritis is sometimes called enteric or gastrointestinal reactive arthritis.

The symptoms of reactive arthritis usually last three to twelve months. Symptoms can return or develop into a chronic disease in a small percentage of people.

Symptoms

Reactive arthritis most typically results in inflammation of the urogenital tract, the joints, and the eyes. Less common symptoms are mouth ulcers and skin rashes. Any of these symptoms may be so mild that people do not notice them. These symptoms usually come and go over a period of several weeks to several months.

Urogenital Tract Symptoms

Reactive arthritis often affects the prostate or urethra in men and the urethra, uterus, or vagina in women. Men may notice an increased need to urinate, a burning sensation when urinating, and a fluid discharge from the penis. Some men with reactive arthritis develop prostatitis (inflammation of the prostate gland). Symptoms of prostatitis can include fever and chills, an increased need to urinate, and a burning sensation while urinating. Women with reactive arthritis may develop problems in the urogenital tract, such as cervicitis (inflammation of the cervix) or urethritis (inflammation of the urethra), which can cause a burning sensation during urination. In addition, some women also develop salpingitis (inflammation of the fallopian tubes) or vulvovaginitis (inflammation of the vulva and vagina). These conditions may or may not cause any joint symptoms.

Joint Symptoms

The arthritis associated with reactive arthritis typically involves pain and swelling in the knees, ankles, and feet. Wrists, fingers, and other joints are affected less often. People with reactive arthritis commonly develop inflammation of the tendons (tendinitis) or at places where tendons attach to the bone (ethesitis). This often results in heel pain or irritation of the Achilles tendon at the back of the ankle. Some people with reactive arthritis also develop heel spurs, which are bony growths in the heel that may cause chronic (long-lasting) foot pain. Approximately half of people with reactive arthritis report lower back and buttock pain. Reactive arthritis also can cause spondylitis (inflammation of the vertebrae in the spinal column) or sacroiliitis (inflammation of the joints in the lower back that connect the spine to the pelvis). People with reactive arthritis who have the HLA-B27 gene are even more likely to develop spondylitis and/or sacroiliitis.

Eye Involvement

Conjunctivitis, an inflammation of the mucous membrane that covers the eyeball and eyelid, develops in approximately half of people with reactive arthritis. Some people may develop uveitis, which is an inflammation of the inner eye. Conjunctivitis and uveitis can cause redness of the eyes, eye pain and irritation, and blurred vision. Eye involvement typically occurs early in the course of reactive arthritis, and symptoms may come and go.

Other Symptoms

Between twenty to forty percent of men with reactive arthritis develop small, shallow, painless sores (ulcers) on the end of the penis. A small percentage of men and women develop rashes or small, hard nodules on the soles of the feet and, less often, on the palms of their hands or elsewhere. In addition, some people with reactive arthritis develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed.

Causes

Reactive arthritis typically begins about one to three weeks after infection. The bacterium most often associated with reactive arthritis is Chlamydia trachomatis, commonly known as chlamydia. It is usually acquired through sexual contact. Some evidence also shows that respiratory infections with Chlamydia pneumoniae may trigger reactive arthritis.

Infections in the digestive tract that may trigger reactive arthritis include Salmonella, Shigella, Yersinia, and Campylobacter. People may become infected with these bacteria after eating or handling contaminated food, such as meats that are not stored at the proper temperature.

Doctors do not know exactly why some people exposed to these bacteria develop reactive arthritis and others do not. They have identified a genetic factor, human leukocyte antigen (HLA) B27, that increases a person's chance of developing reactive arthritis. Approximately eighty percent of people with reactive arthritis test positive for HLA-B27. However, inheriting the HLA-B27 gene does not necessarily mean that a person will get reactive arthritis. This gene is very common. Eight percent of healthy people have the HLA-B27 gene, but only about one-fifth of them will develop reactive arthritis if they contract the triggering infections.

Diagnosis

It can be difficult to diagnose reactive arthritis because there is no specific laboratory test to confirm that a person has it. A doctor may order a blood test to detect the genetic factor HLA-B27, but even if the result is positive, the presence of HLA-B27 does not always mean that a person has the disorder.

The doctor will take a complete medical history and note current symptoms as well as any previous medical problems or infections. Before and after seeing the doctor, it is sometimes useful for a person to keep a record of their symptoms, when they occur, and how long they last. It is especially important to report any flu-like symptoms, such as fever, vomiting, or diarrhea, because they may be evidence of a bacterial infection.

The doctor may use various blood tests besides the HLA-B27 test to help rule out other conditions and confirm a suspected diagnosis of reactive arthritis. For example, the doctor may order rheumatoid factor (RF) or antinuclear antibody (ANA) tests to rule out other autoimmune disorders. Most people who have reactive arthritis will have negative results on these tests. If a patient's test results are positive, he or she may have some other form of arthritis, such as rheumatoid arthritis or lupus. However, a person may have positive results for these tests and may still not have these disorders, either. This is because many people in the US have these antibodies, but they do not always cause disease. Doctors also may order a blood test to determine the erythrocyte sedimentation rate (sed rate/ESR), which is the rate at which red blood cells settle to the bottom of a test tube of blood. A high sed rate often indicates inflammation somewhere in the body. Typically, people with rheumatic diseases, including reactive arthritis, have an elevated sed rate.

The doctor may also perform tests for infections that might be associated with reactive arthritis. Patients generally are tested for a Chlamydia infection because recent studies have shown that early treatment of Chlamydia-induced reactive arthritis may reduce the progression of the disease. The doctor may look for bacterial infections by testing cell samples taken from the patient's throat, as well as the urethra in men or cervix in women. Urine and stool samples also may be tested. A sample of synovial fluid (the fluid that lubricates the joints) may be removed from the arthritic joint. Studies of synovial fluid can help the doctor rule out infection in the joint.

Doctors sometimes use Xrays to help diagnose reactive arthritis and to rule out other causes of arthritis. Xrays can detect some of the symptoms of reactive arthritis, including spondylitis, sacroiliitis, swelling of soft tissues, damage to cartilage or bone near the joint, and calcium deposits where the tendon attaches to the bone.

Treatment

Although there is no cure for reactive arthritis, some treatments relieve symptoms of the disorder. The doctor is likely to use one or more of the following treatments:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce joint inflammation and are commonly used to treat patients with reactive arthritis. Aspirin, ibuprofen, naproxen, and naproxen sodium are examples of NSAIDS. They are often the first type of medication used. All NSAIDs work similarly: by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.

Some NSAIDS are available over the counter, while more than a dozen others, including a subclass called COX-2 inhibitors, are available only with a prescription. All NSAIDS can have significant side effects, and for unknown reasons, some people seem to respond better to one NSAID than another. Any person taking NSAIDS regularly should be monitored by a doctor.

• Corticosteroid injections are for people with severe joint inflammation. Corticosteroids are injected directly into the affected joint, which reduces inflammation. Doctors usually prescribe these injections only after trying unsuccessfully to control arthritis with NSAIDs.
• Topical corticosteroids come in a cream or lotion and can be applied directly onto skin lesions, such as ulcers, associated with reactive arthritis. Topical corticosteroids reduce inflammation and promote healing.
• Antibioticsmay be prescribed to eliminate the bacterial infection that triggered reactive arthritis. The specific antibiotic prescribed depends on the type of bacterial infection present. It is important to follow instructions about how much medicine to take and for how long. If antibiotics are not taken as directed, the infection may persist. Typically, an antibiotic is taken for 7 to 10 days or longer. Some doctors may recommend that a person with reactive arthritis take antibiotics for a long period of time (up to three months). Current research shows that in most cases, this practice is necessary.
• Immunosuppressive medicines are used in a small percentage of patients who have severe symptoms that cannot be controlled with any of the above treatments. For these people, medicine that suppresses the immune system, such as sulfasalazine or methotrexate, may be effective.
• TNF inhibitors--Several relatively new treatments that suppress tumor necrosis factor (TNF), a protein involved in the body's inflammatory response, may be effective for reactive arthritis and other spondyloarthropathies. They include etanercept and infliximab. These treatments were first used to treat rheumatoid arthritis.
• Exercise, when introduced gradually, may help improve joint function. In particular, strengthening and range-of-motion exercises will maintain or improve joint function. Strengthening exercises build up the muscles around the joint to better support it. Muscle-strengthening exercises that do not require moving any joints can be done even when a person has inflammation and pain. Range-of-motion exercises improve movement and flexibility and reduce stiffness in the affected joint. For patients with spine pain or inflammation, exercises to stretch and extend the back can be particularly helpful in preventing long-term disability. Aquatic exercise also may be helpful. Before beginning an exercise program, it is usually recommended that a person talk to a health professional who can recommend appropriate exercises.

Types of Doctors Who Treats Reactive Arthritis

A person with reactive arthritis probably will need to see several different types of doctors because reactive arthritis affects different parts of the body. However, it may be helpful to the doctors and the patient to have one main doctor manage the complete treatment plan. This is usually a rheumatologist. This doctor can coordinate treatments and monitor the side effects from the various medicines the patient may take. The following specialists treat other features of the illness.

• Ophthalmologist--treats eye disease
• Gynecologist--treats genital symptoms in women
• Urologist--treats genital symptoms in men and women
• Dermatologist--treats skin symptoms
• Orthopaedist--performs surgery on severely damaged joints
• Physiatrist--supervises exercise regimens

Chances of Developing Reactive Arthritis

Overall, men between the ages of twenty and forty are most likely to develop reactive arthritis. However, evidence shows that although men are nine times more likely than women to develop reactive arthritis due to sexually acquired infections, women and men are equally likely to develop reactive arthritis as a result of food-borne infections. Women with reactive arthritis often have milder symptoms than men.

How Reactive Arthritis is Spread

Reactive arthritis is not contagious. That is, a person with the disorder cannot pass the arthritis on to someone else. However, the bacteria that can trigger reactive arthritis can be passed from person to person.

Expected Outcome

Most people with reactive arthritis recover fully from the initial symptoms flare up and are able to return to regular activities two to six months after the first symptoms appear. In such cases, the symptoms of arthritis may last up to twelve months, although these are usually very mild and do not interfere with daily activities. Approximately twenty percent of people with reactive arthritis will have chronic (long-term) arthritis, which usually is mild. Studies show that between fifteen and fifty percent of patients will develop symptoms again sometime after the initial flare has disappeared. It is possible that such relapses may be due to reinfection. Back pain and arthritis are the symptoms that most commonly reappear. A small percentage of patients will have chronic, severe arthritis that is difficult to control with treatment and may cause joint deformity.

Research

Researchers continue to investigate the causes of reactive arthritis, and are studying treatments for the condition. For example:

• Researchers are trying to better understand the relationship between infection and reactive arthritis. In particular, they are trying to determine why an infection triggers arthritis and why some people who develop infections get reactive arthritis while others do not. Scientists also are studying why people with the genetic factor HLA-B27 are more at risk than others.
• Researchers are developing methods to detect the location of the triggering bacteria in the body. Some scientists suspect that after the bacteria enter the body, they are transported to the joints, where they remain indefinitely in small amounts.
• Researchers are testing combination treatments for reactive arthritis. In particular, they are testing the use of antibiotics in combination with TNF inhibitors and with other immunosuppressant medicines, such as methotrexate and sulfasalazine.

External Links

American College of Rheumatology

Arthritis Foundation

Spondylitis Association of America