Reactive Arthritis
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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 characteristic reaction of tissues to injury
or disease and is marked by swelling, redness, heat, and pain. Besides
this joint inflammation, 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, and
your doctor may refer to it by yet another term, as a 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
venereal infection in the bladder, the urethra, or, in women, the vagina
(the urogenital tract) that is often transmitted through sexual contact.
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 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 3 to 12
months, although symptoms can return or develop into a long-term disease
in a small percentage of people.
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Reactive arthritis typically begins about 1 to 3 weeks
after infection. The bacterium most often associated with reactive
arthritis is Chlamydia trachomatis, commonly known as chlamydia
(pronounced kla-MID-e-a). 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 improperly prepared 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, but they
have identified a genetic factor, human leukocyte antigen (HLA) B27,
that increases a person's chance of developing reactive arthritis.
Approximately 80 percent of people with reactive arthritis test positive
for HLA-B27. However, inheriting the HLA-B27 gene does not necessarily
mean you will get reactive arthritis. Eight percent of healthy people
have the HLA-B27 gene, and only about one-fifth of them will develop
reactive arthritis if they contract the triggering infections.
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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.
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Overall, men between the ages of 20 and 40 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 venereally 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.
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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 patients do not notice them. They usually come and go over a period
of several weeks to several months.
Urogenital Tract Symptoms
Reactive arthritis often affects the urogenital tract,
including 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,
as well as an increased need to urinate and a burning sensation when
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 arthritic 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). In many people
with reactive arthritis, this 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 low-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 20 and 40 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.
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Doctors sometimes find it 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.
At the beginning of an examination, the doctor will
probably 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 the patient to keep a
record of the symptoms that occur, 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 or antinuclear
antibody tests to rule out reactive arthritis. 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. Doctors also may order a blood test to determine the erythrocyte
sedimentation rate (sed rate), 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 also is likely to 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 x rays to help diagnose reactive
arthritis and to rule out other causes of arthritis. X rays can detect
some of the symptoms of reactive arthritis, including spondylitis,
sacroiliitis, swelling of soft tissues, damage to cartilage or bone
margins of the joint, and calcium deposits where the tendon attaches to
the bone.
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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 for one doctor, usually a rheumatologist (a doctor
specializing in arthritis), to manage the complete treatment plan. This
doctor can coordinate treatments and monitor the side effects from the
various medicines the patient may take. The following specialists treat
other features that affect different parts of the body.
- 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
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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)--NSAIDs reduce joint
inflammation and are commonly used to treat patients with reactive arthritis.
Some traditional NSAIDs, such as aspirin and ibuprofen, are available without
a prescription, but others that are more effective for reactive arthritis,
such as indomethacin and tolmetin, must be prescribed by a doctor. Less
is known about whether a new class of NSAIDs, called COX-2 inhibitors, is
effective for reactive arthritis, but they may reduce the risk of gastrointestinal
complications associated with traditional NSAIDs.
- Corticosteroid injections--For people with severe joint inflammation,
injections of corticosteroids directly into the affected joint may reduce
inflammation. Doctors usually prescribe these injections only after trying
unsuccessfully to control arthritis with NSAIDs.
- Topical corticosteroids--These corticosteroids come in a cream
or lotion and can be applied directly on the skin lesions, such as ulcers,
associated with reactive arthritis. Topical corticosteroids reduce inflammation
and promote healing.
- Antibiotics--The doctor may prescribe antibiotics 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; otherwise the infection may persist. Typically, an antibiotic
is taken for 7 to 10 days or longer.
Some doctors may recommend a person with reactive arthritis take antibiotics
for a long period of time (up to 3 months). Current research shows that
in most cases, this practice is necessary.
- Immunosuppressive medicines--A small percentage of patients with
reactive arthritis 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--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 builds
up the muscles around the joint to better support it. Muscle-tightening
exercises that do not move 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, patients should talk to a
health professional who can recommend appropriate exercises.
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Most people with reactive arthritis recover fully from the
initial flare of symptoms and are able to return to regular activities 2
to 6 months after the first symptoms appear. In such cases, the symptoms
of arthritis may last up to 12 months, although these are usually very
mild and do not interfere with daily activities. Approximately 20
percent of people with reactive arthritis will have chronic (long-term)
arthritis, which usually is mild. Studies show that between 15 and 50
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.
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Researchers continue to investigate the causes of reactive
arthritis and study 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 can remain in small
amounts indefinitely.
- 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.
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National
Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
American College
of Rheumatology/Association of Rheumatology Health Professionals
Arthritis Foundation
Spondylitis
Association of America
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Antibodies--Special proteins produced by the body's
immune system that recognize and help fight infectious agents, such as
bacteria, viruses, and other foreign substances that invade the
body.
Antinuclear antibodies--Antibodies that are in the
bloodstream of people who have connective tissue diseases or certain
autoimmune disorders.
Arthritis--Literally means joint inflammation. It
is a general term for more than 100 conditions known as rheumatic
diseases. These diseases affect not only the joints but also other parts
of the body, including important supporting structures such as muscles,
tendons, and ligaments, as well as some internal organs.
Corticosteroids--Potent anti-inflammatory hormones
that are made naturally in the body or synthetically (man-made) for use
as drugs. They are also called glucocorticoids. The most commonly
prescribed drug of this type is prednisone.
Erythrocyte sedimentation rate--Also referred to as
the "sed" rate. A blood test that signals the presence of inflammatory
disease by measuring the speed at which red blood cells settle to the
bottom of a test tube.
HLA-B27--Human leukocyte antigen-B27. A genetic
marker often--but not always--found in the blood of patients with
certain forms of arthritis, such as reactive arthritis and ankylosing
spondylitis.
Immune system--The system that protects the body
from infections.
Range of motion--A measurement of the extent to
which a joint can go through all of its normal movements.
Rheumatoid arthritis--A chronic inflammatory
disease that causes pain, stiffness, swelling, and loss of function in
the joints. The primary target of rheumatoid arthritis is the synovium,
or joint lining. This tissue, which normally is smooth and shiny,
becomes inflamed, painful, and swollen. The disease can also cause
inflammation in the blood vessels and the outer lining of the heart and
lungs.
Rheumatoid factor--A kind of antibody found in the
blood of many individuals who have rheumatoid arthritis. Rheumatoid
factor may be found in many diseases besides rheumatoid arthritis.
However, some people without health problems will also test positive for
rheumatoid factor.
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Ankylosing Spondylitis
