Reactive Arthritis: Overview and More

Reactive arthritis is a type of joint pain and inflammation that occurs as a reaction to an infection elsewhere in the body. The joints most likely to be affected by reactive arthritis are your knees, ankles, and feet. However, the inflammatory reaction can also involve your eyes and the urinary tract, as well as associated genital structures.

While reactive arthritis can affect both sexes, men between the ages of 20 and 40 are most likely to develop it.

Also Known As

Reactive arthritis was formerly known as Reiter's syndrome. Your doctor may also refer to it as a seronegative spondyloarthropathy.

Reactive Arthritis Symptoms

The seronegative spondyloarthropathies are a group of disorders that can cause inflammation throughout the body, especially in the spine. Other disorders in this group include psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, and Crohn's disease.

Inflammation is your body's natural reaction to injury or disease and is marked by:

Swelling
Redness
Heat
Pain

Specific reactive arthritis symptoms and related complications can vary depending on what part(s) of the body are affected, be it the joints, urogenital tract, eyes, or skin.

Joints

Reactive arthritis typically involves joint pain and swelling in the knees, ankles, and feet, but the wrists, fingers, and other joints can also be affected.

People with reactive arthritis commonly develop tendinitis, which often leads to pain in the ankle or Achilles tendon. Some cases involve heel spurs—bony growths in the heel that may cause chronic foot pain.

Furthermore, approximately half of the people with reactive arthritis report low-back and buttock pain. Reactive arthritis also can cause spondylitis or sacroiliitis (inflammation of the sacroiliac joints at the base of the spine).

Urogenital Tract

Reactive arthritis often affects the urogenital tract, with different symptoms in men and women.

In men, it impacts the prostate and urethra. Men may notice:

Increased need to urinate
Burning sensation when urinating
Penis pain
Fluid discharge from the penis

Some men with reactive arthritis develop prostatitis, which can cause fever and chills along with an increased need to urinate and a burning sensation when peeing.

In women, this disease affects the urethra, uterus, and vagina.

Additionally, women with reactive arthritis may develop inflammation of the:

Cervix (cervicitis): May include bleeding between periods, abnormal vaginal discharge, and pain with intercourse
Urethra (urethritis): Can cause a burning sensation during urination and frequent urination
Fallopian tubes (salpingitis, pelvic inflammatory disease): Can cause abnormal vaginal discharge, spotting between periods, painful periods, pain during sex, painful urination, nausea and vomiting, fever, lower back pain, abdominal pain, and fever
Vulva and vagina (vulvovaginitis, vulvitis, vaginitis): May cause irritation, itching, strong-smelling vaginal discharge, and pain during urination

Eyes

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 inflammation of the uvea (the pigmented layer in the eye beneath the cornea).

Conjunctivitis and uveitis can cause:

Redness of the eyes
Eye pain and irritation
Blurred vision

Eye involvement typically occurs early in the course of reactive arthritis, and symptoms may disappear only to return again.

Skin

Skin symptoms, involving sores and rashes, tend to be less common. Small percentages of people with reactive arthritis develop:

Small, shallow, painless sores on the end of the penis
Rashes
Small, hard nodules on the soles of the feet, palms of the hands, or elsewhere
Mouth ulcers that come and go; these may be painless and go unnoticed

These symptoms usually wax and wane over a period of several weeks to several months.

Symptoms of reactive arthritis usually last between three and 12 months. Generally speaking, women with reactive arthritis often have milder symptoms than men. In a small percentage of people, symptoms can come and go or develop into a long-term disease.

Causes

In many people, reactive arthritis is triggered by sexually transmitted infections (STIs). This form of the disorder is sometimes called genitourinary or urogenital reactive arthritis.

In others, it's caused by an infection in the gastrointestinal tract from eating food or handling substances that are contaminated with bacteria. This form is sometimes called enteric or gastrointestinal reactive arthritis.

Chlamydia

The bacterium most often associated with reactive arthritis is Chlamydia trachomatis, commonly known as chlamydia. A chlamydia infection can lead to reactive arthritis typically about two to four weeks after infection.

You may not be aware of the chlamydia infection, but your doctor will likely test you for it if they suspect reactive arthritis but you haven't had recent GI symptoms.

Chlamydia is usually acquired through sexual contact. Some evidence also shows that respiratory infections with Chlamydia pneumoniae may trigger reactive arthritis as well.

Men are nine times more likely than women to develop reactive arthritis due to venereal infections.

GI Tract Infections

Infections in the digestive tract that may trigger reactive arthritis include:

These infections are usually the result of food poisoning, which occurs when you either eat or handle contaminated foods. Women and men are equally likely to develop reactive arthritis as a result of food-borne infections.

Is It Contagious?

While the bacteria that trigger reactive arthritis can be passed from person to person, reactive arthritis itself is not contagious.

Genetic Predisposition

Doctors don't know exactly why some people exposed to the above bacteria develop reactive arthritis and others don't, but they have identified a genetic factor—human leukocyte antigen (HLA) B27—that increases the chance of developing reactive arthritis.

Up to 80% of people with reactive arthritis test positive for HLA-B27, but that doesn't mean inheriting the gene always results in the disease. While about 6% of healthy people have the HLA-B27 gene, only about 15% of them will develop reactive arthritis if they contract a triggering infection.

Researchers are trying to better understand why this is so, as well as why an infection can trigger arthritis altogether. Scientists are also studying why people with the genetic factor HLA-B27 are more at risk than others.

Interestingly, people who have the HLA-B27 gene are more likely to develop spine-related issues as a result of reactive arthritis than those without the gene.

Diagnosis

Reactive arthritis affects several parts of the body. So, to properly diagnose and treat it, you may need to see several different types of doctors, each of whom will conduct their own examinations and may run (or repeat) certain tests.

Your Medical Team

A rheumatologist (a doctor specializing in arthritis and related issues) is typically the "quarterback" of a reactive arthritis medical team, serving as the main person to coordinate the treatment plan with the input of other specialists, as well as monitor for any side effects.

Such specialists (and their areas of focus) may include:

Ophthalmologist: Eye diseases
Gynecologist: Genital symptoms in women
Urologist: Genital symptoms in men and women
Dermatologist: Skin symptoms
Orthopedist: Surgery on severely damaged joints
Physiatrist: Exercise regimens

Examination

At the beginning of an examination, expect a doctor to take a complete medical history and ask about your current symptoms. It can help if you keep a record of your symptoms, when they occur, and how long they last.

It is especially important to report any flu-like symptoms such as the following, as they may be evidence of a bacterial infection:

Fever
Vomiting
Diarrhea

Tests

There's no single test that can diagnose reactive arthritis, so your doctor will likely look at several factors before making a diagnosis. If your infection was mild and didn't require medical treatment, it can make the diagnostic process harder.

Your doctor may order any combination of the following test and other tests deemed necessary:

Genetic factor HLA-B27 blood test, though a positive result does not always mean your have the disorder—just that you're pre-disposed
Rheumatoid factor or antinuclear antibody tests to help rule out reactive arthritis, as a positive result may indicate another condition (e.g., rheumatoid arthritis or lupus)
Erythrocyte sedimentation rate, as a high "sed rate" often indicates inflammation somewhere in the body, which can point to rheumatic disease

Your doctors will likely test for infections that might be associated with reactive arthritis, such as chlamydia. Cell samples may be taken from the throat, the urethra (in men), or cervix (in women) via swapping.

Your urine and stool samples also may be tested.

To rule out infection in a painful joint, a doctor may remove and test a sample of synovial fluid.

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.

Imaging

Doctors sometimes use X-rays to help diagnose reactive arthritis and to rule out other causes of arthritis. X-rays can detect other symptoms including:

Spondylitis
Sacroiliitis
Soft tissue swelling
Damage to cartilage and joints
Calcium deposits

Treatment

Although there is no cure for reactive arthritis, several treatments are available that may relieve your symptoms.

Antibiotics

Antibiotics help eliminate bacterial infections that trigger reactive arthritis. The specific antibiotic prescribed depends on the type of bacterial infection you have.

Some doctors may recommend antibiotics for a long period of time (up to three months), but the research on this practice is inconsistent and the source of some disagreement in the medical community, especially when it comes to cases triggered by GI infections.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce joint inflammation and are commonly used to treat patients with reactive arthritis. Some NSAIDs are available without a prescription, such as:

Other NSAIDs that are usually more effective for reactive arthritis must be prescribed by a doctor, including:

Tivorbex (indomethacin)
Tolmetin

Topical Corticosteroids

These corticosteroids come in a cream or lotion form that can be applied directly to skin sores associated with reactive arthritis. Topical corticosteroids reduce inflammation and promote healing.

Corticosteroid Shots

For those with severe joint inflammation, injections of corticosteroids directly into the affected joint may reduce inflammation.

Immunosuppressants/DMARDs

Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate or sulfasalzine may help control severe symptoms that cannot be controlled by other drugs.

TNF Blockers

If your case proves hard to treat with the above options, your doctor may prescribe a TNF blocker, such as Enbrel (etanercept) and Remicade (infliximab).

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.

Exercise

Exercise may help improve your joint function, but it's important to introduce it gradually and with guidance from a physiatrist or physical therapist. Recommended types of exercise include:

Strengthening exercises to build up muscles around the joint for better support.
Range-of-motion exercises to improve flexibility and movement.
Muscle-tightening exercises that don't involve joint movement: These may be helpful if you have too much inflammation and pain for other types of exercise.

If you have pain and inflammation in the spine, exercises that stretch and extend your back may be particularly helpful in preventing long-term disability.

Aquatic exercise also may be helpful, as water's buoyancy greatly reduces the pressure on your joints.

Prognosis

Most people with reactive arthritis recover fully from the initial flare of symptoms and are able to return to regular activities two to six months after the first symptoms appear. Mild symptoms may linger for up to 12 months, but they generally don't interfere with daily activities.

Approximately 30% to 50% of people with reactive arthritis will develop symptoms again sometime after the initial flare has disappeared. Some will develop chronic (long-term) arthritis, which usually is mild. 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.