A Guide to Reactive Arthritis

Reactive arthritis was formerly known as Reiter's syndrome, and your doctor may refer to it 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

In many, reactive arthritis is triggered by a venereal infection in the bladder or urethra, or, in women, the vagina 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 is sometimes called enteric or gastrointestinal reactive arthritis.

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.

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.

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
• 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.

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.

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.

Reactive arthritis most typically results in inflammation of the:

• Urogenital tract
• Joints
• 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.

Reactive arthritis often affects the urogenital tract, including the:

• Prostate or urethra in men
• Urethra, uterus, or vagina in women

Men may notice an increased need to urinate, a burning sensation when urinating, penis pain and a fluid discharge from the penis. Some men with reactive arthritis develop prostatitis. 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 or urethritis, which can cause a burning sensation during urination. In addition, some women also develop salpingitis or vulvovaginitis. These conditions may or may not cause any arthritic symptoms.

Joint pain symptoms of reactive arthritis typically involves pain and swelling in the:

• Knees
• Ankles
• Feet

Wrists, fingers, and other joints are affected less often. People with reactive arthritis commonly develop tendinitis. In many with reactive arthritis, this results in ankle pain or Achilles tendinitis. Some with reactive arthritis also develop heel spurs, which are bony growths in the heel that may cause chronic foot pain. Approximately half of people with reactive arthritis report low-back and buttock pain.

Reactive arthritis also can cause spondylitis or sacroiliitis. People with reactive arthritis who have the HLA-B27 gene are even more likely to develop spondylitis and/or sacroiliitis.

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. 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 come and go.

Around 25 percent of men with reactive arthritis develop small, shallow, painless sores 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. Some with reactive arthritis develop mouth ulcers that come and go, for some, these ulcers are painless and go unnoticed.

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)

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
• Diarrhea

These symptoms may be evidence of a bacterial infection. Doctors sometimes find it difficult to diagnose reactive arthritis because there is no specific laboratory test to confirm that a person has reactive arthritis.

Doctors may order a blood test for the genetic factor HLA-B27, but a positive result does not always mean that a person has the disorder.

Doctors may order other blood tests to help rule out other conditions and confirm diagnosis. Rheumatoid factor or antinuclear antibody tests can help rule out reactive arthritis. Most who have reactive arthritis will have negative results on these tests. If the test results are positive, you may have some other type of arthritis, such as:

• Rheumatoid arthritis
• Lupus

Doctors may also test for erythrocyte sedimentation rate. A high "sed rate" often indicates inflammation somewhere in the body. Typically, people with rheumatic diseases have an elevated sed rate.

Doctors likely will test for infections that might be associated with reactive arthritis. Patients generally are tested for a Chlamydia infection (studies have shown that early treatment of Chlamydia-induced reactive arthritis may reduce disease progression). Cell samples may be taken from the throat, urethra in men or cervix in women. Urine and stool samples also may be tested. A sample of synovial fluid may be removed from the arthritic joint. Studies of synovial fluid can help rule out infection in the joint.

Doctors sometimes use x-ray 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

Although there is no cure for reactive arthritis, some treatments relieve symptoms of the disorder.

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:

• Aspirin
• Ibuprofen

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

• Indomethacin
• Tolmetin

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

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 help eliminate bacterial infections that trigger reactive arthritis. The specific antibiotic prescribed depends on the type of bacterial infection present. Some doctors may recommend a person with reactive arthritis take antibiotics for a long period of time (up to 3 months). Research shows that in most cases, this practice is necessary.

DMARDs such as methotrexate or sulfasalzine may help control severe symptoms that cannot be controlled by other drugs.

TNF blockers, such as Enbrel (etanercept) and Remicade (infliximab), may be effective for reactive arthritis and other spondyloarthropathies.

Before beginning an exercise program, patients should talk to a health professional who can recommend appropriate exercises.

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.

Exercises to stretch and extend the back can be particularly helpful in preventing long-term disability for patients with spine pain or inflammation.

Aquatic exercise also may be helpful for reactive arthritis. Water's buoyancy greatly reduces the pressure on your joints, making it easier to perform needed range of motion exercise.

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% of people with reactive arthritis will have chronic (long-term) arthritis, which usually is mild.

Studies show that between 15 and 50% 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.

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.