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Reactive Arthritis



What Is 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 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 a type of "spondyloarthritis" 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 an 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 several months, although symptoms can return or develop into a long-term disease in a small percentage of people.

What Causes Reactive Arthritis?

Reactive arthritis typically begins within 2 to 4 weeks after infection. The bacterium most often associated with reactive arthritis is Chlamydia trachomatis, commonly known as chlamydia (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. However, inheriting the HLA B27 gene does not necessarily mean you will get reactive arthritis.

Is Reactive Arthritis Contagious?

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.

Who Gets Reactive Arthritis?

Overall, young adult men are most likely to develop reactive arthritis. However, evidence shows that although men are nine times more likely than women to develop reactive arthritis caused by 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.

What Are the Symptoms of Reactive Arthritis?

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.

Joint Symptoms

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.

How Is Reactive Arthritis Diagnosed?

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 (see "Key Words"). 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 another rheumatic disease (such as 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 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.

What Type of Doctor 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 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.

How Is Reactive Arthritis Treated?

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.1


1All medicines can have side effects. Some medicines and side effects are mentioned in this publication. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your health care provider or pharmacist if you have any questions about the possible side effects.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Aspirin, ibuprofen, naproxen, and naproxen sodium are examples of NSAIDs.2 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.


2 Warning: Side effects of NSAIDs include stomach problems; skin rashes; high blood pressure; fluid retention; and liver, kidney, and heart problems. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs, because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. NSAIDs should only be used at the lowest dose possible for the shortest time needed.

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.

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.

Exercise

Exercise, when introduced gradually, may help maintain and improve joint function. In particular, strengthening and range-of- motion exercises can be effective. Strengthening exercises build 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.

What Is the Prognosis for People Who Have Reactive Arthritis?

Most people with reactive arthritis recover fully from the initial flare of symptoms and are able to return to regular activities a few months after the first symptoms appear. In such cases, the symptoms of arthritis may last up to a year, although these are usually very mild and do not interfere with daily activities. Some 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 caused by reinfection. Back pain and arthritis are the symptoms that most commonly reappear. A few patients will have chronic, severe arthritis that is difficult to control with treatment and may cause joint damage.

What Research Is Being Conducted on Reactive Arthritis?

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

-NIH



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