Reactive Arthritis

  • Reactive arthritis involves inflammation of joints due to an infection in another part of your body. The most common triggers are the genital, urinary, or gastrointestinal systems.
  • Reactive arthritis can occur after genital (venereal) infection with Chlamydia trachomatis or enteric infection (dysentery) with ShigellaSalmonellaCampylobacterYersinia, or Clostridium difficile.
  • Reactive arthritis shares many features with psoriatic arthritis, ankylosing spondylitis, and Crohn’s disease and ulcerative colitis.
  • Reactive arthritis can affect the joints, the spine, the eyes, urinary tract, mouth, colon, and heart.
  • There is no single laboratory test for diagnosing reactive arthritis. The HLA-B27 genetic marker is commonly found in the blood.
  • Treatment of reactive arthritis is directed toward the specific body area(s) inflamed or affected.

Reactive arthritis is a chronic form of inflammatory arthritis featuring the following three conditions: (1) inflamed joints, (2) inflammation of the eyes (conjunctivitis), and (3) inflammation of the genital, urinary, or gastrointestinal systems.

This form of joint inflammation is called “reactive arthritis” because it is felt to involve an immune system that is “reacting” to bacterial infections in the genital, urinary, or gastrointestinal systems. Accordingly, certain people’s immune systems are genetically primed to react aberrantly when these areas are exposed to certain bacteria. The aberrant reaction of the immune system leads to spontaneous inflammation in the joints and eyes. This can confound the patient and the doctor when the infection has long passed at the time of presentation with arthritis or eye inflammation.

In the past, reactive arthritis has been referred to as Reiter syndrome (a term that has lost favor because of Dr. Hans Reiter’s dubious history, one of enthusiastically embracing Nazi politics and medical abominations). Reiter syndrome would also refer to a specific type of reactive arthritis, limiting inflammation to the eyes, urethra, and joints.

Reactive arthritis most frequently occurs in patients in their 30s or 40s. The form of reactive arthritis that occurs after genital infection (venereal) occurs more often in males. The form that develops after bowel infection (dysentery) occurs in equal frequency in males and females.

Reactive arthritis is considered a systemic rheumatic disease. This means it can affect other organs than the joints, causing inflammation in tissues such as the eyes, mouth, skin, kidneys, heart, and lungs. Reactive arthritis shares many features with several other arthritic conditions, such as psoriatic arthritis, ankylosing spondylitis, and arthritis associated with Crohn’s disease and ulcerative colitis. These arthritic conditions can cause similar infection and inflammation in the spine and other joints, eyes, skin, mouth, and various organs. Given their similarities and tendency to inflame the spine, these conditions are collectively referred to as “spondyloarthropathies.”

Sign & Symptoms of Reactive Arthritis

Conjunctivitis

  • Persistent pinkeye (conjunctivitis) can be a sign of an underlying illness in the body. These are rheumatic diseases, such as rheumatoid arthritis, reactive arthritis, and systemic lupus erythematosus.
  • Conjunctivitis is also seen in Kawasaki’s disease (a rare condition associated with fever in infants and young children) and certain inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease.

Reactive arthritis symptoms can be divided into those that affect the joints and those that affect the non-joint areas.

The classic joints that can become inflamed in reactive arthritis are the knees, ankles, and feet. The particular joints involved are usually asymmetric. One side of the body or the other is affected by signs and symptoms, rather than simultaneously. The inflammation leads to joint pain, stiffness, swelling, warmth, and redness. Patients may develop a rash of entire fingers or toes, giving the appearance of a “sausage digit.” This feature is also seen in patients with another type of arthritis called psoriatic arthritis associated with skin inflammation of psoriasis. The arthritis of reactive arthritis can be related to the spine’s inflammation, leading to stiffness and joint pain in the back or neck (characteristic of all of the spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis).

Cartilage can also become inflamed, especially around the breastbone, where the ribs meet in the chest; this condition is called costochondritis. Muscles attach to the bones by tendons. In reactive arthritis, the tendon insertion points can become inflamed (enthesitis), tender, and painful when exercised. Achilles tendinitis is common with reactive arthritis.

Non-joint areas that become inflamed and cause symptoms of pain and irritation in patients with reactive arthritis include the eyes (conjunctivitis), genitals, urinary tract (urethra, bladder, and prostate gland), skin, mouth lining, large bowel, and the aorta.

Inflammation of the white portion of the eye (conjunctivitis) and the eye (iritis) is frequently seen early in reactive arthritis and may be intermittent. When the whites of the eye are inflamed, causing conjunctivitis, there may be no pain. When the colored part of the eye (iris) is inflamed, causing iritis and uveitis, it can be excruciating and mostly worse when looking into bright lights (medically referred to as photophobia).

Urinary tract inflammation commonly involves the urethra, the tube that drains urine from the bladder. This inflammation (urethritis) can be associated with burning on urination and or pus drainage from the penis’s end. The skin around the penis can become inflamed and peel. The bladder and prostate gland can also become inflamed, leading to urination from cystitis and prostatitis.

The skin of the palms of the hands and or the feet’ soles can develop tiny fluid-filled blisters that sometimes are filled with old blood. The affected skin can peel and may mimic psoriasis. The classic appearance is medically referred to as keratoderma blennorrhagica. Similar inflammation of the penis tip can cause an irritating rash in males, referred to as circinate balanitis.

The mouth can develop open sores (ulcerations) on the hard and soft palate and even on the tongue. These may go unnoticed by the patient, as they are often painless. Inflammation of the large bowel (colitis) can cause diarrhea or pus or blood in the stool. Inflammation of the aorta (aortitis) can be seen in a small percentage of reactive arthritis patients. It can lead to failure of the aortic valve of the heart, which can cause heart failure. The heart’s electrical conducting pathway can also become scarred in reactive arthritis, leading to irregular heartbeats (arrhythmias) that may require placement of a pacemaker to regulate the heartbeat.

Causes of Reactive Arthritis

As mentioned, reactive arthritis is felt in part to be genetic. There are specific genetic markers that are far more frequent in patients with reactive arthritis than in the average population. For example, the HLA-B27 gene is commonly seen in patients with reactive arthritis. Even in patients who have the genetic background that predisposes them to develop reactive arthritis, exposure to certain infections seems to be required to trigger the disease’s onset.

Reactive arthritis can occur after venereal infections. The most common bacterium that has been associated with this post-venereal form of reactive arthritis is an organism called Chlamydia trachomatis. Reactive arthritis also occurs after infectious dysentery, with bacterial organisms in the bowel, such as SalmonellaShigellaYersiniaCampylobacter, and Clostridium difficile. Typically, arthritis develops one to three weeks after the onset of the bacterial infection.

Reactive arthritis has also been reported associated with bladder infusions of BCG used for treating bladder cancer.

Treatment for Reactive Arthritis

Treatment of reactive arthritis is based on where it has become manifest in the body. For joint inflammation, patients are generally initially treated with nonsteroidal anti-inflammatory drugs (NSAIDs). These NSAIDs include aspirin, indomethacin (Indocin), tolmetin (Tolectin), sulindac (Clinoril), piroxicam (Feldene), and others. Among their potential side effects are gastrointestinal irritation, including ulceration and bleeding. Nonsteroidal anti-inflammatory drugs should be taken with food to minimize this risk. Corticosteroids, such as prednisone, can help reduce inflammation and are used in the short-term treatment of inflammation in reactive arthritis. They can be given by mouth or by local injection into the joint. Corticosteroids are also used to decrease tendon inflammation in some forms of tendinitis.

Antibiotics may be prescribed if one still has the infection that triggered reactive arthritis.

Sulfasalazine (Azulfidine) is useful in some patients with persistent reactive arthritis. Potential side effects of this sulfa-based medication include sulfa rash reaction and suppression of the bone marrow. Therefore, blood counts are monitored when Azulfidine is used long-term.

For the aggressive inflammation of chronic joint inflammation in reactive arthritis, medications that suppress the immune system, including the disease-modifying anti-rheumatic drug (DMARD) methotrexate (Rheumatrex, Trexall), are used. Methotrexate can be given orally by injection. It is administered weekly and requires regular monitoring of blood counts and blood liver tests because of potential toxicity to the bone marrow and liver.

Tumor necrosis factor blockers (TNF): The cell protein TNF acts as an inflammatory agent in rheumatoid arthritis. There is some evidence that TNF blockers can also be helpful in reactive arthritis.

Reactive arthritis has been reported in association with HIV infection (AIDS virus). In this context, immune-suppression medicine is generally avoided because of the potential for worsening HIV disease.

Eye inflammation can be alleviated with anti-inflammatory drops. Some patients with severe iritis require local injections of cortisone to prevent damaging inflammation to the eye, leading to blindness.

Cortisone creams can help the inflammation around the penis. When bacteria are discovered in the bowel or urine, antibiotics specific for those bacteria are given.

Exercise has been shown to help people with arthritis. It would help if you had a physical therapist show you specific exercises for your joints.