What is reactive arthritis
Reactive arthritis (ReA), formerly known as Reiter’s syndrome, Reiter’s disease or Reiter’s arthritis, is a relatively short-lived form of arthritis (joint inflammation and pain). Reactive arthritis develops as a reaction to certain bacterial infections, most often genital tract or bowel infections. In younger people it is more common than other forms of arthritis.
Generally following the initial bacterial infection after one to four weeks, and lasting up to about six months, ReA varies widely in severity and normally occurs as an isolated illness with no further problems. However, some people will experience repeated bouts in response to further infections, and a few will develop ongoing arthritis.
Reactive arthritis symptoms
The symptoms of reactive arthritis (ReA) can range from mild to severe. They often appear suddenly and tend to last for several months, fluctuating in severity during that time. They normally stop within about six months and include:
- Asymmetric oligoarthritis , inflammation of large, weight-bearing joints
- Conjunctivitis, eye pain and redness
- Urethritis, painful urination)
- Genital discharge
- Keratoderma blennorhagicum, scaly rash on the palms or soles of feet
- Mouth ulcers
- Balanitis, sore rash on end of penis
- Weight loss
Reactive arthritis causes
Reactive arthritis (ReA) is an inflammatory disease of the joints that occurs in reaction to an infection occurring in another part of the body. Typically, reactive arthritis is triggered by chlamydia, but can also be triggered by other infections, often from food poisoning. The triggering infection may have been so mild as to have gone unnoticed. ReA is not an infection of the joints, and the severity of the initial infection is not related to the severity of the ensuing arthritis.
It is not known exactly why these symptoms develop outside areas of the body that are or were infected. Reactive arthritis is thought to be an autoimmune disorder, in which fragments of dead bacteria or viruses can remain in the body after infection, to be carried through the bloodstream and deposited in the joint linings. In some cases, this may trigger the immune system to react by attacking healthy tissue, causing inflammation.
Reactive arthritis (ReA) is always brought on by an infection elsewhere in the body. The most common infections to trigger reactive arthritis are:
- Urethritis. This is an infection of the urethra, the tube which passes urine from the bladder. Often this is caused by a sexually transmitted infection (STI), most commonly chlamydia.
- Gastroenteritis. Infection of the gut, commonly from food poisoning, can trigger ReA, such as shigella, salmonella, campylobacter and yersinia.
- Chlamydia pneumoniae. These bacteria, which can cause a cough or lung infection, are often a trigger.
Other infections, including viral infections, such as glandular fever or flu, can also trigger reactive arthritis.
It is not known exactly what predisposes a person to develop ReA in response to infection. Certain factors that are more common in people with the condition include being:
- Aged roughly 20 to 40 years old
- A carrier of the HLA-B27 gene
- HIV positive
Reactive arthritis diagnosis
Diagnosis is generally done after referral to a rheumatologist, which is a type of doctor specializing in inflammation and pain in the joints, muscles, or fibrous tissue.
Unlike other types of arthritis, there is no specific test which can diagnose reactive arthritis. Instead, a rheumatologist must gather information to rule out other conditions and home in on the cause of a patient’s symptoms. Diagnosis may be gathered from a combination of reported medical history and symptoms, physical exam, laboratory tests and medical imaging.
Interview and physical exam
It is important that a person let their doctor know about recent or ongoing infections. They should also describe joint pain and other symptoms, as well as how long they have been going on for.
A doctor will look for signs of reactive arthritis, such as swollen joints, swollen fingers and toes, tender areas, and skin and eye inflammation, and may check the genitals to note any symptoms of sexually transmitted infection, such as rashes, sores or abnormal discharge.
- Confirming infection. After infection, antibodies remain in the blood which may be picked up by a blood test. However, such tests may not always be accurate or easy to interpret. Ongoing infection can be detected with urine and stool samples, genital swabs and throat swabs.
- Measuring inflammatory markers. Abnormally high levels of certain markers in the blood would support a diagnosis that symptoms are caused by an inflammatory condition, such as reactive arthritis. Inflammatory markers which may be detected by a blood test include:
- Erythrocyte sedimentation rate (ESR or sed rate)
- C-reactive protein (CRP)
- Testing for the HLA-B27 gene. People who carry a gene called HLA-B27 are more likely to develop reactive arthritis. This gene can be detected with a blood test.
- Ruling out other conditions. Arthrocentesis, i.e. drawing fluid from an affected joint with a needle, can rule out certain other conditions as the cause of symptoms, such as gout. Reactive arthritis can be ruled out if a blood test finds the presence of antibodies linked with other conditions, such as rheumatoid factor, which indicates rheumatoid arthritis, and anti-nuclear antibodies (ANAs), which indicates lupus.
A doctor may also recommend an X-ray or magnetic resonance imaging (MRI) of the affected joint. This can help to rule out other conditions that present with similar symptoms, such as septic arthritis, Lyme disease or inflammatory bowel disease.
Reactive arthritis treatment
While there is no reactive arthritis cure, the condition generally resolves within a few months, up to about a year. In some patients, the condition does not fully resolve, and some chronic symptoms may remain.
Treatments for reactive arthritis can be divided into three groups:
- Antibiotics to treat infection
- Treatment of joint inflammation and pain
- Treatment of other symptoms
If the triggering infection is found to be still present, a short course of oral (by mouth) antibiotics is advised.
Good to know: Antibiotics do not usually lessen or shorten symptoms of joint inflammation once it has developed. Once reactive arthritis has been triggered, it will normally run its course long after the initial infection has cleared.
Treatment of joint inflammation and pain
Non-steroidal anti-inflammatory drugs (NSAIDs) can be used to treat mild to moderate symptoms of joint inflammation and pain.
Physiotherapy may be advised to keep the affected joints moving, to help retain flexibility and strength until symptoms subside.
If the joint inflammation becomes severe or ongoing, there are several treatment options available to improve symptoms and help prevent long-term joint damage:
- Arthrocentesis (drawing fluid with a needle) from the affected joints
- A steroid injection close to the inflamed tendon or into a muscle, so as to aid spreading throughout the body
- A short course of low-dose steroid tablets
If the above treatments don’t work well enough, disease-modifying anti-rheumatic drugs (DMARDS) or tumor necrosis factor (TNF) inhibitors, also called TNF blockers, may be prescribed.
Treating other symptoms
Conjunctivitis (inflammation of the whites of the eyes) can be treated with eye drops, though it usually goes away without any treatment. If iritis (inflammation of the coloured parts of the eyes) has been diagnosed, steroid eye drops may be prescribed.
Balanitis (inflammation of the end of the penis) usually goes away on its own, but if not, it can be treated with a mild steroid cream.
Acetaminophen can be taken to reduce a fever. Other symptoms are rare and may need specialist care if they develop.
Q: Reactive arthritis vs septic arthritis - what is the difference?
A: Septic arthritis, also known as infectious arthritis, and reactive arthritis are both arthritic conditions that result from the immune system’s response to infection. However, septic arthritis is caused by an active infection directly within an arthritic joint. Reactive arthritis is a reaction to an infection elsewhere in the body - commonly of the bowel or genital tract - and may affect several joints. Septic arthritis is generally more serious than reactive arthritis, as it is much more likely to cause permanent and irreversible damage.
Q: Reactive arthritis vs rheumatoid arthritis - what is the difference?
A: Reactive arthritis and rheumatoid arthritis are both arthritic conditions. Both tend to report pain and stiffness in the morning, sometimes with fever and fatigue.
However, reactive arthritis normally starts with inflammation in the larger joints, such as the hips or knees, whereas rheumatoid arthritis usually starts in the smaller joints, such as the hands and feet, or occasionally the knees. Rheumatoid arthritis is also more common in women between 30 and 60 years old, whereas reactive arthritis occurs more often in men under 40 years old.
Q: Is viral-associated arthritis the same as viral reactive arthritis?
A: No. Though reactive arthritis may be triggered by a virus, viral-associated arthritis is a separate condition. While reactive arthritis lasts several months, viral-associated arthritis lasts only a few days or weeks. Viral-associated arthritis is commonly caused by parvovirus, which is easily spread through children at school, but tends only to cause arthritic symptoms in adults.
Q: Are there home remedies for reactive arthritis?
A:** Home remedies and self care can help to alleviate symptoms.
One of the most common is the use of ice packs and heat pads to soothe and reduce the swelling. Splints can be used on the wrists and heel, and shoe pads can be used for the ankles, so as to lessen any strain. Gentle exercise combined with rest can help keep joints moving and maintain muscle strength and flexibility.
While it has not been conclusively proven, there is some evidence that fish body oils have reduced the need for non-steroidal anti-inflammatory drugs (NSAIDS) in some people. This is distinguished from fish liver oils, which would be toxic in the large quantities needed to have enough of an effect.
Q: What is the reactive arthritis triad?
A: A reactive arthritis triad of symptoms, involving eye pain and redness, painful urination and arthritis is frequently described as a classic indicator of the condition, after it was first described as such. However, it is now known that this is only found in a minority of cases.
UpToDate. "Patient education: Reactive arthritis (Beyond the Basics)." 9 October 2017. Accessed 30 April 2018. ↩
An infection within a joint is a separate condition, known as septic arthritis. ↩
Patient. "Reactive Arthritis. Information about Reactive Arthritis." Accessed 1 May 2018. ↩