Reactive Arthritis (Reiter's Syndrome) Causes, Symptoms, Diagnosis, Treatment, Prevention

Reactive Arthritis (Reiter's Syndrome) Causes, Symptoms, Diagnosis, Treatment, Prevention

What is Reactive Arthritis (Reiter's Syndrome)?

Reactive arthritis, formerly referred to as Reiter's syndrome, is a form of arthritis that affects the joints, eyes, urethra (the tube that carries urine from the bladder to the outside of the body), and skin.

The disease is recognized by various symptoms in different organs of the body that may or may not appear at the same time. It may come on quickly and severely or more slowly, with sudden remissions or recurrences.

Reactive arthritis most frequently occurs in patients in their 30s or 40s, but it can occur at any age. The form of reactive arthritis that occurs after genital infection (venereal) occurs more frequently 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. Each of these arthritic conditions can cause similar disease and inflammation in the spine and other joints, eyes, skin, mouth, and various organs. In view of their similarities and tendency to inflame the spine, these conditions are collectively referred to as "spondyloarthropathies."

What Causes Reactive Arthritis (Reiter's Syndrome)?

The cause of reactive arthritis is still unknown, but research suggests the disease is caused, in part, by a genetic predisposition: Approximately 75% of those with the condition have a positive blood test for the genetic marker HLA-B27.

In sexually active males, most cases of reactive arthritis follow infection with Chlamydia trachomatis or Ureaplasma urealyticum, bothsexually transmitted diseases.

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 Salmonella, Shigella, Yersinia, and Campylobacter. Typically, the 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.

What are risk factors for developing Reactive Arthritis (Reiter's Syndrome)?

  • Gender: Reactive arthritis is more frequent in men between 20 and 40 years of age.
  • Hereditary factors: There are inherited genes, such as HLA-B27, that increase the risk for developing reactive arthritis.
  • Further risk factors include sexual promiscuity and exposure to bacteria that cause dysentery.

How does Reactive Arthritis (Reiter's Syndrome) occur?

It is not clear why reactive symptoms develop in areas of the body that are not infected. When you have an infection your immune system makes antibodies and other chemicals to get rid of the infecting germ (bacteria, virus, etc). The battle between the immune system and infecting germs can create other chemicals and debris such as fragments of dead germs.

One theory is that some of this debris may get into the bloodstream. It may then lodge in certain areas of the body such as the synovium of joints. This may trigger the inflammation in the joint.

Infections that can trigger reactive arthritis include:

Infection of the urethra

This is also called urethritis. It is the most common trigger. About 1 in 100 people who have an infection of the urethra also develop reactive arthritis. The urethra is the tube that passes urine out from the bladder. Some sexually transmitted infections can cause urethritis. Infection with a sexually transmitted bacteria called Chlamydia is the most common. Symptoms of the infection include a discharge from the urethra and pain when you pass urine.

Infection of the gut

This is also called gastroenteritis and is the other common trigger. Various bacteria can infect the gut and cause vomiting and/or diarrhoea. For example, Shigella, Salmonella, Campylobacter, and Yersinia. These infections are often caused by food poisoning. About 1 in 100 people who have a gut infection with one of these bacteria also develop reactive arthritis.

Infection with Chlamydophila pneumoniae

This bacterium can cause a respiratory tract infection (causing a cough or a lung infection) and can sometimes be a trigger.

Viral infections

Viral infections that can cause a sore throat, cough or skin rash are sometimes the trigger. The infection may be mild and soon forgotten, but it may still trigger an arthritis.

No triggering infection

No triggering infection can be found in about 1 in 10 cases.

Sometimes people with HIV infection can get reactive arthritis. This is likely to be because both conditions can be transmitted sexually rather than HIV infection acting as a trigger for reactive arthritis.

What are Reactive Arthritis (Reiter's Syndrome) symptoms and signs?

Symptoms usually develop 2-4 weeks after the infection - often after the triggering infection has gone. For example, you may have had a bout of diarrhoea and vomiting a couple of weeks previously which you may even have forgotten about.

Joint symptoms

These usually develop fairly quickly, over a day or so. In some cases they develop more gradually.

  • One or more joints may be affected.
  • The joints in the legs such as knees, ankles and toes are the ones most commonly affected. Inflammation of joints at the base of the spine is also common, causing low backache and buttock pain. However, any joint can be affected.
  • Stiffness may develop at first before any pain.
  • Joints near the skin surface, such as the knee, may become quite swollen.
  • The severity of pain and swelling can vary from mild to severe.
  • The tendons and ligaments next to some joints may also become inflamed. The most common site for this is the Achilles tendon at the back of the ankle which may become painful. If the ligaments in a finger or toe become inflamed at the same time as the joints, the whole finger or toe may look swollen. This may then look like a sausage finger or toe.

Urogenital Tract Symptoms

Reactive Arthritis (Reiter's Syndrome) often affects the urogenital tract, including the prostate, urethra, and penis in men and the fallopian tubes, uterus, and vagina in women. Men may notice an increased need to urinate, a burning sensation when urinating, and a discharge from the penis. Some men with Reactive Arthritis develop prostatitis, inflammation of the prostate gland. Symptoms of prostatitis can include fever, chills, increased need to urinate, and a burning sensation when urinating.

Women with Reactive Arthritis also develop signs in the urogenital tract, such as inflammation of the cervix (cervicitis) or inflammation of the urethra (urethritis), which can cause a burning sensation during urination. In addition, some women also develop salpingitis (inflammation of the fallopian tubes) or vulvovaginitis (inflammation of the vulva and vagina). These conditions may or may not cause any symptoms.

Eye Involvement

Conjunctivitis, an inflammation of the mucous membrane that covers the eyeball and eyelid, develops in about 50 percent of people with urogenital Reactive Arthritis and 75 percent of people with enteric Reiter's syndrome. A few people may develop uveitis, 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.

Other Symptoms of Reactive Arthritis (Reiter's Syndrome)

About 20 to 40 percent of men with Reactive Arthritis develop small, shallow, painless sores or lesions, called balanitis circinata, on the end of the penis. A small percentage of men and women develop rashes of small hard nodules on the soles of the feet, and less often on the palms of the hands or elsewhere. These rashes are called keratoderma blennorrhagica. In addition, some people with Reactive Arthritis develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed.

About 10 percent of people with Reactive Arthritis, usually those with prolonged disease, develop heart problems including aortic regurgitation (leakage of blood from the aorta into the heart chamber) and pericarditis (inflammation of the membrane that covers and protects the heart).

How Is Reactive Arthritis (Reiter's Syndrome) Diagnosed?

Diagnosis of reactive arthritis can be complicated by the fact that symptoms often occur several weeks apart. A doctor may diagnose reactive arthritis when the patient's arthritis occurs together with or shortly following inflammation of the eye and the urinary tract and lasts a month or longer.

There is no specific test for diagnosing reactive arthritis, but the doctor may check the urethral discharge for sexually transmitted diseases. Stool samples may also be tested for signs of infection. Blood tests of reactive arthritis patients are typically positive for the HLA-B27 genetic marker, with an elevated white blood cell count and an increased erythrocyte sedimentation rate (ESR) -- both signs of inflammation. The patient may also be mildly anemic (having too few red blood cells in the bloodstream).

X-rays of the joints outside the back do not usually reveal any abnormalities unless the patient has had recurrent episodes of the disease. On an X-ray, joints that have been repeatedly inflamed may show areas of bone loss, signs of osteoporosis, or bony spurs. Joints in the back and pelvis (sacroiliac joints) may show abnormalities and damage from reactive arthritis.

What is the treatment for Reactive Arthritis (Reiter's Syndrome)?

Treating any triggering infection

  • If the trigger is an infection of the urethra, a short course of antibiotics will usually be advised.
  • Gut infections have often cleared on their own by the time the reactive arthritis develops. But, if a stool sample shows that a germ is still present then treatment may be advised to clear it.
But note: clearing the triggering infection does not usually alter the course of the arthritis. Once the arthritis is triggered, it will usually run its course well after any infection has gone. However, some studies suggest that long-term treatment with antibiotics may help to reduce the length of the arthritis in some cases, particularly if chlamydia is the triggering infection. The use of long-term treatment with antibiotics in reactive arthritis is currently being investigated.

Treating the joint symptoms of Reactive Arthritis (Reiter's Syndrome)

Anti-inflammatory painkillers ease pain and stiffness. There are many different brands and your doctor will usually prescribe one. There is no best buy and some people find that one type suits them better than others. So, if one does not suit at first, another may be fine. See separate leaflet called 'Anti-inflammatory Painkillers' for more details.

Some joints become very swollen. The fluid may be removed by a doctor with a needle and syringe which can ease the pain.

An injection of steroid medicine directly into a joint is an option if it becomes badly inflamed. Steroids are good at reducing inflammation. Sometimes steroid tablets may be taken by mouth if symptoms are particularly bad.

You may need to rest very swollen joints until the symptoms ease. But as soon as you can, it is important to get the affected joints moving and exercising again.

Physiotherapy helps to keep the joints moving. It also helps to keep the muscles around affected joints strong if you are not using a joint very much.

If symptoms persist for more than a few months, or if other treatments have not worked, then you may be advised to take a disease-modifying medicine. These aim to reduce the damaging effect on the joints. There are several - for example, sulfasalazine and methotrexate. These medicines have no immediate effect on pain or inflammation. They take several weeks to work. However, they may help to prevent long-term joint damage if symptoms persist.

Treating other symptoms of Reactive Arthritis (Reiter's Syndrome)

  • Conjunctivitis usually goes without any treatment.
  • Uveitis may need steroid eye drops to suppress inflammation in the eye.
  • Balanitis usually needs no treatment, but a mild steroid cream may be needed in some cases.
  • Paracetamol can reduce fever.
  • Other symptoms are rare and may need specialist advice if they develop.

Prevention for Reactive Arthritis (Reiter's Syndrome)

Genetic factors appear to play a role in whether you're likely to develop reactive arthritis. Though you can't change your genetic makeup, you can reduce your exposure to the bacteria that may lead to reactive arthritis.

Make sure your food is stored at proper temperatures and is cooked properly. These steps can help you to avoid the many food-borne bacteria that can cause reactive arthritis, including salmonella, shigella, yersinia and campylobacter.

In addition, practice safe sex because preventing sexually transmitted diseases may lower your risk of developing reactive arthritis.

What Is the Prognosis for People Who Have Reactive Arthritis (Reiter's Syndrome)?

Most people with Reactive Arthritis recover fully from the initial flare of symptoms and are able to return to regular activities within 2 to 6 months after the first symptoms appear. Arthritis may last up to 6 months, although the symptoms are usually very mild and do not interfere with daily activities. Only 20 percent of people with Reactive Arthritis will have chronic arthritis, which is usually mild. Some patients experience symptom recurrence. Studies show that about 15 to 50 percent of patients will develop symptoms sometime after the initial flare has disappeared. Back pain and arthritis are the symptoms that most commonly reappear. A small percentage of patients will have deforming arthritis and severe symptoms that are difficult to control with treatment.

What Are Researchers Trying To Learn About Reactive Arthritis (Reiter's Syndrome)?

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 of infection to Reactive Arthritis. In particular, they are trying to determine why an infection triggers arthritis and why some people who develop infections get Reactive Arthritis and others do not. Scientists have identified a genetic link—people who are positive for HLA–B27 are more susceptible to Reiter's—and are studying why these people are more at risk than others. 

Researchers are trying to develop 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 studying new treatments for Reactive Arthritis; for example, prolonged treatment with antibiotics or a combination of antibiotics and other drugs such as methotrexate or sulfasalazine. Several recent studies have shown that prolonged treatment with antibiotics may reduce the duration of symptoms in some patients with Reactive Arthritis caused by Chlamydia infection.