Reactive arthritis

Reactive arthritis (ReA) is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis.^[1] Reactive arthritis has symptoms similar to arthritis or rheumatism. It is caused by another disease, and is thus "reactive", i.e., dependent on the other condition. The "trigger" infection is typically missing in chronic cases.

Reactive arthritis is the combination of three seemingly unlinked symptoms—an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis), and urethritis. A useful mnemonic is "the patient can't see, can't pee and can't climb a tree". It is also known as arthritis urethritica, venereal arthritis and polyarteritis enterica. It is a type of seronegative spondyloarthropathy.

Reactive arthritis is an RF-seronegative, HLA-B27-linked spondyloarthropathy (autoimmune damage to the cartilages of joints) often precipitated by genitourinary or gastrointestinal infections.

It most commonly strikes individuals aged 20-40, it is more common in men than in women, and more common in white men than in black men. This is due to white individuals being more likely to have tissue type HLA-B27 than black individuals. People with HIV have an increased risk of developing reactive arthritis as well. Food poisoning is a common cause.

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History

Reactive arthritis was first described by Hans Reiter, a German military physician, who in 1916 described the disease in a World War I soldier who had recovered from a bout of diarrhea. The term Reiter's syndrome is being phased out, partly due to a move in the field of medicine to give descriptive names, rather than personal names, to conditions, and partly due to Dr. Reiter's experiments in Nazi concentration camps. Another reference states Reiter's syndrome is to be used when areas other than joints are affected.

Causes

It is set off by a preceding infection, the most common of which would be a genital infection with Chlamydia trachomatis in the US. Other bacteria known to cause reactive arthritis which are more common worldwide are Neisseria gonorrhoeae, Ureaplasma urealyticum, Salmonella spp., Shigella spp., Yersinia spp., and Campylobacter spp.^[2] A bout of food poisoning or a gastrointestinal infection may also trigger the disease (those last four genera of bacteria mentioned are enteric bacteria). Reactive arthritis usually manifests about 1-3 weeks after a known infection. The mechanism of interaction between the infecting organism and the host is unknown. Synovial fluid cultures are negative, suggesting that RA is caused either by an over-excited autoimmune response or by bacterial antigens which have somehow become deposited in the joints.

Signs and symptoms

Symptoms generally appear within 1-3 weeks but can range from 4-35 days from the onset of the inciting episode of the disease.

The classical presentation is that the first symptom experienced is a urinary symptom such as burning pain on urination (dysuria) or an increased need to urinate (polyuria or frequency). Other urogenital problems may arise such as prostatitis in men, and cervicitis, salpingitis and/or vulvovaginitis in women.   The arthritis that follows usually affects the large joints such as the knees causing pain and swelling with relative sparing of small joints such as the wrist and hand.

Eye involvement occurs in about 50% of men with urogenital reactive arthritis and about 75% of men with enteric reactive arthritis. 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.

Roughly 20 to 40 percent of men with reactive arthritis develop penile lesions called balanitis circinata (circinate balanitis) on the end of the penis. A small percentage of men and women develop small hard nodules called keratoderma blennorrhagica on the soles of the feet, and less often on the palms of the hands or elsewhere. In addition, some people with Reactive Arthritis develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed. Some people suffer serious gastrointestinal problems similar to those of Crohn's Disease.

About 10 percent of people with Reactive Arthritis, especially those with prolonged disease, will develop cardiac manifestations including aortic regurgitation and pericarditis.

Commonly remembered with the mnemonic "Can't See, Can't Pee, Can't Climb a Tree"

Diagnosis

There are countless clinical symptoms, but the clinical picture is dominated by polyarthritis. There is pain, swelling, redness, and heat in the joints. MRI's are effective for diagnosis.

The urethra, cervix and throat may be swabbed in an attempt to culture the causative organisms. Cultures may be carried out on urine and stool samples. Synovial fluid from an affected knee may be aspirated to look at the fluid under the microscope and for culture.

Also, a blood test for the gene HLA-B27 may be given to determine if the patient has the gene. About 75 percent of all patients with Reiter's Syndrome have the gene.

Treatment

The main goal of treatment is to identify and eradicate the underlying infectious source with the appropriate antibiotics if still present. Otherwise, treatment is symptomatic for each problem. Analgesics, steroids and immunosuppressants may be needed for patients with severe reactive symptoms that do not respond to any other treatment.

Prognosis

Reactive arthritis may be self limiting, frequently recurring or develop continually. Most patients have severe symptoms lasting a few weeks to six months. Approximately 15 to 50 percent of cases have recurrent bouts of arthritis. Chronic arthritis or sacroiliitis occurs in 15-30 percent of cases. Repeated attacks over many years is common, and more than 40 percent of the patients end up with chronic and disabling arthritis, heart disease, diabetes or impaired vision. However, most people with reactive arthritis can expect to live normal life spans and maintain a near-normal lifestyle with modest adaptations to protect the involved organs.

References

Images

• Picture - Conjunctivitis in reactive arthritis (Chlamydia)
• Picture - Psoriasiform skin changes in reactive arthritis (Chlamydia)
• Picture - arm lesions in reactive arthritis (Chlamydia)
• Picture - hand lesions in reactive arthritis (Chlamydia)