Reiters Arthritis Or Reactive Arthritis
Reactive arthritis is also known as Reiter’s syndrome, although this latter term is losing ground gradually to reactive arthritis. It is associated with gastrointestinal infections by Salmonella and other organisms, and with genitourinary infections such as with Chlamydia. There is a significant connection with the human leucocyte antigen, HLA B27, which links reactive arthritis to other arthritic diseases such as ankylosing spondylitis which puts it in the group of conditions known as seronegative spondyloarthropathies. Although conjunctivitis and urethritis are commonly connected with this form of arthritis, the arthritis can occur without these infections.
Once a person has an infection of the genitourinary system or the gastrointestinal system then the arthritis can come on around two to four weeks later, with a respiratory infection with Chlamydia also a possible causative factor. There may be no apparent preceding infection in around ten percent of patients. Many anatomical structures can be affected by the inflammation, including the mucous membrane, the eyes, the joints, the spine, the ligament-bone and tendon-bone junctions and the gastro-intestinal system. Patients with HLAB27 are fifty times more likely to develop reactive arthritis than those without it.
Longer lasting and more damaging arthritis is suffered by those patients who are HLAB27 positive or have a strong familial tendency to this condition. From 1 to 4 percent of those suffering a gut related infection may develop reactive arthritis but this number varies greatly even with the same infecting agent. How the biological agent and the person’s body react to cause the arthritis is not known and none of the infecting agents are found in the joint fluids. Immune reaction to the infectious agents does occur and antibodies have been isolated from joint fluids, suggesting this might be an immune mediated inflammatory condition.
The natural history of reactive arthritis is of a self-limiting condition and the symptoms gradually resolve over three to twelve months despite the symptoms being severe in some patients. Recurrence of the arthritis is a significant probability and this is increased if the patient is HLAB27 positive. Re-exposure to triggering factors or infections can cause a new episode. The arthritis can become severe, disabling and destructive of the joints in around fifteen percent of sufferers. Twenty to forty years of age is the typical range for this condition, with males and females equally represented after gut infections, but males predominating by nine to one after urogenital infections.
Reactive arthritis usually comes on quickly as an acute presentation with patients presenting with tiredness, high temperature and a feeling of being unwell. Lower extremity arthritis of a few joints, arranged non symmetrically (unlike rheumatoid arthritis) is common. Heel pain from inflammation of the insertion of the Achilles tendon into the heel bone is common and low back pain is present in half of the patients. Lower limb joints involved in weight bearing are typically affected, with more severely affected patients exhibiting hands and feet symptoms. Back pain symptoms are commonly reported but examination shows few findings apart from a reduction in lumbar flexion.
The treatment of reactive arthritis depends on how severe the symptoms are. Non-steroidal anti-inflammatory drugs are a corner stone of treatment, taken regularly to allow sufficiently effective anti-inflammatory cover. Physiotherapy is often used to reduce pain, maintain joint ranges and maximise muscle strength in the more severe sufferers. Steroids can be injected into a painful joint and can give long term relief of symptoms, or they can be given systemically if there is inadequate control of the symptoms using anti-inflammatories. Antibiotics are sometimes used but may not change the natural history of the condition.
If the arthritic symptoms are chronic or the patient suffers from ongoing, poorly controlled inflammation then consideration will be given to the prescription of disease modifying anti-rheumatoid drugs or DMARDS. As they have been mostly used in other arthritic conditions it is not clear what precise effect these agent have in reactive arthritis. Sulfasalazine and methotrexate are typical examples, however biological agents such as TNF-blockers have not been shown to be effective.
