Reactive Arthritis, formerly Reiter Syndrome

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Reactive Arthritis

(Formerly Reiter Syndrome)

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Reactive Arthritis involves inflammation of joints (arthritis), eyes (conjunctivitis), and the genital, urinary or gastrointestinal systems. Reactive Arthritis can occur after genital (venereal) infection or bowel infection (dysentery). Reactive Arthritis shares many features with psoriatic arthritis, ankylosing spondylitis, and the arthritis of Crohn disease and ulcerative colitis. Reactive Arthritis can affect the joints, the spine, the eyes, urinary tract, mouth, colon, and heart. There is no one laboratory test for diagnosing Reactive Arthritis. HLA-B27 genetic marker is commonly found. Treatment of Reactive Arthritis is directed toward the specific body area(s) inflamed.

What is Reactive Arthritis?

Reactive Arthritis is a chronic form of inflammatory arthritis wherein the following three conditions are combined: (1) arthritis; (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 which is " reacting " to the presence of 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. Reactive arthritis has in the past been referred to as Reiter syndrome (a term that has lost favor because of Dr. Hans Reiter’s dubious past). Reactive Arthritis most frequently occurs in patients in their thirties or forties, but it can occur at any age. The form of Reiter syndrome which occurs after genital infection (venereal) occurs more frequently in males. The form which 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, 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?

As mentioned, Reactive Arthritis is felt in part to be genetic. There are certain genetic markers that are far more frequent in patients with Reactive Arthritis than in the normal 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 developing Reactive Arthritis, exposure to certain infections seem to be required to trigger the onset of the disease.

Reactive Arthritis can occur after venereal infections. The most common bacteria that has been associated with this post-venereal form of Reactive Arthritis is an organism called Chlamydia. 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.

What are symptoms of Reactive Arthritis?

The symptoms of Reactive Arthritis can be divided into those which affect the joints and those which affect the non-joint areas.

The classic joints that become inflamed in Reactive Arthritis are the knees, ankles, feet, and wrists. The particular joints involved are usually asymmetric, that is, one side of the body or the other is affected, rather than both sides simultaneously. The inflammation leads to stiffness, pain, swelling, warmth, and redness of the joints involved. Patients may develop inflammation of entire fingers or toes which can give the appearance of a " sausage digit. " This is also seen in patients with another type of arthritis associated with psoriasis, called psoriatic arthritis. The arthritis of Reactive Arthritis can be associated with inflammation of the spine, leading to stiffness and pain in the back or neck (characteristic of all of the spondyloarthropathies).

Cartilage can also become inflamed, especially around the breastbone where the ribs meet in the front of the chest, this condition is called costochondritis. Muscles attach to the bones by tendons. In Reactive Arthritis, the tendon insertion points can become inflamed (tendinitis), tender, and painful when exercised.

Non-joint areas that become inflamed and cause symptoms in Reactive Arthritis include the eyes, genitals, urinary tract (urethra, bladder and prostate gland), mouth lining, large bowel, and the aorta.

Inflammation of the whites of the eye (conjunctivitis) and the iris of 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, it can be very painful and especially worse when looking into bright lights.

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 end of the penis. The skin around the penis can become inflamed and scale. The bladder and prostate gland can also become inflamed, leading to an urge to urinate.

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 patients who have Reiter syndrome. It can lead to failure of the aortic valve of the heart, which can cause heart failure. The electrical conducting pathway of the heart can also become scarred in Reactive Arthritis, leading to irregular heartbeats (arrhythmias) that may require placement of a pacemaker to regulate the heartbeat.

How is Reactive Arthritis diagnosed?

There is no singular lab test used to diagnose Reactive Arthritis. Reactive Arthritis is diagnosed based upon recognition of the combination of arthritis with inflammation of the eyes, and the genital, urinary, and/or gastrointestinal systems. The doctor takes a medical history to note the time course of possible infection in the genital or urinary tracts, or the bowel. Stiffness and pain over time are noted. Inflammatory types of joint problems typically cause more stiffness in the morning. Blood tests such as a " sedimentation rate " may be obtained to document the presence of inflammation in the body. The rheumatoid factor, which is typically present in rheumatoid arthritis, is usually negative in Reactive Arthritis. The HLA-B27 gene marker blood test can be helpful, especially in the diagnosis of patients with spine disease.

X-rays of the spine or other joints can reveal typical changes of inflammation in these areas. Occasionally, there are areas of unusual calcifications at the points where the tendons attach to the bones, indicating past inflammation in these areas. Those patients with eye inflammation may require ophthalmology evaluation to document the degree of inflammation in the iris. Stool cultures might be obtained to detect the presence of infections in the bowel. Similarly, urinalysis and culture of the urine may be necessary to detect bacterial infection in the urinary tract. The prostate gland, which can also be inflamed in a patient with Reactive Arthritis, may be examined for tenderness.

How is Reactive Arthritis treated?

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 antiinflammatory drugs (NSAIDs). These medications include aspirin, indomethacin (INDOCIN), tolmetin (TOLECTIN), sulindac (CLINORIL), piroxicam (FELDENE), and others. Among their potential side effects are gastrointestinal irritation, including ulceration and bleeding. They should be taken with food to minimize this risk. Corticosteroids can be helpful to 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. They are also used to decrease tendon inflammation in some forms of tendinitis.

Sulfasalazine (AZULFIDINE) has been shown to be effective in some patients with Reactive Arthritis and persistent arthritis. This is a sulfa-based medication which can have side effects including sulfa rash reaction and suppression of the bone marrow. Therefore, blood counts are monitored when AZULFADINE is used long term.

For the aggressive inflammation of chronic arthritis in Reactive Arthritis, medications which suppress the immune system, including methotrexate (RHEUMATREX), are used. Methotrexate can be given orally by injection. It is given on a weekly basis and requires regular monitoring of blood counts and blood liver tests because of potential toxicity to the bone marrow and liver.

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 the HIV disease.

Eye inflammation can be alleviated with antiinflammatory drops. Some patients with severe iritis require local injections of cortisone to prevent damaging inflammation to the eye, which can lead to blindness.

The inflammation around the penis can be helped by cortisone creams (such as TOPICORT). When bacteria are discovered in the bowel or urine, antibiotics specific for those bacteria are given.

In the future, other medications will be developed which are more specific in the treatment of Reactive Arthritis. Trials with long-term antibiotic treatment are under way, and it is possible that these may be especially effective in reactive arthritis associated with Chlamydia infection.

For further information about Reactive Arthritis, please visit the following site:

The Arthritis Foundation

You can also contact:

The Arthritis Foundation P.O Box 19000 Atlanta, Georgia 30326 or contact your local chapter.

National Arthritis and Musculoskeletal and Skin Diseases Clearinghouse Box AMS Bethesda, land 20892 301-495-4484