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Basics of Reactive Arthritis
Reactive Arthritis is a form of arthritis that produces pain swelling redness and heat in the joints. It is one of a family of arthritic disorders affecting the spine. Reactive Arthritis commonly involves the joints of the spine and the sacroiliac joints areas where the spine attaches to the pelvis.
Three characteristic features of the disease include: inflammation of the joints urinary tract and eyes. More recently doctors have recognized a fourth major feature: ulcerations of the skin and mouth.
Prognosis
Most people with reactive arthritis can expect to live normal life spans. The majority of people with the disease maintain a near-normal lifestyle with modest adaptations to protect the involved joints.
Incidence
Reactive arthritis primarily affects young white men between the ages of 20 and 40 although it can occur in older people or children. African American men rarely get the disease and women get it only a fifth as often as men.
Symptoms
Reactive arthritis often begins following inflammation of the intestinal or urinary tract. In susceptible people this inflammation sets off a disease process that involves the joints eyes urinary tract and skin. A brief description of how each of these may be affected is below.
Not all of these symptoms occur in every person with reactive arthritis. Nor do they all occur at once in the same person. Symptoms of the disease tend to come and go but not always at the same time as the worsening of the joints.
Joint swelling
When reactive arthritis first begins it is characterized by a great deal of swelling and pain in the affected joints. Joint involvement is usually asymmetric (meaning it affects different joints on opposite sides of the body) and confined to a small number of joints. Often the spine sacroiliac joints and large joints of the legs are involved. A few small joints in the toes or fingers also may be affected. In addition people with Reiter's syndrome may experience inflammation in areas where tendons connect to bones as in the heels.
The joint involvement of reactive arthritis tends to follow one of two courses. A small percentage of people have continuing joint involvement that is constant. Most people however have periodic attacks of arthritis that last from three to six months. In each attack the general pattern and severity tend to be similar to previous attacks with a small number of joints--often different joints--involved each time.
After the first attack almost half of those with reactive arthritis will never have another attack. Statistics are similar after the second attack. But with subsequent attacks it is more likely that the disease will become a permanent form of arthritis.
In most cases the joint inflammation that is associated with reactive arthritis does not lead to permanent joint damage or disability.
Conjunctivitis
About 40 percent of people with reactive arthritis experience conjunctivitis an inflammation of the membranes under the eyelids early in the disease process. Conjunctivitis may be so mild that it's hardly noticed or it may be painful and accompanied by secretions. Fortunately it usually is short-lived and rarely causes permanent damage.
Later in the disease process about five percent of people with the disease develop iritis an inflammation of the iris and deeper tissues that causes the pupil to open and close. Iritis is a serious condition; immediate medical attention by an ophthalmologist is required. If it is not promptly treated scarring may occur and affect vision.
Urinary tract involvement
The most common form of urinary tract involvement in people with reactive arthritis is urethritis an inflammation of the urethra or tube that drains urine from the bladder out of the body. The typical symptom of urethritis burning during urination may or may not be present.
In men reactive arthritis often is accompanied by a discharge from the penis. The discharge usually is painless and carries no bacterial infection. Inflammation also may appear in the prostate gland of men with reactive arthritis. Cystitis which is an inflammation of the bladder is a common form of urinary tract involvement in women with reactive arthritis.
In most cases these problems will go away on their own and cause no permanent damage.
Skin problems
People with reactive arthritis often experience small hardly noticeable sores on the soft palate or back of their throat. Painless superficial sores on the penis occur in about one-third of men with reactive arthritis. Some women with the disease develop sores on their external genitalia.
In addition people with reactive arthritis may experience a rash on the soles of the feet made up of thickened and over-pigmented outer layers of skin. This type of skin involvement occurs less commonly on the palms of the hands and on other areas of the body.
Causes
The direct cause of reactive arthritis is not known; however both genetic and environmental factors are involved. About 75 percent of people with reactive arthritis have a gene called HLA-B27. HLA-B27 is one of a family of genes that play an important role in the body's defense against infection.
It is important to note that having the HLA-B27 gene does not mean you will develop reactive arthritis. Approximately eight percent of white Americans and two to three percent of African Americans carry the gene; the majority of them don't have any form of arthritis. Having the gene however may predispose certain people to react to an infectious agent that enters the body through the urinary or intestinal tract.
When people get reactive arthritis through inflammation of the intestinal tract it usually follows a bout of diarrhea caused by eating foods contaminated with bacteria such as salmonella shigella campylobacter or yersinia. There is speculation that the inflammation in the urinary tract is caused by a variety of different organisms but no specific infectious agent has been identified.
Some researchers have found fragments of infectious agents in the affected joints. The arthritis appears to result from an immune or inflammatory reaction to the fragments. Exactly how joints and other organs become involved after the initial infection is not known.
Studies show that some people develop or have a relapse of reactive arthritis after having sexual intercourse with a new partner yet reactive arthritis itself cannot be transmitted through sexual contact.
Diagnosis
Getting a definite diagnosis of reactive arthritis may take some time since diagnosis primarily depends on a physical examination showing characteristic physical findings or signs of the disease.
Sometimes not all signs are present at once and not all people exhibit all of them. The more physical findings you experience the more definite the diagnosis.
Certain features especially the skin lesions are so characteristic that their presence along with joint involvement is sufficient to make the diagnosis of reactive arthritis.
Uncertainty in making a diagnosis happens if joint inflammation occurs without the other symptoms. In such cases a doctor may suspect reactive arthritis and perform a test for the HLA-B27 genetic type. If that test is positive or if the spine and sacroiliac joints are involved your doctor can at least tell that the disease is in the family of the spondyloarthropathies. In those cases a physician may make a diagnosis of incomplete reactive arthritis. You may need to see an arthritis specialist.
Treatment
Appropriate treatment can suppress the disease activity and manage the symptoms of reactive arthritis.
The goal of treatment for arthritis associated with reactive arthritis is to reduce inflammation in the affected joints thereby reducing the accompanying pain and limited mobility.
Health care team
Because the disease affects different parts of the body some people with reactive arthritis may need to see different specialists over the course of the disease. The arthritis specialist will be able to coordinate the treatment of this disorder. Other specialists you may need to see include dermatologists who diagnose and treat disorders of the skin; ophthalmologists who specialize in diseases of the eye; and urologists who treat the urinary tract. Your treatment team also may include physical and occupational therapists.
Exercise and therapy
Physical and occupational therapy often is prescribed in conjunction with medical therapy. Physical therapy consists of different treatments to reduce inflammation as well as exercises to increase the mobility of joints and strengthen surrounding tissues. By promoting improved muscle tone you can help protect your joints from damage and keep them working optimally.
Occupational therapy involves learning to perform activities of daily living in an efficient manner placing less stress on joints and thus making activities easier and joint damage less likely.
Medications
Medications usually include a class of medications called nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs usually are sufficient to suppress the swelling heat and pain of the joints. In some cases doctors use injections of the hormone cortisone to control pain and inflammation in specific joints. If neither of these keeps the disease under control stronger drugs may be needed.
Surgery
In the vast majority of people with reactive arthritis the above approaches are sufficient. In the few people for whom management does not prevent severe joint damage surgical reconstruction of the joints such as total hip replacement or total knee replacement by orthopedic surgeons can restore pain-free function.
Long-term management
The symptoms of urinary tract and skin involvement often clear up on their own but the use of appropriate antibiotics and topical skin medications may be necessary at times.
Iritis because of its potential for damaging the eye requires close supervision by an ophthalmologist. Depending on the severity of the condition your doctor may prescribe anti inflammatory medication in the form of eye drops pills or direct injection into the eye tissues.
Because reactive arthritis has been associated with sexual exposure in some people some doctors recommend using a condom to prevent recurrences of the disease. The condom is used to prevent a recurrence not to prevent transmission of reactive arthritis.
Asking for help
Coping with the pain and unpredictability of reactive arthritis can be difficult at times.
It's important that you learn as much as you can about the disease and how to manage it. Sometimes talking to a family member or friend can provide much needed emotional support. Working with a counselor psychologist or social worker helps some people with reactive arthritis develop better coping skills.
Support groups have been a source of help for thousands of people with different forms of arthritis. Just knowing that you are not alone and that others understand what you're going through can make coping a little easier.
Credits
Some of this material may also be available in an Arthritis Foundation brochure.
Adapted from the pamphlet originally prepared for the Arthritis Foundation by Harry G. Bluestein M.D. This material is protected by copyright.
