Brief overview
- What is reactive arthritis? An inflammation of the joints triggered by a bacterial infection in another part of the body (usually in the urinary and genital organs or in the gastrointestinal tract). Old name of the disease: Reiter’s disease or Reiter’s syndrome.
- Symptoms: painful joint inflammation (usually in the knee, ankle, hip joints), conjunctivitis and urethritis – together called Reiter’s triad. Sometimes also skin and mucous membrane changes, more rarely inflammation in the area of tendons, spine or internal organs. Fever may be concomitant.
- Cause: Unclear. Probably the immune system cannot adequately fight the causative bacterial infection – bacterial proteins or live bacteria remain in joints and mucous membranes, to which the immune system continues to react.
- Treatment: Medications such as antibiotics, cortisone-free painkillers and anti-inflammatories (such as ibuprofen), cortisone (in severe cases), so-called DMARDs (in chronic cases). Accompanying phsyiotherapeutic measures.
- Prognosis: Reactive arthritis usually heals by itself within a few months. In the remaining cases, patients suffer from it for a longer period of time. In addition, relapses are possible.
Reactive arthritis: Definition
People of all ages around the world can develop reactive arthritis. However, most of those affected are younger than 40. In Germany, 30 to 40 out of 100,000 adults suffer from reactive arthritis.
Old name: Reiter’s disease
In 1916, the Berlin physician, bacteriologist and hygienist Hans Reiter described for the first time a disease with the three main symptoms of joint inflammation (arthritis), urethritis (urethritis) and conjunctivitis – collectively known as the “Reiter triad”.
The disease was named after him as Reiter’s disease (Reiter’s syndrome, Reiter’s disease). However, since Hans Reiter was a high official in the National Socialist regime, the disease was renamed “reactive arthritis” at the beginning of the 21st century, first abroad and then also in Germany.
Reactive arthritis: symptoms
Symptoms in reactive arthritis usually appear about two to four weeks after an infection of the urinary or genital organs, gastrointestinal tract, or respiratory tract. However, it can take up to six weeks before the first symptoms are felt.
Joint complaints
Usually only one or a few joints are affected (mono- to oligoarthritis) and only rarely several joints at the same time (polyarthritis) as in other rheumatic diseases. Sometimes the inflammation changes from one joint to another.
The inflammation-related pain, redness and hyperthermia are particularly common in the knee and ankle joints and in the hip joints. Typically, one or more toe joints are also affected, and sometimes finger joints (dactylitis). If an entire toe or finger is swollen, it is referred to as “sausage toe” or “sausage finger.”
Eye inflammation
Also common in reactive arthritis is inflammation of one or both sides of the eye, especially inflammation of the conjunctiva (conjunctivitis). Sometimes inflammation of the iris or cornea (keratitis) develops. Typical symptoms are photophobia, red, burning, painful eyes and possibly impaired vision.
In severe cases, eye inflammation can even lead to blindness.
Skin and mucous membrane changes
Sometimes reactive arthritis also causes various skin changes – often on the soles of the hands and feet: The affected areas may resemble psoriasis, or the skin is excessively keratinized (keratoma blennorrhagicum).
Some Reiter’s disease patients have painful, reddish-bluish skin nodules in the area of the ankle and lower leg (erythema nodosum).
The oral mucosa is also affected in some cases. There is often increased saliva production and deposits on the tongue. Over the course of several days, the deposits then develop into a so-called map tongue, in which brownish or white discolored areas alternate with areas that still look normal.
Inflammation of the urinary tract and genital organs
Urethritis may also occur together with reactive arthritis. Affected individuals experience frequent urination and pain when urinating. The latter may also be due to cystitis or prostatitis – also possible concomitants of reactive arthritis.
Sometimes patients also experience discharge from the urethra – or from the vagina. Reactive arthritis can also be accompanied by inflammation of the mucous membranes in the cervix (cervicitis).
Less common accompanying symptoms
In addition to the joints, tendons, tendon sheaths and tendon insertions can also become inflamed. The Achilles tendon in the heel is particularly frequently affected. Affected persons mainly report pain when moving the foot. If the tendon plate on the sole of the foot becomes inflamed, walking is associated with severe pain.
Some people with reactive arthritis suffer from general symptoms such as fever, faintness and weight loss. Muscle pain may also occur.
Some patients develop mild inflammation of the kidneys, while more severe kidney disease is rare. There is also a risk of inflammation of the heart muscle. This, in turn, sometimes triggers cardiac arrhythmias.
Reactive arthritis: causes and risk factors
It is unclear exactly how reactive arthritis (Reiter’s disease) develops. The trigger is usually an infection with bacteria in the gastrointestinal tract, the urinary and genital organs or (more rarely) the respiratory tract. Typical pathogens are chlamydia and enterobacteria (salmonella, yersinia, shigella, campylobacter).
For example, one to three percent of people who contract a urinary tract infection with the bacterium Chlamydia trachomatis subsequently develop reactive arthritis. After gastrointestinal infections with enterobacteria, this is the case for 30 percent of patients.
In people with reactive arthritis, the body is probably unable to completely eliminate the pathogens from the previous infection: From the originally infected tissue, the bacteria therefore enter the joints and mucous membranes via the blood and lymphatic channels. Proteins of the pathogen or even living bacteria probably remain there. The immune system continues to fight the foreign components, causing inflammation at various sites in the body. For example, when the joint membrane comes into contact with the surface proteins of certain bacteria, it responds with an inflammatory response.
Reactive arthritis: risk factors
More than half of all people with reactive arthritis are genetically predisposed. In them, the so-called HLA-B27 can be detected – a protein on the surface of almost all body cells. It is also frequently found in some other inflammatory rheumatic diseases (such as rheumatoid arthritis and ankylosing spondylitis). Patients with reactive arthritis who have HLA-B27 are at higher risk for a more severe and prolonged course of the disease. In addition, the axial skeleton (spine, sacroiliac joint) is more affected in them.
Reactive arthritis: examinations and diagnosis
Medical history
If you describe symptoms such as those listed above, the physician will quickly suspect reactive arthritis. Especially if you are a young adult in whom one or a few large joints have suddenly become inflamed, the suspicion of “Reiter’s disease” is obvious.
The doctor will then ask you whether you have had, for example, a bladder or urethra infection (for example, from pathogens transmitted during sex), a diarrheal illness or a respiratory tract infection in the last few days or weeks. If so, the suspicion of reactive arthritis is strengthened.
Pathogen detection
Sometimes, however, such infections occur without (clear) symptoms and thus go unnoticed. Or the patient does not remember it. Therefore, if reactive arthritis is suspected, an attempt is made to detect causative infectious agents. To do this, the doctor will ask you for a stool or urine sample. Swabs of the urinary tract, anus, cervix or throat can also be searched for infectious agents.
However, the acute infection usually occurred a few weeks ago, so that such direct pathogen detection is often no longer possible. Indirect pathogen detection can then be of further help: the blood is tested for specific antibodies against pathogens that can be considered as triggers of reactive arthritis.
Further blood tests
Detection of HLA-B27 in the blood is successful in most but not all patients. Thus, the absence of HLA-B27 does not rule out reactive arthritis.
Imaging procedures
Imaging of the affected joints and spinal segments provides more accurate information about the extent of joint damage. Your doctor may use procedures such as the following:
- Ultrasound examination
- Magnetic resonance imaging (MRI)
- Bone scintigraphy
X-rays do not show any changes in affected joints during the first six months of reactive arthritis. They are therefore more useful later in the course of the disease – or to rule out other diseases as the cause of the joint symptoms.
Joint puncture
Sometimes a joint puncture is necessary. This involves piercing the joint cavity with a fine hollow needle to remove some joint fluid for a more detailed examination (synovial analysis). This can help identify other causes of joint inflammation. For example, if bacteria such as Staphylococcus aureus or Haemophilus influenzae are found in the joint fluid, this indicates septic arthritis. The detection of Borrelia indicates Lyme borreliosis.
Other examinations
Furthermore, the doctor can check, for example, whether the kidney function is restricted by the reactive arthritis. A urine test helps with this.
A measurement of the electrical activity of the heart (electrocardiography, ECG) and a heart ultrasound (echocardiography) should rule out the possibility that the immune reaction has also affected the heart.
If your eyes are also affected, you will definitely need to see an ophthalmologist as well. He can examine your eyes more closely and then suggest a suitable treatment. This will help prevent vision problems later on!
Reactive arthritis: Treatment
Reactive arthritis is primarily treated with medication. In addition, physiotherapeutic measures can help against the symptoms.
Treatment with medication
If your doctor has proven an infection with bacteria as the trigger of reactive arthritis, you will receive suitable antibiotics. If the bacteria are sexually transmitted chlamydia, your partner must also be treated. Otherwise, he or she could infect you again after taking the antibiotics.
If the causative pathogens are not known, antibiotic therapy is not advisable.
The symptoms can be treated with painkillers and anti-inflammatory drugs. Suitable drugs include cortisone-free (non-steroidal) anti-inflammatory drugs (NSAIDs) such as diclofenac and ibuprofen.
If the disease is severe, glucocorticoids (cortisone) must often be used for a short time. Cortisone can also be injected directly into the joint if a bacterial joint infection has been ruled out.
If the reactive arthritis does not subside within a few months, it is referred to as chronic arthritis. In this case, treatment with so-called basic therapeutics (basic drugs), known as disease-modifying anti-rheumatic drugs (DMARDs), may be necessary. They can inhibit inflammation and modulate the immune system and generally form the basis of treatment for inflammatory rheumatic diseases (such as rheumatoid arthritis).
Physiotherapy
Physiotherapeutic measures support the drug treatment of reactive arthritis. For example, cold therapy (cryotherapy, for example in the form of cryopacks) can alleviate acute inflammatory processes and pain. Movement exercises and manual therapy can keep joints mobile or make them more mobile and prevent regression of the muscles.
What you can do yourself
Try to take it easy on the affected joints. However, if the physiotherapist recommends exercises for you to do at home, you should do them conscientiously.
You can also apply cooling compresses to acutely inflamed, painful joints on your own.
However, patients with high blood pressure should be careful with cold applications and ask their doctor for advice beforehand.
Reactive arthritis: course of the disease and prognosis
Many sufferers are interested in one question in particular: How long does reactive arthritis last? The reassuring answer is that reactive arthritis usually heals on its own after six to twelve months. Until then, medication and physiotherapy can alleviate the symptoms.
In 20 percent of cases, chronic reactive arthritis is associated with the occurrence of other inflammatory spinal diseases (spondyloarthritides), such as psoriatic arthritis or axial spondyloarthritis.
Complications arise, for example, when the joint inflammation permanently impairs the joint function – up to the destruction of the joint. In the eye, the inflammatory process can spread from the conjunctiva to the iris and the adjacent eye structures. This can permanently impair visual function. A so-called cataract can develop, which can lead to blindness.
In half of the patients, the disease returns after some time (recurrence), caused by a renewed infection. So anyone who has already had reactive arthritis is at increased risk of developing it again. Sometimes, however, only individual symptoms occur, such as conjunctivitis.
You can protect yourself from a chlamydia infection as a (renewed) trigger of reactive arthritis by always using condoms during sex – especially if you have different sexual partners.
