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Reactive Arthritis - Causes, Diagnosis, and Treatment

Published on Jul 18, 2022 and last reviewed on Jul 28, 2022   -  5 min read

Abstract

Infection in another part of the body causing joint pain and swelling is known as reactive arthritis. To know more about the condition read the article below.

What Is Reactive Arthritis?

Reactive arthritis is inflammatory arthritis caused by a distant infection in joints where no cultivable bacteria exist. Although alternative sites of infection have been documented, the main infection usually occurs in the gastrointestinal (GI) or genitourinary (GU) tract. It can be difficult to pinpoint the initiating infection because rheumatic symptoms normally appear after the infection has passed. Reactive arthritis was once known as Reiter's syndrome and Fiessinger-Leroy disease.

What Is the Cause for Reactive Arthritis?

Reactive arthritis does not spread. The bacteria that causes it, on the other hand, can be spread sexually or through contaminated food. Reactive arthritis affects just a small percentage of those exposed to these germs. Genital Chlamydia trachomatis is the most prevalent cause of reactive arthritis. At the time of diagnosis, at least 70% of women and 50% of men are asymptomatic.

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Why Is Early Diagnosis of Reactive Arthritis Important?

It typically mimics other illnesses in the acute phase, resulting in a delayed diagnosis. It is important to diagnose reactive arthritis early for the following reasons:

  • Some people develop chronic inflammatory arthritis, which requires long-term immunomodulatory medication, depending on the source of infection and other causes.

  • Early identification and treatment will benefit less disease-related organ damage and joint damage, as well as better patient outcomes.

  • From the epidemic of global COVID-19, additional cases of reactive arthritis are developing.

  • This is significant because many cases of post-COVID-19 reactive arthritis may have specialized treatment and may be misinterpreted as post-COVID effect or extended COVID syndrome.

  • Aside from these factors, the identification of reactive arthritis allows for contact tracing and infection control measures, which can help limit the virus's spread to the general population.

Is Reactive Arthritis Part of the Spondyloarthropathy Spectrum?

Yes, the spondyloarthropathy spectrum includes reactive arthritis. It also includes:

Inflammation of the site where tendons and ligaments insert into the bone surface (enthesitis), finger inflammation (dactylitis), and sacroiliac joint inflammation (sacroiliitis), as well as extra-articular symptoms like psoriasis, inflammation of the eyes (uveitis), and inflammatory bowel disease, are the characteristic overlapping features of these diseases. There is a substantial link with HLA-B27 as well.

What Are the Clinical Manifestations of Reactive Arthritis?

The major clinical features of reactive arthritis are,

  • Articular and periarticular features.

  • Mucocutaneous.

  • Genitourinary.

  • Ocular features.

What Are the Articular and Periarticular Features of Reactive Arthritis?

RA1

  • Large joint: Oligoarthritis - lower limbs.

  • Small joint: Polyarthritis - upper limbs.

  • Inflammation of the cervical, lumbar, and lumbosacral spine.

  • Sacroiliitis: Lower back pain and buttock pain which gets severe at the night.

  • Enthesitis: Difficulty in walking.

  • Dactylitis: Swelling of the toe or finger.

What Are the Mucocutaneous Features of Reactive Arthritis?

  • Keratoderma blennorhagicum: Pustule-like lesion in the heal.

  • Circinate balanitis: Psoriasiform (lesions similar to psoriasis) sores over the penis that is painless and superficial.

  • Oral ulcerations.

  • Thick and dystrophic nails are similar to psoriatic onychodystrophy.

What Are the Genitourinary Features of Reactive Arthritis?

RA2

  • Urethritis: Urethral inflammation.

  • Cervicitis: Inflammation of the cervix.

  • Salpingo-oophoritis: Inflammation of the appendage of uterine.

  • Cystitis: Inflammation of the urinary tract.

  • Prostatitis: Inflammation of the prostate gland.

What Are the Ocular Features of Reactive Arthritis?

  • Conjunctivitis: Inflammation of the conjunctiva - redness and itch of an eye.

  • Keratitis: Inflammation of the cornea - red eye.

  • Episcleritis: Inflammation of episclera (the layer between sclera and conjunctiva).

  • Uveitis: Inflammation of uvea (eyewall).

How to Diagnose Reactive Arthritis?

History taking is essential to identify the primary infection, sexual history, and family history of spondyloarthropathy.The patient has to be examined for joint effusions, dactylitis, enthesitis, oral ulcers, ocular inflammation, skin rashes, and urethral discharge. For genitourinary infections, a urine sample or urethral swab is collected and sent for nucleic acid amplification testing. For the Chlamydia pneumoniae infection, the sample should be sent for antibody testing. To diagnose a gastrointestinal infection, an enzyme immune assay is done for yersinia, salmonella, and campylobacter and stool polymerase chain reaction (PCR) for Clostridium difficile infection. Blood investigations such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and HIV (human immunodeficiency virus) testing should also be done if required.

Ocular infection is confirmed with slit lamp examination. Synovial fluid analysis is done for the exclusion of septic arthritis and crystal arthritis.

Imaging:

Narrowing of joint space, swelling of soft tissue, bone erosion, new bone formation in the periosteum, bone spur formation at enthesitis, in sacroiliitis - syndesmophytes are the radiographic features. Spinal MRI (magnetic resonance imaging) will show edema of bone marrow and erosions of the sacroiliac joint.

What Are the Classification Criteria for Reactive Arthritis?

According to the fourth International Workshop on Reactive Arthritis classification criteria by Barun et al:

Major Criteria:

1. Arthritis with two or all three symptoms:

  • Asymmetric arthritis.

  • Monoarthritis or oligoarthritis.

  • Predominantly affects lower limbs.

2. Preceding symptomatic infection with one or two of the following:

  • Enteritis: Diarrhea for one day or three days to six weeks before arthritis.
  • Urethritis: Dysuria or discharge, for at least one day, three days to six weeks before arthritis.

Minor Criteria - At least one of the following symptoms:

1. Evidence of triggering infection:

  • Positive nucleic acid amplification test.
  • Positive stool culture.

2. Evidence of persistent synovial infection: Positive immunohistology or PCR.

How Do You Manage Reactive Arthritis?

Antibiotics are given for triggering infection and chlamydia trachomatis infections. Initial therapy is given with non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, systemic glucocorticoids, and steroids. Disease-modifying antirheumatic drugs (DMARDs) is given for diseases lasting more than six months. Sulfasalazine and Methotrexate are the first-line regimens. Biologic therapy is given with anti-tumor necrosis factor (TNF) agents like Etanercept.

To reduce inflammation and skin irritation, medications range from topical corticosteroids and topical Salicylic acid ointments on thick skin surfaces like corns and calluses to vitamin D3 analogs which bind to vitamin D3 receptor genes that are involved in the proliferation and differentiation of cells causing inflammation. Vitamin D3 analogs are the mainstay of treatment. Methotrexate, retinoids, or TNF (tumor necrosis factor) inhibitors can also be given systematically if topical treatment fails.

What Is the Prognosis of Reactive Arthritis?

  • Duration of acute phase: Three to five months.

  • Duration of chronic disease: More than six months.

  • Over the course of several years, 50 % of patients develop repeated or protracted symptoms. Chronic or recurrent diseases can cause multiple joint inflammations. Some of the patients are physically disabled.

Conclusion:

The development of reactive arthritis is influenced by genetic factors. The genetic composition cannot be changed, but you can limit your exposure to microorganisms that cause reactive arthritis. Keep your food at the right temperature and cook it thoroughly to avoid various foodborne microorganisms that cause reactive arthritis. Reactive arthritis can be caused by sexually transmitted diseases. To help reduce your risk, use condoms.

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Frequently Asked Questions


1.

What Causes Reactive Arthritis?

Organisms like Salmonella, Shigella, Yersinia, and Campylobacter can cause gastrointestinal problems, triggering reactive arthritis. Chlamydia can spread through sexual contact and is the most common cause of reactive arthritis.

2.

What Are the Common Symptoms of Reactive Arthritis?

Reactive arthritis usually occurs after a person gets infected in any part of the body, like throat infection or a gastrointestinal infection. The common symptoms associated with reactive arthritis are,
- Excruciating joints.
- Feeling extremely tired without any effort.
- Swollen joints.

3.

Is Reactive Arthritis Curable?

Yes, reactive arthritis is entirely curable. Most cases get fully cured in a year, whereas rarely some people might experience symptoms for more than a year. In addition, specific treatments can help with relieving symptoms related to reactive arthritis.

4.

Does COVID-19 Trigger Reactive Arthritis?

Some people are known to develop reactive arthritis after being infected by COVID-19. However, drugs like NSAIDs (nonsteroidal anti-inflammatory drugs) and Prednisolone are known to relieve the symptoms in such cases.

5.

What Is the Best Way to Treat Reactive Arthritis?

The most commonly used drug for treating the pain and inflammation associated with reactive arthritis are NSAIDs (nonsteroidal anti-inflammatory drugs) such as Indomethacin.

6.

Can Prednisone Be Used to Treat Arthritis?

If arthritis is caused due to autoimmune conditions where the body’s immune system attacks its cells resulting in arthritis, Prednisone can help stop the attack. However, they are not as effective as other arthritis drugs. However, they can prevent the person from developing long-term side effects.

7.

Can an X-Ray Be Used to Diagnose Reactive Arthritis?

Yes, X-rays are reliable diagnostic sources to diagnose reactive arthritis. The X-rays are known to be normal during the initial stages. However, as arthritis progresses, the synovial joints, symphyses, and entheses (the site where ligament or tendon attaches to the bone) are seen to be affected.

8.

Can Stress Aggravate the Symptoms of Reactive Arthritis?

Yes, a person’s mental health directly influences their physical health. Unmanaged stress can aggravate the symptoms associated with arthritis.

9.

Are Reactive Arthritis and Reiter’s Syndrome Different From Each Other?

No, Reiter’s syndrome is the common name for reactive arthritis.

10.

What Foods Can Worsen Arthritis?

The following food items can aggravate the symptoms associated with arthritis,
- Sugary foods like cakes and candies.
- Dairy and its products.
- Fatty foods.
- Carbohydrates like rice and bread.
- Tobacco in any form.
- Alcohol.
- Gluten.

Last reviewed at:
28 Jul 2022  -  5 min read

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