Reactive Arthritis in the Elderly

Introduction

Reactive arthritis (ReA) is an inflammatory joint condition that appears several days to weeks following a gastrointestinal or genitourinary infection. It is characterized by a classic triad of arthritis, urethritis, and conjunctivitis, though a significant number of patients do not exhibit this triad. Formerly known as "Reiter syndrome," it was named after Hans Reiter, who initially identified this syndrome. However, the term Reiter syndrome has been abandoned after few years. Current understanding attributes the disorder to an abnormal autoimmune response triggered by gastrointestinal infections caused by salmonella, shigella, campylobacter, or chlamydia.

What Is Reactive Arthritis in the Elderly?

Reactive arthritis can affect anyone globally, and it is often preceded by a bacterial infection in the digestive, urinary, or genital tract, typically occurring a few weeks before its onset. While sexually transmitted infections may be associated with the beginning of reactive arthritis, many cases are linked to non-sexually transmitted infections. Various factors contribute to the risk of developing the condition, including:

• Sex: Both men and women can contract reactive arthritis, with men having a higher likelihood of developing it due to a sexually transmitted infection. However, if the condition results from a gastrointestinal infection, men and women are equally affected.

• Age: Reactive arthritis is most prevalent in individuals aged 20 to 40.

• Genetics: Individuals carrying the HLA-B27 gene face an elevated risk of developing reactive arthritis, experiencing more severe symptoms, and enduring prolonged symptoms. Nevertheless, those without the HLA-B27 gene can still be susceptible to the condition.

• HIV Infection: The presence of AIDS (acquired immunodeficiency syndrome) or HIV (human immunodeficiency virus) infection increases the risk of developing reactive arthritis.

What Causes Reactive Arthritis?

Reactive arthritis is triggered by bacterial infections, particularly those affecting the genitourinary tract (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis, and Ureaplasma urealyticum) or gastrointestinal tract (Salmonella enteritidis, Shigella flexneri, S. dysenteriae, Yersinia enterocolitica, Campylobacter jejuni, Clostridium difficile). The incidence varies from 0 percent to 15 percent after gastrointestinal infections with Salmonella, Shigella, Campylobacter, or Yersinia, and is roughly 2 percent to 4 percent after urogenital infections, mostly with Chlamydia trachomatis. Various factors, such as epidemiological and environmental conditions, bacterial pathogenicity, and differences in study designs, may influence these rates. Enteric reactive arthritis commonly occurs after enteric infections, while chlamydia-associated reactive arthritis is more endemic, especially in developed countries. In rare instances, reactive arthritis cases have been reported following the administration of the Bacillus Calmette-Guerin (BCG) vaccine for bladder cancer treatment.

What Are the Symptoms of Reactive Arthritis In the Elderly?

Reactive arthritis can manifest with varying degrees of severity, ranging from mild symptoms to more debilitating ones that impede daily activities. Typically, symptoms emerge 1 to 6 weeks after an infection in the digestive, urinary, or genital tract, although the infection has usually resolved by the time symptoms appear. The onset is generally abrupt, usually unfolding over a few days. This condition involves inflammation of the joints, eyes, and urinary tract, but not every individual with reactive arthritis will experience all three manifestations, and if present, they may not occur simultaneously. The primary symptoms include:

• Joint Pain and Stiffness: Joints, particularly the larger ones in the lower limbs, like knees and ankles, may become painful, red, and swollen. Morning stiffness or nighttime pain is common, typically affecting one side of the body. Lower back and buttock pain may also be present. Heel or foot pain may indicate enthesitis, inflammation at the location where a ligament or tendon joins a bone. Swollen, inflamed, and painful fingers or toes (dactylitis) may occur.

• Inflammation of the Urinary Tract: More prevalent when reactive arthritis follows a genital or urinary tract infection. In women, urinary tract inflammation may extend to the cervix, fallopian tubes, vulva, or vagina. Signs include increased urinary frequency and burning during urination.

• Eye Inflammation: Conjunctivitis and uveitis can lead to redness, pain, burning, itching, crusted eyelids, blurred vision, or sensitivity to light.

Additional symptoms of reactive arthritis encompass:

• Fatigue or a general sense of unwellness.

• Fever.

• Weight loss.

• Diarrhea and abdominal pain.

• Small mouth ulcers.

• In men, painless ulcers on the penis.

• Skin rash (keratoderma blennorrhagica) with raised, reddish bumps, often on the palms or soles, which may merge into a larger scaly rash.

• Thickened nails.

While the symptoms of reactive arthritis often resolve on their own within a few weeks or months, they may become chronic in some individuals.

How to Diagnose Reactive Arthritis in the Elderly?

There is no singular test for diagnosing reactive arthritis, but doctors may consider the possibility of this condition if the patient is experiencing joint pain and has had a recent infection in the digestive, urinary, or genital tract. The following are the steps for the diagnostic process:

1. Medical History and Physical Exam:

• Inquiry about symptoms and their onset, including recent infection symptoms.

• Examination of joints for tenderness or swelling, and inspection of skin, mucosal surfaces, and eyes for rashes, ulcers, or signs of inflammation.

2. Lab Tests:

• HLA-B27 Test: Detects the genetic risk factor for reactive arthritis, but a positive result does not conclusively confirm the condition, and a negative result doesn't rule it out.

• Bacterial Cultures: Testing stool and urine for bacteria that commonly trigger reactive arthritis. A negative result is not definitive due to the likely resolution of infection by the time arthritis symptoms appear.

• Joint Fluid Test: Analyzing synovial fluid from a joint to assess inflammation levels and rule out other causes like joint infection or gout.

• Erythrocyte Sedimentation Rate (sed rate) and C-reactive Protein: Blood tests measuring inflammation levels; however, they aren't specific to reactive arthritis.

3. Imaging Studies:

• X-rays: Reveal joint status, including signs of reactive arthritis such as sacroiliac joint inflammation in the lower back, though abnormalities may not be apparent until later in the disease course.

• Ultrasounds, Computed Tomography, and Magnetic Resonance Imaging: Specialized imaging for early-stage joint changes in reactive arthritis.

4. Other Tests:

Additional blood tests like rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody tests associated with rheumatoid arthritis, and antinuclear antibody (ANA) tests linked to systemic lupus erythematosus, may be ordered to eliminate conditions with similar symptoms.

Conclusion

Reactive arthritis refers to inflammation of the joints, which is characterized by the classic triad of arthritis, urethritis, and conjunctivitis. It is caused due to bacterial infection. It can affect anyone globally, regardless of gender; mainly, it affects the age group between 20 to 40 years. Joint inflammation is one of reactive arthritis's primary symptoms. Joint pain, eye inflammation, and urinary tract infection are other symptoms. Reactive arthritis can be treated by pharmacological and non-pharmacological methods. Proper diagnosis is needed for needful medical intervention. Reactive arthritis can be cured totally, but it takes time.