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Reactive Arthritis

Definition :
Reactive arthritis (ReA) is an inflammatory condition that develops in response to an infection in another part of your body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis.

Though inflammation of your joints (arthritis) is a defining feature of reactive arthritis, this condition can also be associated with inflammation in parts of your body including your eyes, skin and the tube that carries urine from your bladder (urethra).

For most people, signs and symptoms of reactive arthritis come and go, eventually disappearing within 12 months. Treatments for reactive arthritis involve therapies to manage your symptoms and to eliminate any underlying infection.

Reactive arthritis is among a group of disorders known as seronegative spondyloarthropathies that can cause inflammation in the joints of the spine, legs and arms and in other parts of the body.

Causes:
Reactive arthritis develops in reaction to an infection in another part of your body, often in your gastrointestinal or genitourinary tract. You may not be aware of the triggering infection because it may cause only mild symptoms or none at all. The severity of your initial infection isn't related to the severity of your reactive arthritis.

Numerous bacteria can cause reactive arthritis. Different forms of reactive arthritis are named based on the origin of the infection :

  • Urogenital. If the triggering infection originates in the penis, vagina, bladder or urethra, it's called urogenital (genitourinary) ReA, or uroarthritis. Chlamydia is the bacterium most often associated with reactive arthritis.
  • Gastrointestinal. If your infection is the result of something that you eat or touch, such as raw meat that's carrying bacteria, your condition is called gastrointestinal (enteric) ReA, or enteroarthritis. Food-borne bacteria include salmonella, shigella, yersinia and campylobacter.

Reactive arthritis isn't contagious. However, the bacteria that cause it can pass from person to person, such as during sexual contact and food preparation. But only a few of the people who are exposed to these bacteria develop reactive arthritis.

Risk Factors:
Certain factors increase your risk of reactive arthritis :
  • Sex. Reactive arthritis occurs most frequently in men 20 to 40 years old. Though women also can acquire reactive arthritis, they usually have milder signs and symptoms. Women and men are equally likely to develop reactive arthritis in reaction to food-borne infections. However, men are more likely than women to develop reactive arthritis in response to sexually transmitted bacteria.
  • Hereditary factors. Reactive arthritis may have a genetic component because most people with the condition also have a certain molecule on the surfaces of their cells that can be inherited. Having this genetic marker — called the human leukocyte antigen B27 (HLA-B27) — doesn't mean that you'll develop reactive arthritis, but it can increase your chances of developing reactive arthritis if you're exposed to specific bacteria.

When to seek medical advice :
Contact your doctor if you develop signs and symptoms that may indicate reactive arthritis. Also contact your doctor if you're being treated for the disease and new signs and symptoms develop.

Symptoms :
Signs and symptoms of reactive arthritis include :

  • Arthritis, usually in your ankles, knees, feet and hips
  • Inflammation of your urogenital tract (urethritis), which increases your need to urinate (urinary frequency) and causes burning during urination or a discharge (abnormal secretions) from the penis in men
  • Eye inflammation (conjunctivitis)
  • Inflammation of your inner eye (uveitis)
  • Mouth ulcers
  • Skin rashes
  • Inflammation of your tendons (tendinitis) and tendon sheaths (tenosynovitis)
  • Inflammation at the point where your tendons and bones connect (enthesitis) that can result in bony growths, such as heel spurs
  • Lower back and buttock pain
  • Inflammation of the vertebrae (spondylitis)
  • Inflammation of the joints that connect your spine to your pelvis (sacroiliitis)
  • Fever
  • Weight loss
  • Inflammation of the prostate gland (prostatitis)
  • Inflammation of the cervix (cervicitis)

The signs and symptoms of reactive arthritis generally start days to weeks after exposure to a triggering infection in susceptible people. Your signs and symptoms may come and go over a period of several weeks or months. Reactive arthritis can go undetected for a long time, because your signs and symptoms may be mild.

Reiter syndrome is a specific type of reactive arthritis that includes arthritis, conjunctivitis and urethritis.

Diagnosis:
Reactive arthritis can go undiagnosed for a long time because your signs and symptoms may be mild. In many cases, however, people with undiagnosed reactive arthritis first visit their doctor when one of their joints, such as a knee, ankle or other joint, suddenly becomes swollen.

Your doctor likely will perform a physical exam — which may include examining your joints, checking your skin for lesions and examining your eyes for inflammation. Your doctor may ask you about your medical history, including current symptoms and any past infections you've had.

No specific test shows whether you have reactive arthritis. Instead, your doctor may perform a number of tests to help confirm a suspected case of reactive arthritis and to rule out other conditions. Tests include :

  • Cultures. Your doctor may perform cultures to see if you have any of the infections often associated with reactive arthritis. These tests involve placing samples of body fluids onto a substance that enhances the growth of bacteria. However, some bacteria are difficult to grow in the laboratory, so other microbiologic tests may be performed. Alternatives include blood tests that detect antibodies against bacteria (serologic tests) and polymerase chain reaction (PCR) — a test that can identify portions of genetic material (DNA).

    Chlamydia, a common precursor to reactive arthritis, can be identified with a culture. Early identification and treatment of chlamydia may slow the progression of reactive arthritis.

  • Sedimentation rate. Your doctor may check a blood test to see if you have an elevated sedimentation rate — which is the speed at which your red blood cells settle to the bottom of a tube. An elevated rate can indicate inflammation. People with reactive arthritis often have an elevated sedimentation rate.
  • Rheumatologic tests. Your doctor may try to look for an alternative diagnosis to reactive arthritis by performing rheumatoid factor and anti-nuclear antibody tests. Rheumatoid factor is an antibody often found in the blood of people with rheumatoid arthritis. Anti-nuclear antibodies are proteins that are generally found in people who have connective tissue or autoimmune disorders. If you have reactive arthritis, you'll probably test negative on both of these tests.
  • X-rays. X-rays of your joints can indicate whether you have any of the characteristic signs of reactive arthritis, including soft tissue swelling, calcium deposits where tendons attach to bones and cartilage damage. X-rays can also rule out other types of arthritis.
  • Genetic tests. You may undergo a blood test to see if you carry the inherited HLA-B27 antigen. Though the presence of the HLA-B27 antigen doesn't necessarily mean you have reactive arthritis, it may help with the diagnosis. Reactive arthritis can also occur in people without HLA-B27.

Complications :
Signs and symptoms of reactive arthritis may last three to 12 months. However, many people can control their signs and symptoms with treatment and return to their normal routine within two to six months of the onset of reactive arthritis.

Up to half the people with reactive arthritis redevelop signs and symptoms after their initial condition disappears. It's possible that relapses are the result of reinfection. Arthritis and back pain are the symptoms that reappear most often, but urogenital and eye inflammation also tend to recur.

Approximately one in five people with reactive arthritis develops long-term (chronic) arthritis, though the arthritis often is mild. The severity of your initial reactive arthritis symptoms isn't related to your risk of developing a chronic condition.

In some cases, reactive arthritis can lead to the following complications :

  • Uveitis. This condition causes inflammation of your uvea, which is the middle layer of your eye. You may experience light sensitivity, redness, pain, floaters and blurry vision. Uveitis can cause permanent vision loss if not detected and treated early. This condition can recur.
  • Arrhythmia. This is an abnormal heart rhythm that results from damage to your heart's electrical conduction system. You may need to use a pacemaker. This is an uncommon complication of reactive arthritis.
  • Aortic insufficiency. In this condition, also called aortic valve regurgitation, your heart's aortic valve doesn't close normally. As a result, blood flows backward from the aorta, the largest blood vessel that carries blood away from your heart, into the left lower chamber of your heart (left ventricle). This occurs during diastole, in which the heart muscle relaxes after a contraction and the ventricles fill with blood. This is an uncommon complication of reactive arthritis.

Treatment:
The goal of treatment is to manage your symptoms and treat any underlying bacterial infections that may still be present.

Medications
Your doctor may recommend one or more of the following medications :

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can relieve the inflammation and pain of reactive arthritis. Some, such as ibuprofen (Advil, Motrin, others) and aspirin, are available without a prescription. Indomethacin (Indocin), diclofenac (Voltaren) and sulindac (Clinoril) may be more effective, but require a prescription.
  • Corticosteroids. These medications can suppress inflammation in your joints. If only a few of your joints are severely inflamed, an injection of a corticosteroid into each affected joint can reduce inflammation and allow you to return to your normal activity level. If many of your joints are inflamed, your doctor may prescribe oral corticosteroids, such as prednisone. Long-term use of corticosteroids can be associated with many side effects and complications, depending on the dosage and the duration of treatment. Corticosteroids in the form of lotions (topical corticosteroids) can relieve inflammation and promote healing of skin rashes.
  • Antibiotics. Your doctor may prescribe an antibiotic to eliminate the bacterial infection that triggered your reactive arthritis if it's still detectable in your body. Which antibiotic you take depends on the bacteria that are present.
  • Tumor necrosis factor (TNF) blockers. TNF is a cell protein (cytokine) that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers target or block this protein and can help relieve pain and stiffness and improve tender or swollen joints. Doctors initially used TNF blockers to treat rheumatoid arthritis. Preliminary studies suggest that these medications, such as etanercept (Enbrel) and infliximab (Remicade), can decrease inflammation and relieve pain and stiffness for some people with reactive arthritis.

Physical therapy
Exercise can help people with arthritis improve joint function. Your doctor may have you meet with a physical therapist, who can provide you with specific exercises for your joints and muscles.

Strengthening exercises are valuable for developing the muscles around your affected joints, which increases the joint's support. Performing range-of-motion exercises can increase your joints' flexibility and reduce stiffness.

Prevention:
Genetic factors appear to play a role in whether you're likely to develop reactive arthritis. Though you can't change your genetic makeup, you can reduce your exposure to the bacteria that may lead to reactive arthritis.

Make sure your food is stored at proper temperatures and is cooked properly. These steps can help you to avoid the many food-borne bacteria that can cause reactive arthritis, including salmonella, shigella, yersinia and campylobacter.

In addition, practice safe sex because preventing sexually transmitted diseases may lower your risk of developing reactive arthritis.

 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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