Reactive arthritis

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Reactive arthritis
SOA-arthritis.jpg
Reactive arthritis of the knee
Specialty Rheumatology

Reactive arthritis, also known as Reiter's syndrome, is a form of inflammatory arthritis [1] that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can trigger the disease. [2] By the time the patient presents with symptoms, often the "trigger" infection has been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.

Contents

The arthritis often is coupled with other characteristic symptoms; this has been called Reiter's syndrome, Reiter's disease or Reiter's arthritis. The term "reactive arthritis" is increasingly used as a substitute for this designation because of Hans Reiter's war crimes with the Nazi Party.

The manifestations of reactive arthritis include the following triad of symptoms: an inflammatory arthritis of large joints, inflammation of the eyes in the form of conjunctivitis or uveitis, and urethritis in men or cervicitis in women. Arthritis occurring alone following sexual exposure or enteric infection is also known as reactive arthritis. Patients can also present with mucocutaneous lesions, as well as psoriasis-like skin lesions such as circinate balanitis, and keratoderma blennorrhagicum. Enthesitis can involve the Achilles tendon resulting in heel pain. [3] Not all affected persons have all the manifestations.

The clinical pattern of reactive arthritis commonly consists of an inflammation of fewer than five joints which often includes the knee or sacroiliac joint. The arthritis may be "additive" (more joints become inflamed in addition to the primarily affected one) or "migratory" (new joints become inflamed after the initially inflamed site has already improved). [4] [5]

Reactive arthritis is an RF-seronegative, HLA-B27-linked arthritis [6] often precipitated by genitourinary or gastrointestinal infections. The most common triggers are intestinal infections (with Salmonella , Shigella or Campylobacter ) and sexually transmitted infections (with Chlamydia trachomatis ); [7] however, it also can happen after group A streptococcal infections. [8] [9]

It most commonly strikes individuals aged 20–40 years of age, is more common in men than in women, and more common in white than in black people. This is owing to the high frequency of the HLA-B27 gene in the white population. [10] [11] It can occur in epidemic form. Patients with HIV have an increased risk of developing reactive arthritis as well.

Numerous cases during World Wars I and II focused attention on the triad of arthritis, urethritis, and conjunctivitis (often with additional mucocutaneous lesions), which at that time was also referred to as Fiessenger–Leroy–Reiter syndrome. [12]

Signs and symptoms

Keratoderma blennorrhagicum due to reactive arthritis Feet-Reiters syndrome.jpg
Keratoderma blennorrhagicum due to reactive arthritis

Causes

Reactive arthritis is associated with the HLA-B27 gene on chromosome 6 and by the presence of enthesitis as the basic pathologic lesion [15] and is triggered by a preceding infection. The most common triggering infection in the US is a genital infection with Chlamydia trachomatis . Other bacteria known to cause reactive arthritis which are more common worldwide are Ureaplasma urealyticum , Salmonella spp., Shigella spp., Yersinia spp., and Campylobacter spp. [16] A bout of food poisoning or a gastrointestinal infection may also precede the disease (the last four genera of bacteria mentioned above are enteric bacteria). [17] Shigella is the most common organism causing reactive arthritis following diarrhea. Chlamydia trachomatis is the most common cause of reactive arthritis following urethritis. Ureaplasma and mycoplasma are rare causes. There is some circumstantial evidence for other organisms causing the disease, but the details are unclear. [17]

Reactive arthritis usually manifests about 1–3 weeks after a known infection. The mechanism of interaction between the infecting organism and the host is unknown. Synovial fluid cultures are negative, suggesting that reactive arthritis is caused either by an autoimmune response involving cross-reactivity of bacterial antigens with joint tissues or by bacterial antigens that have somehow become deposited in the joints.[ citation needed ]

Diagnosis

There are few clinical symptoms, but the clinical picture is dominated by arthritis in one or more joints, resulting in pain, swelling, redness, and heat sensation in the affected areas.

The urethra, cervix and the throat may be swabbed in an attempt to culture the causative organisms. Cultures may also be carried out on urine and stool samples or on fluid obtained by arthrocentesis.

Tests for C-reactive protein and erythrocyte sedimentation rate are non-specific tests that can be done to corroborate the diagnosis of the syndrome. A blood test for the genetic marker HLA-B27 may also be performed. About 75 percent of all the patients with reactive arthritis have this gene.

Diagnostic criteria

Although there are no definitive criteria to diagnose the existence of reactive arthritis, the American College of Rheumatology has published sensitivity and specificity guidelines. [18]

Percent Sensitivity and Specificity of Various Criteria for Typical Reactive Arthritis
Method of diagnosisSensitivitySpecificity
1. Episode of arthritis of more than 1 month with urethritis and/or cervicitis84.3%98.2%
2. Episode of arthritis of more than 1 month and either urethritis or cervicitis, or bilateral conjunctivitis85.5%96.4%
3. Episode of arthritis, conjunctivitis, and urethritis50.6%98.8%
4. Episode of arthritis of more than 1 month, conjunctivitis, and urethritis48.2%98.8%

Treatment

The main goal of treatment is to identify and eradicate the underlying infectious source with the appropriate antibiotics if still present. Otherwise, treatment is symptomatic for each problem. Nonspecific urethritis may be treated with a short course of tetracycline. Analgesics, particularly NSAIDs, are used. Steroids, sulfasalazine and immunosuppressants may be needed for patients with severe reactive symptoms that do not respond to any other treatment. Local corticosteroids are useful in the case of iritis.[ citation needed ]

Prognosis

Reactive arthritis may be self-limiting, frequently recurring, chronic or progressive. Most patients have severe symptoms lasting a few weeks to six months. 15 to 50 percent of cases involve recurrent bouts of arthritis. Chronic arthritis or sacroiliitis occurs in 15–30 percent of cases. Repeated attacks over many years are common, and patients sometimes end up with chronic and disabling arthritis, heart disease, amyloid deposits, ankylosing spondylitis, immunoglobulin A nephropathy, cardiac conduction abnormalities, or aortitis with aortic regurgitation. [19] However, most people with reactive arthritis can expect to live normal life spans and maintain a near-normal lifestyle with modest adaptations to protect the involved organs.

Epidemiology

Because women may be underdiagnosed, the exact incidence of reactive arthritis is difficult to estimate. A few studies have been completed, though. In Norway between 1988 and 1990, the incidence was 4.6 cases per 100,000 for chlamydia-induced reactive arthritis and 5 cases per 100,000 for that induced by enteric bacteria. [20] In 1978 in Finland, the annual incidence was found to be 43.6 per 100,000. [21]

History

When reactive arthritis appears in a triad that also includes ophthalmic and urogenital manifestations, the eponym "Reiter's syndrome" is often applied; German physician Hans Conrad Julius Reiter described the condition in a soldier he treated during World War I.

A number of physicians have suggested that the eponym is undeserved. Reiter's Nazi Party affiliation, and in particular his involvement in forced human experimentation in the Buchenwald concentration camp (which, after his capture at the end of World War II, resulted in his prosecution in Nuremberg as a war criminal), have come to overshadow his medical accomplishments. Furthermore, he was not the first physician to make associations between the arthritis and other symptoms—the names arthritis urethritica, venereal arthritis and polyarteritis enterica had previously been applied—and the full triad was described by another physician in the 19th century. [22]

Notable cases

See also

Related Research Articles

<span class="mw-page-title-main">Chlamydia</span> Sexually transmitted infection caused by the bacterium Chlamydia trachomatis

Chlamydia, or more specifically a chlamydia infection, is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. Most people who are infected have no symptoms. When symptoms do appear they may occur only several weeks after infection; the incubation period between exposure and being able to infect others is thought to be on the order of two to six weeks. Symptoms in women may include vaginal discharge or burning with urination. Symptoms in men may include discharge from the penis, burning with urination, or pain and swelling of one or both testicles. The infection can spread to the upper genital tract in women, causing pelvic inflammatory disease, which may result in future infertility or ectopic pregnancy.

<span class="mw-page-title-main">Rheumatoid arthritis</span> Type of autoimmune arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months.

Urethritis is the inflammation of the urethra. The most common symptoms include painful or difficult urination and urethral discharge. It is a commonly treatable condition usually caused by infection with bacteria. This bacterial infection is often sexually transmitted, but not in every instance; it can be idiopathic, for example. Some incidence of urethritis can appear asymptomatic as well.

<span class="mw-page-title-main">Conjunctivitis</span> Inflammation of the eye

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur. Itching is more common in cases due to allergies. Conjunctivitis can affect one or both eyes.

Rheumatology is a branch of medicine devoted to the diagnosis and management of disorders whose common feature is inflammation in the bones, muscles, joints, and internal organs. Rheumatology covers more than 100 different complex diseases, collectively known as rheumatic diseases, which includes many forms of arthritis as well as lupus and Sjögren's syndrome. Doctors who have undergone formal training in rheumatology are called rheumatologists.

Nongonococcal urethritis (NGU) is an inflammation of the urethra that is not caused by gonorrheal infection.

<span class="mw-page-title-main">Tietze syndrome</span> Inflammation, tenderness, and pain of the chest wall with swelling present

Tietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by German surgeon Alexander Tietze and was subsequently named after him. The condition is characterized by tenderness and painful swelling of the anterior (front) chest wall at the costochondral, sternocostal, or sternoclavicular junctions. Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

Spondyloarthropathy or spondyloarthrosis refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself, but many conditions involve both spondylopathy and spondyloarthropathy.

<span class="mw-page-title-main">Psoriatic arthritis</span> Long-term inflammatory arthritis

Psoriatic arthritis (PsA) is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. This often happens in association with changes to the nails such as small depressions in the nail (pitting), thickening of the nails, and detachment of the nail from the nailbed. Skin changes consistent with psoriasis frequently occur before the onset of psoriatic arthritis but psoriatic arthritis can precede the rash in 15% of affected individuals. It is classified as a type of seronegative spondyloarthropathy.

Juvenile idiopathic arthritis (JIA) is the most common, chronic rheumatic disease of childhood, affecting approximately 16 to 150 out of 100,000 children. Juvenile, in this context, refers to disease onset before 16 years of age, while idiopathic refers to a condition with no defined cause, and arthritis is inflammation within the joint.

<span class="mw-page-title-main">Henoch–Schönlein purpura</span> Medical condition

Henoch–Schönlein purpura (HSP), also known as IgA vasculitis, is a disease of the skin, mucous membranes, and sometimes other organs that most commonly affects children. In the skin, the disease causes palpable purpura, often with joint pain and abdominal pain. With kidney involvement, there may be a loss of small amounts of blood and protein in the urine, but this usually goes unnoticed; in a small proportion of cases, the kidney involvement proceeds to chronic kidney disease. HSP is often preceded by an infection, such as a throat infection.

Mycoplasmataceae is a family of bacteria in the order Mycoplasmatales. This family consists of the genera Mycoplasma and Ureaplasma.

<span class="mw-page-title-main">Erythema nodosum</span> Medical condition

Erythema nodosum (EN) is an inflammatory condition characterized by inflammation of the fat cells under the skin, resulting in tender red nodules or lumps that are usually seen on both shins. It can be caused by a variety of conditions, and typically resolves spontaneously within 30 days. It is common in young people aged 12–20 years.

<span class="mw-page-title-main">Hans Reiter (physician)</span> German Nazi physician (1881–1969)

Hans Conrad Julius Reiter was a German Nazi physician who conducted medical experiments at the Buchenwald concentration camp. He wrote a book on "racial hygiene" called Deutsches Gold, Gesundes Leben – Frohes Schaffen. In 1916, he described a disease with the symptoms urethritis, conjunctivitis and arthritis, which became known as Reiter's syndrome.

Mixed connective tissue disease, commonly abbreviated as MCTD, is an autoimmune disease characterized by the presence of elevated blood levels of a specific autoantibody, now called anti-U1 ribonucleoprotein (RNP) together with a mix of symptoms of systemic lupus erythematosus (SLE), scleroderma, and polymyositis. The idea behind the "mixed" disease is that this specific autoantibody is also present in other autoimmune diseases such as systemic lupus erythematosus, polymyositis, scleroderma, etc. MCTD was characterized as an individual disease in 1972 by Sharp et al., and the term was introduced by Leroy in 1980.

<span class="mw-page-title-main">Balanitis circinata</span> Medical condition

Balanitis circinata is a skin condition comprising a serpiginous ring-shaped dermatitis of the glans penis. While circinate balanitis is one of the most common cutaneous manifestations of reactive arthritis, it can also occur independently. Topical corticosteroid therapy is the most commonly used treatment, and topical calcineurin inhibitors have also been used successfully.

<span class="mw-page-title-main">Lupus</span> Human autoimmune disease

Lupus, technically known as systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Common symptoms include painful and swollen joints, fever, chest pain, hair loss, mouth ulcers, swollen lymph nodes, feeling tired, and a red rash which is most commonly on the face. Often there are periods of illness, called flares, and periods of remission during which there are few symptoms.

Ephraim Engleman was an American rheumatologist and a Clinical Professor of Medicine at the University of California, San Francisco. He had a major national and international impact on rheumatology during more than six decades, and wrote more than one hundred scientific and medical papers.

John Arthur Harland Hancock was a British venereologist and editor of the British Journal of Venereal Diseases who wrote on non-gonococcal urethritis and reactive arthritis, what was known as Reiter's disease at the time. In 1945, while studying medicine at the London Hospital, he was one of the voluntary students sent to Belsen to assist nutritionist Arnold Peter Meiklejohn in feeding the starving inmates. There, he became unwell with typhus and was treated back at The London by Lord Evans.

<span class="mw-page-title-main">Trabecular oedema</span> Medical condition

Trabecular edema, also known as bone marrow edema (BME), is a traditional term describing the interstitial fluid accumulation at the trabecular bone marrow. The term was first used in 1988, referring to the changes in the bone marrow due to inflammation. Bone marrow edema was later renamed to bone marrow lesion (BML), as later studies show that the increased fluid content in the trabecular bone was more likely caused by inflammatory responses instead of fluid influx. Hence, this narrows down the condition to the damage at the articular surface of the trabecular bones. Despite so, the terms BME and BML are still used interchangeably in radiology.

References

  1. ↑ American College of Rheumatology. "Reactive Arthritis" . Retrieved 24 January 2017.
  2. ↑ Mayo Staff (5 March 2011). "Reactive Arthritis (Reiter's Syndrome)". Mayo Clinic. Retrieved 16 May 2011.
  3. ↑ H. Hunter Handsfield (2001). Color atlas and synopsis of sexually transmitted diseases, Volume 236. McGraw-Hill Professional. p. 148. ISBN   978-0-07-026033-7.
  4. ↑ Primer on the Rheumatic Diseases, By John H. Klippel, page 218
  5. ↑ Rheumatology in Practice, By J. A. Pereira da Silva, Anthony D. Woolf page 5.9
  6. ↑ Ruddy, Shaun (2001). Kelley's Textbook of Rheumatology, 6th Ed. W. B. Saunders. pp. 1055–1064. ISBN   978-0-7216-9033-9.
  7. ↑ Siala, Mariam; et al. (2008). "Analysis of bacterial DNA in synovial tissue of Tunisian patients with reactive and undifferentiated arthritis by broad-range PCR, cloning and sequencing". Arthritis Research & Therapy . BioMed Central. 10 (2): R40. doi: 10.1186/ar2398 . PMC   2453759 . PMID   18412942.
  8. ↑ Infectious Diseases Immunization Committee (1995). "Poststreptococcal arthritis". The Canadian Journal of Infectious Diseases. 6 (3): 133–135. doi: 10.1155/1995/470341 . PMC   3327910 . PMID   22514384.
  9. ↑ "Reactive Arthritis". www.rheumatology.org. Retrieved 18 September 2019.
  10. ↑ Sampaio-Barros PD, Bortoluzzo AB, Conde RA, Costallat LT, Samara AM, Bértolo MB (June 2010). "Undifferentiated spondyloarthritis: a longterm followup". The Journal of Rheumatology. 37 (6): 1195–1199. doi:10.3899/jrheum.090625. PMID   20436080. S2CID   45438826.
  11. ↑ Geirsson AJ, Eyjolfsdottir H, Bjornsdottir G, Kristjansson K, Gudbjornsson B (May 2010). "Prevalence and clinical characteristics of ankylosing spondylitis in Iceland – a nationwide study". Clinical and Experimental Rheumatology. 28 (3): 333–40. PMID   20406616.
  12. ↑ Harrison's Rheumatology, Second Edition [Anthony Fauci, Carol Langford], Ch.9 THE SPONDYLOARTHRITIDES, Reactive Arthritis, page.134
  13. ↑ Mark A. Marinella (1 September 2001). Recognizing Clinical Patterns: Clues to a Timely Diagnosis. Hanley & Belfus. p. 44. ISBN   978-1-56053-485-3.
  14. ↑ Zadik Y, Drucker S, Pallmon S (August 2011). "Migratory stomatitis (ectopic geographic tongue) on the floor of the mouth". J Am Acad Dermatol. 65 (2): 459–60. doi:10.1016/j.jaad.2010.04.016. PMID   21763590.
  15. ↑ Kataria, RK; Brent LH (June 2004). "Spondyloarthropathies". American Family Physician. 69 (12): 2853–2860. PMID   15222650. Archived from the original on 9 July 2008. Retrieved 16 June 2013.
  16. ↑ Hill Gaston JS, Lillicrap MS (2003). "Arthritis associated with enteric infection". Best Pract Ice & Research. Clinical Rheumatology. 17 (2): 219–239. doi:10.1016/S1521-6942(02)00104-3. PMID   12787523.
  17. 1 2 Paget, Stephen (2000). Manual of Rheumatology and Outpatient Orthopedic Disorders: Diagnosis and Therapy (4th ed.). Lippincott, Williams, & Wilkins. pp. chapter 36. ISBN   978-0-7817-1576-8.
  18. ↑ American College of Rheumatology. "Arthritis and Rheumatism" . Retrieved 16 May 2011.
  19. ↑ eMedicine/Medscape (5 January 2010). "Reactive Arthritis" . Retrieved 16 May 2011.
  20. ↑ Kvien, T.; Glennas, A.; Melby, K.; Granfors, K; et al. (1994). "Reactive arthritis: Incidence, triggering agents and clinical presentation". Journal of Rheumatology . 21 (1): 115–22. PMID   8151565.
  21. ↑ Isomäki, H.; Raunio, J.; von Essen, R.; Hämeenkorpi, R. (1979). "Incidence of rheumatic diseases in Finland". Scandinavian Journal of Rheumatology. 7 (3): 188–192. doi:10.3109/03009747809095652. PMID   310157.
  22. ↑ Wallace, D. J.; Weisman, M. (2000). "Should a war criminal be rewarded with eponymous distinction? The double life of Hans Reiter (1881–1969)". JCR: Journal of Clinical Rheumatology. 6 (1): 49–54. doi:10.1097/00124743-200002000-00009. PMID   19078450.
  23. ↑ "Cause of the death of Columbus (in Spanish)". Eluniversal.com.mx. Archived from the original on 24 September 2014. Retrieved 29 July 2009.
  24. ↑ Kelly, Fiach (4 January 2008). "Comedian reveals how he tracked birth parents to solve family health mystery". Irish Independent. Retrieved 4 January 2008.
  25. ↑ Lisa Gray (29 November 2006). "Murray targets Christmas as date for Rangers return". The Independent.
  26. ↑ "Silverchair frontman's dramatic fight-back from crippling illness". The Sydney Morning Herald. 1 December 2002. Retrieved 22 July 2016.
  27. ↑ Daniel Taylor (22 November 2016). "Second footballer reveals abuse by serial paedophile Barry Bennell". The Guardian.
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