Reactive arthritis

Reactive arthritis (Reiter's Syndrome)
Classification and external resources
Diagnosis revealed that the rash on the bottom of this individual’s feet, known as keratoderma blennorrhagica, was due to Reiter's syndrome.
ICD-10	M02.
ICD-9	099.3
DiseasesDB	29524
eMedicine	med/1998
MeSH	C01.539.100.500

Reactive arthritis (ReA), previously known as Reiter's syndrome, is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis.^[1] It has symptoms similar to various other conditions collectively known as "arthritis". It is caused by another infection and is thus "reactive", i.e., dependent on the other condition. The "trigger" infection has often been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.

Reactive arthritis has also been known as arthritis urethritica, venereal arthritis and polyarteritis enterica. It is a type of seronegative spondyloarthropathy. The former name Reiter’s syndrome, after German physician Hans Conrad Julius Reiter, became discredited in the past decade as Reiter's history of eugenics, Nazi party membership, human experiments in the Buchenwald concentration camp, and prosecution in Nuremburg as a war criminal came to light.

The manifestations of reactive arthritis include a combination of three seemingly unlinked disorders: an inflammatory arthritis of large joints, often including the spine; inflammation of the eyes in the form of (conjunctivitis or uveitis); and urethritis in men or cervicitis in women. A useful mnemonic is "the patient can't see, can't pee, can't bend the knee" or "can't see, can't pee, can't climb a tree." A fourth common manifestation is a complex of psoriasis-like skin lesions, including the rashes termed circinate balanitis and keratoderma blennorrhagica. Not all affected persons have all manifestations, and the formal definition of reactive arthritis is the occurrence of otherwise unexplained noninfectious inflammatory arthritis combined with urethrits in men or cervicitis in women.

Reactive arthritis is an RF-seronegative, HLA-B27-linked spondyloarthropathy ^[2] (autoimmune damage to the cartilages of joints) often precipitated by genitourinary or gastrointestinal infections. The most common triggers are sexually transmitted chlamydial infections and perhaps, less commonly, gonorrhea; and Salmonella, Shigella, or Campylobacter intestinal infections.

Reactive most commonly strikes individuals aged 20–40, is more common in men than in women, and is more common in white men than in black men. This is owing to white individuals' being more likely to have tissue type HLA-B27 than black individuals. People with HIV have an increased risk of developing reactive arthritis as well.

Signs and symptoms

Symptoms generally appear within 1–3 weeks but can range from 4 to 35 days from the onset of the inciting episode of the disease.

The classical presentation is that the first symptom experienced is a urinary symptom such as burning pain on urination (dysuria) or an increased frequency of urination. Other urogenital problems may arise such as prostatitis in men and cervicitis, salpingitis and/or vulvovaginitis in women. The arthritis that follows usually affects the large joints such as the knees causing pain and swelling with relative sparing of small joints such as the wrist and hand.

Eye involvement occurs in about 50% of men with urogenital reactive arthritis and about 75% of men with enteric reactive arthritis. Conjunctivitis and uveitis can include redness of the eyes, eye pain and irritation, or blurred vision. Eye involvement typically occurs early in the course of reactive arthritis, and symptoms may come and go.

Roughly 20 to 40 percent of men with reactive arthritis develop penile lesions called balanitis circinata (circinate balanitis) on the end of the penis. A small percentage of men and women develop small hard nodules called keratoderma blennorrhagica on the soles of the feet and, less often, on the palms of the hands or elsewhere. In addition, some people with reactive arthritis develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed. Some people suffer serious gastrointestinal problems similar to those of Crohn's disease.

About 10 percent of people with reactive arthritis, especially those with prolonged disease, will develop cardiac manifestations, including aortic regurgitation and pericarditis.

Causes

It is set off by a preceding infection, the most common of which would be a genital infection with Chlamydia trachomatis in the US. Other bacteria known to cause reactive arthritis which are more common worldwide are Ureaplasma urealyticum, Salmonella spp., Shigella spp., Yersinia spp., and Campylobacter spp.^[3] A bout of food poisoning or a gastrointestinal infection may also precede the disease (those last four genera of bacteria mentioned are enteric bacteria). There is some circumstantial evidence for other organisms causing the disease, but the details are unclear.^[4] 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 ReA is caused either by an over-stimulated autoimmune response or by bacterial antigens which have somehow become deposited in the joints.

Diagnosis

There are countless clinical symptoms, but the clinical picture is dominated by polyarthritis. There is pain, swelling, redness, and heat in the joints. MRI is effective for diagnosis.

The urethra, cervix and throat may be swabbed in an attempt to culture the causative organisms. Cultures may be carried out on urine and stool samples. Synovial fluid from an affected knee may be aspirated to look at the fluid under the microscope and for culture.

Also, a blood test for the genetic marker HLA-B27 may be given to determine if the patient has the gene. About 75 percent of all patients with reactive arthritis have the gene. Also C Reactive Protein test can be used to determine reactive arthritis.

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.^[5]

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. Analgesics, steroids and immunosuppressants may be needed for patients with severe reactive symptoms that do not respond to any other treatment.

Prognosis

Reactive arthritis may be self-limiting, frequently recurring, chronic or progressive. Most patients have severe symptoms lasting a few weeks to six months. Fifteen to 50 percent of cases have 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, immunoglobulin A nephropathy, cardiac conduction abnormalities, or aortitis with aortic regurgitation.^[6] 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 know. A few studies have been completed, though. In Norway between 1988 and 1990, 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.^[7] In 1978 in Finland, the annual incidence was found to be 43.6 per 100,000.^[8]

History

Reactive arthritis was first described by Hans Conrad Julius Reiter, a German military physician who in 1916 described the disease in a World War I soldier who had recovered from a bout of diarrhea. There is movement that the term Reiter's syndrome should be phased out, partly owing to a move in the field of medicine to give descriptive names, rather than personal names, to conditions, and partly owing to Dr. Reiter's experiments in Nazi concentration camps.^[9] However, the term remains one of the more recognized references to the disease.

Scottish association football player Ian Murray has suffered from reactive arthritis.^[10] American right-wing pundit (and Presidential candidate in 1992 and 1996) Pat Buchanan has stated that Reiter's Syndrome was the reason he was designated as 4-F in the Vietnam-era draft.

References

External links

• Reactive arthritis topic list - Merck Manual
• Reiter's Syndrome - WrongDiagnosis.com