Reiter’s syndrome

What is Reiter's Syndrome?  What are the causes?

            Reactive arthritis, otherwise known as Reiter’s syndrome, is a form of arthritis that can affect the joints, eyes, urethra, and skin.  It primarily affects males between the ages of 20 and 40 who are sexually active; particularly those who are HIV positive and at a notably higher risk than the general public.  Reactive arthritis can also affect women and children, who generally contract the intestinal form of the disease.  The arthritis can occur in different organs throughout the body as well as at different times.  The disease can either come on severely or at a more gradual pace with remissions and recurrences. 

            Although the cause of reactive arthritis is still uncertain, genetic predisposition and other factors have been suggested to play a role.  Recent studies show that 80% of Caucasians and 50% to 60% of African-Americans with reactive arthritis test positive for HLA-B27; a genetic marker found through blood tests.

            Most cases of sexually active males with reactive arthritis occur following an infection with a sexually transmitted disease, such as Chlamydia trachomatis or Ureaplasma urealyticum.  Less often, the symptoms of reactive arthritis can develop following intestinal infections that cause food poisoning, including Shigella, Salmonella, Yersinia, or Campylobacter bacteria.

How is reactive arthritis diagnosed?

            Reactive arthritis is a rare disorder that is characterized by non-gonococcal urethritis (inflammation of the urinary tract), conjunctivitis (inflammation of the mucous membranes that line the eyes) and arthritis (inflammation of the joints).  Lesions (sores) can also occur on the skin and the mucous membranes in one’s mouth and indicate the presence of the disease.  The disease is transmitted through sexual contact, although occasionally an underlying enteric infection (of the small bowel) may contribute to the onset of the disease.  All of these symptoms may disappear and resurface over time, making them difficult to effectively monitor. 

Urogenital Tract Symptoms: Reactive arthritis often affects the urogenital tract, including the prostate, urethra, and penis for men.  Men may note the presence of an infection when they experience a burning sensation when urinating, an increased need to urinate, and/or an abnormal discharge from the penis.  Some men who are infected may also experience prostatitis; the swelling of the prostate gland. 

            Women are affected in the urogenital area, including the fallopian tubes, uterus, and vagina.  They often experience inflammation of the cervix (cervicitis) or inflammation of the urethra (urethritis) which can cause pain during urination.  Some women may also experience salpingitis (inflammation of the fallopian tubes) or vulvovaginitis (inflammation of the vulva and vagina).

Joint Symptoms or Arthritis:  The arthritis associated with reactive arthritis generally causes painful swelling of joints in the knees, ankles, and feet.  Other common developments of the syndrome include enthesopathy, or inflammation where a tendon attaches to a bone.  Patients can also commonly develop heel spurs, which are bony growths on the heel that cause severe foot pain.

            Reactive arthritis can also cause spondylitis (inflammation of the vertebrae in the spinal column) or sacroiliitis (inflammation of the joints in the lower back that connect the spine to the pelvis).  Patients who have the HLA-B27 gene are more likely to experience these symptoms. 

Conjunctivitis:  Inflammation of the mucous membranes that line the inner eye occurs in approximately 50% of people with urogenital symptoms and 75% of those with enteric symptoms.  Conjunctivitis can cause swelling, redness, irritation of the eye, and even blurred vision.    

            Despite the fact that there is no specific test for diagnosing reactive arthritis, there are various ways to check for symptoms of the disease that can indicate its presence.  For example, the urethral discharge is typically tested for sexually transmitted diseases.  Blood tests can indicate whether or not patients possess the HLA-B27 genetic marker. Its presence is typically associated with signs of inflammation, including an elevated white blood cell count and an increased erythrocyte sedimentation rate (ESR).   Anemia, or the lack of sufficient red blood cells causing a lack of oxygen in the organs and tissues, is another indicator of reactive arthritis.

            Patients with recurring episodes of reactive arthritis are typically radiologically examined by x-ray to reveal joint inflammation, areas of bone loss, indicators of osteoporosis or bony spurs. 

 How is reactive arthritis treated?

            Since it is such a rare disease, there is no specific treatment for reactive arthritis.  However, various symptoms may be treated individually.  Joint inflammation can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs).  Lesions and eye inflammation can be treated with steroids.  Those patients who suffer from chronic arthritis may benefit from physical therapy and exercise.  A closer look at the treatments includes:

Bed rest – Resting one’s body even for a brief period of time has been shown to be an effective way to relieve joint pain and inflammation caused by arthritis by relieving the body of the pressure of its own weight.

Exercise – Strengthening and range-of-motion exercises can alleviate some of symptoms of reactive arthritis before they even disappear.  These exercises will improve bodily function and build up muscle to help support the joints.  Range-of-motion exercises improve one’s flexibility and decrease stiffness often caused by the disease.

Nonsteroidal anti-inflammatory drugs (NSAID's) – These medications are used to reduce the swelling and inflammation of joints affected by reactive arthritis.  Popular drugs include ibuprofen and aspirin.

Corticosteroid injections – Injections of corticosteroids directly into infected joints can effectively reduce inflammation.  They are used most typically on the knees and ankles and tend to be the subsequent course of action following unsuccessful treatment with NSAIDs.

Topical corticosteroids – The application of a topical ointment onto skin lesions can reduce their inflammation and induce their healing.

Antibiotics – Antibiotics are administered to treat the bacterial infections that can cause reactive arthritis.  However, current research shows that the recommended dosage of antibiotics for patients, which spans over the course of a few months, usually has no effect on the disease and is therefore unnecessary.  However, in cases where Chlamydia triggers the reactive arthritis, extensive antibiotic treatment can shorten the duration of the patient’s symptoms. 

Immunosuppressive medicines – For those patients who are not responsive to the methods of treatment described above, a small percent of patients may be helped by the use of medications that suppresses the immune system, including methotrexate or sulfasalazine.

How can I prevent reactive arthritis?

            Wearing condoms during sexual activity is the only known preventative measure for reactive arthritis.  However, there are various measures one can take to help stop the disease from worsening.

Authors:

Derek Berberian, Syracuse University, Syracuse, New York

Ana Bracilovic, M.D., Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York City, New York