Reactive arthritis...Love hurts
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Information from the American College of Rheumatology
Reactive arthritis is an inflammatory form of arthritis that occurs anywhere from 1 to 4 weeks after an acute infection.
It is asymmetric, affects a few joints, causes systemic involvement, and is associated with the genetic marker, HLA-B27.
Findings include an inflammatory arthritis, inflammation at the attachment of tendons into bone (enthesitis), and skin problems similar to psoriasis.
Reactive arthritis is more common in men than women. The peak age of onset is in the third decade although it may come on at almost any age. The infection that leads to this problem is usually a venereal disease or an intestinal problem.
Common bacteria that have induced reactive arthritis include Shigella, Salmonella, Yersinia, and Campylobacter in the bowel, and Chlamydia and Ureaplasma in the urogenital system.
There is a classic trio of findings in the typical reactive arthritis patient. These include arthritis, urethritis (inflammation of the urinary tract), and conjunctivitis (inflammation of the eye). Roughly, a third of patients will present with all three problems.
Systemic symptoms such as fever, fatigue, and weight loss can occur along with the arthritis. The arthritis is asymmetric, acute, and is most common in the knees, ankles, and feet. Fingers and toes may swell and look like a sausage (dactylitis).
Inflammatory back pain occurs in about half the patients. Inflammatory changes on x-ray are seen in the spine and in the sacroiliac joints.
Inflammation at the insertion of tendons and ligaments into bone (enthesitis) are seen most commonly in the back (Achilles tendon) and bottom of the heel, pubic area, and hip.
Sores in the mouth and around the genital area may be seen. Scaly skin can be seen on the palms and soles of the feet.
Inflammatory eye disease can also occur. Both eyes may be affected at the same time.
Less commonly, the heart or lungs may be involved.
Laboratory findings show an elevated erythrocyte sedimentation rate (ESR), anemia, elevated white cell count in the blood. Fluid drawn from an involved joint will be inflammatory with a lot of white blood cells.
X-rays demonstrate soft tissue swelling and erosions. New bone growth may be seen and is a tip off to this diagnosis. Heel spurs, inflammation of the sacroiliac joints, and spurs in the spine may also be seen. Magnetic resonance imaging is more sensitive.
Treatment goals include suppression of inflammation, preservation of joint function, maintenance of quality of life, and induction of remission.
Early on, patient education, physical and occupational therapy, stretching and range-of-motion exercises are important.
Medical management includes erasing any infection that might be a trigger. Antibiotics (doxycycline) given for three months may be helpful for reactive arthritis due to urogenital infection. Unfortunately, reactive arthritis that comes about from bowel infections doesn’t usually respond to antibiotics.
In those patients who continue to have symptoms despite aggressive antibiotic therapy, non steroidal anti inflammatory drugs may be helpful.
Injections of steroids into affected joints sometimes are beneficial.
Disease modifying anti rheumatic drugs (DMARDS) are used in patients where NSAIDS aren’t effective. The most common drugs in this category that are used for reactive arthritis include sulfasalazine, methotrexate, and azathioprine.
Data on the use of biologic therapy for reactive arthritis is limited.
Most patients will recover from reactive arthritis. Some patients experience recurrent attacks. Only about one third of patients will have chronic disease.
Debridement of the joint arthroscopically can be helpful. Joint replacement surgery is reserved for those patients who have end stage joint problems.
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