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Reactive Arthritis (Reiter’s disease)

by Josephine Andrews
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Reactive arthritis (Reiter’s disease) is an inflammatory disease of the joints, which can be accompanied by conjunctivitis and urethritis, among other things. It develops as a result of a bacterial infection and in many cases heals on its own. However, in some sufferers, Reiter’s disease persists for years or decades. Read more about the causes, symptoms and treatment of reactive arthritis here.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

H10M02N34 _

quick overview

  • What is reactive arthritis? An inflammation of the joints caused by a bacterial infection in another part of the body (usually in the urinary and genital organs or in the gastrointestinal tract). Old name of the disease: Morbus Reiter or Reiter’s syndrome.
  • Symptoms : painful joint inflammation (usually in the area of ​​​​the knee, ankle, hip joint), conjunctivitis and urethritis – collectively referred to as Reiter’s triad. Sometimes also skin and mucous membrane changes, more rarely inflammations in the area of ​​tendons, spine or internal organs. Fever can accompany it.
  • Cause : Unclear. The immune system is probably not able to fight the bacterial infection that caused it – bacterial proteins or live bacteria remain in the joints and mucous membranes, to which the immune system continues to react.
  • Treatment : Drugs such as antibiotics, cortisone-free painkillers and anti-inflammatories (such as ibuprofen ), cortisone (in severe cases), so-called DMARDs (in chronic cases). Accompanying physiotherapeutic measures.
  • Prognosis : Reactive arthritis usually heals on its own within a few months. In the remaining cases, patients suffer from it for a longer period of time. In addition, relapses are possible.

Reactive arthritis: definition

Reactive arthritis is an inflammatory disease of the joints (arthritis) that develops as a sort of reaction (reactive) to a bacterial infection outside of the joints. In addition to the joints, the inflammation often also affects the urethra , the conjunctiva of the eyes and sometimes also the skin . In addition, the spine can be involved – with vertebral body inflammation ( spondyloarthritis ). That is why reactive arthritis is now classified as an inflammatory spinal disease (spondyloarthritis).

People of all ages can develop reactive arthritis worldwide. However, most of those affected are younger than 40 years. In Germany, 30 to 40 out of 100,000 adults suffer from reactive arthritis.

Old name: Reiter’s disease

In 1916, the Berlin doctor, bacteriologist and hygienist Hans Reiter first described a disease with the three main symptoms of joint inflammation (arthritis), urethritis (urethritis) and conjunctivitis (conjunctivitis) – collectively referred to as ” Reiter’s triad “.

The disease was named after him as Morbus Reiter (Reiter syndrome, Reiter’s disease). However, since Hans Reiter was a high official in National Socialism, the disease was renamed “reactive arthritis” at the beginning of the 21st century, first abroad and then also in Germany.

Reactive arthritis: symptoms

The symptoms of reactive arthritis usually appear about two to four weeks after an infection of the urinary and genital organs, the gastrointestinal tract or the respiratory tract. However, it can also take up to six weeks before the first symptoms are felt.

joint problems

People with reactive arthritis mainly suffer from joint problems. These symptoms vary from patient to patient: Some sufferers only have slight joint pain (arthralgia). Others develop more or less severe joint inflammation (arthritis) with pain, swelling and warmth in the joint area.

Usually only one or a few joints (mono- to oligoarthritis) are affected and only rarely several joints at the same time (polyarthritis) as in other rheumatic diseases. Sometimes the inflammation moves from one joint to another.

The inflammation-related pain, redness and overheating in the knee and ankle joints as well as in the hip joints are particularly common. Typically, one or more toe joints are also affected, sometimes finger joints (dactylitis). If an entire toe or finger is swollen, it is referred to as a “sausage toe” or “sausage finger”.

eye inflammation

Also common in reactive arthritis is unilateral or bilateral eye inflammation, especially inflammation of the conjunctiva (conjunctivitis). Sometimes inflammation of the iris (iritis) or cornea (keratitis) develops. Typical symptoms are photophobia , reddened, burning, painful eyes and possibly disturbed vision .

In severe cases, an eye infection can even lead to blindness.

Skin and mucous membrane changes

Sometimes reactive arthritis also leads to different skin changes – often on the soles of the hands and feet : The affected areas can be reminiscent of psoriasis (psoriasis) or the skin is excessively calloused (keratoma blennorrhagicum).

Brownish discolorations can also form, especially under the soles of the feet and in the palms of the hands. Over the course of a few days, these areas of skin thicken and form crust-like, sometimes bumpy, bumps. Fluid can collect in these blisters or bumps. If the blisters burst, a brownish crust develops on the skin.

Painful, reddish-bluish skin nodules in the area of ​​the ankles and lower legs (erythema nodosum) are found in some patients with Reiter’s disease.

The oral mucosa is also partially affected. Increased salivation and deposits on the tongue often occur . Over the course of several days, a so-called map tongue develops from the deposits , in which brownish or white discolored areas alternate with areas that still look normal.

Inflammation of the urinary tract and genitals

Inflammation of the urethra can also occur together with reactive arthritis. Those affected feel a frequent urge to urinate and pain when urinating . The latter can also be due to cystitis or prostatitis – also possible side effects of reactive arthritis.

Sometimes patients also have discharge from the urethra – or from the vagina. Reactive arthritis can also be accompanied by inflammation of the mucous membrane in the cervix (cervicitis).

Less common accompanying symptoms

The spine is affected in almost a third of all cases of reactive arthritis. Inflammation of the sacroiliac joint (sacroiliac joint) is possible, which is referred to as sacroiliitis. Vertebral body inflammation (spondylitis) in the lumbar, chest and neck areas can also occur. Low back pain and low back pain , which tends to be worst in the early morning and ease with movement, are possible signs of spinal involvement.

In addition to the joints, tendons, tendon sheaths and tendon attachments can also become inflamed. The Achilles tendon on the heel is particularly often affected. Those affected primarily report pain when the foot moves . If the tendon plate on the sole of the foot becomes inflamed, walking is associated with severe pain.

Some people with reactive arthritis experience general symptoms such as fever, fatigue, and weight loss. Muscle pain can also occur.

Some patients develop mild inflammation of the kidneys, while more severe kidney disease is rare. There is also a risk that the heart muscle will become inflamed. This in turn triggers cardiac arrhythmia.

Reactive arthritis: causes and risk factors

It is unclear exactly how reactive arthritis (Reiter’s disease) develops. The trigger is usually an infection with bacteria in the gastrointestinal tract, the urinary and genital organs or (rarely) the respiratory tract. Typical pathogens are chlamydia and enterobacteria (salmonella, yersinia, shigella, campylobacter).

One to three percent of people who contract a urinary tract infection with the bacterium Chlamydia trachomatis then develop reactive arthritis. This is the case for 30 percent of patients after gastrointestinal infections with enterobacteria.

Typical symptoms of an infection preceding reactive arthritis can include burning when urinating, frequent urination, discharge from the urethra or vagina, diarrhea, sore throat or coughing. However, the infection can also have gone unnoticed and without symptoms.

In people with reactive arthritis, the body is probably not able to completely eliminate the pathogens of the previous infection: The bacteria therefore reach the joints and mucous membranes from the originally infected tissue via the blood and the lymphatic system. Proteins of the pathogen or even living bacteria then presumably remain there. The immune system continues to fight the foreign components, causing inflammation in various parts of the body. For example, when the synovial membrane comes into contact with the surface proteins of certain bacteria, it reacts with an inflammatory response.

Reactive arthritis: risk factors

More than half of all people with reactive arthritis are genetically predisposed. The so-called HLA-B27 can be detected in them – a protein on the surface of almost all body cells. It is also frequently found in some other inflammatory rheumatic diseases (such as rheumatoid arthritis and Bechterew’s disease ). Patients with reactive arthritis who possess HLA-B27 are at greater risk of more severe and prolonged disease progression. In addition, the axial skeleton (spine, sacroiliac joint) is more severely affected.

Reactive arthritis: investigations and diagnosis

medical history

To clarify joint problems and any other symptoms, the doctor will first talk to you in detail. In this way, he can collect your medical history (anamnesis), which helps him to narrow down the possible causes of your symptoms.

If you talk about symptoms like those listed above, the doctor will quickly suspect reactive arthritis. Especially if you are a young adult who suddenly has one or a few large joints inflamed, the suspicion of “Reiter’s disease” is obvious.

The doctor will then ask you whether you have had a bladder or urethritis (eg caused by pathogens transmitted during sex), diarrhea or a respiratory infection in the last few days or weeks. If so, the suspicion of reactive arthritis is confirmed.

pathogen detection

However, sometimes such infections also occur without (clear) symptoms and thus go unnoticed. Or the patient no longer remembers it. Therefore, if reactive arthritis is suspected, an attempt is made to identify causative infectious agents. The doctor will ask you for a stool or urine sample. Swabs from the urinary tract, anus , cervix or throat can also be searched for infectious agents.

However, the acute infection was usually a few weeks ago, so that direct detection of the pathogen is often no longer possible. Indirect pathogen detection can then help : The blood is tested for specific antibodies against pathogens that can trigger reactive arthritis.

More blood tests

In addition, blood values ​​​​are determined in reactive arthritis: In this disease, the blood sedimentation rate and the C-reactive protein (CRP) – as general inflammation parameters – are increased.

The detection of HLA-B27 in the blood is successful in most, but not all patients. The absence of HLA-B27 does not rule out reactive arthritis.

imaging procedures

Imaging procedures of the affected joints and the sections of the spine provide more precise information about the severity of the joint damage. Your doctor may use procedures such as:

X-rays show no changes in the affected joints in the first six months of reactive arthritis. They are therefore more useful later in the course of the disease – or to rule out other diseases as the cause of the joint problems.

joint puncture

Sometimes a joint puncture is necessary. A fine hollow needle is used to pierce the joint cavity in order to remove some synovial fluid for a more detailed examination (synovial analysis). This can help identify other causes of joint inflammation. If, for example, bacteria such as Staphylococcus aureus or Haemophilus influenzae are found in the synovial fluid, this indicates septic arthritis. The detection of Borrelia speaks for Lyme disease.

If crystal deposits are found in the synovial fluid and in the articular cartilage, it is probably arthritis with calcium phosphate crystal deposits (chondrocalcinosis).

Other investigations

The doctor can also check, for example, whether the kidney function is restricted by reactive arthritis. A urine test will help.

A measurement of the electrical heart activity (electrocardiography, EKG ) and a heart ultrasound ( echocardiography ) should rule out that the immune reaction has also affected the heart.

If your eyes are also affected, you must also consult an ophthalmologist. He can examine your eyes more closely and then suggest an appropriate treatment. In this way, later visual disturbances can be prevented!

Reactive arthritis: treatment

Reactive arthritis is primarily treated with medication. In addition, physiotherapeutic measures can help against the symptoms.

treatment with medication

If your doctor has identified a bacterial infection as the cause of reactive arthritis, you will be given appropriate antibiotics . If the bacteria are sexually transmitted chlamydia, your partner must also be treated. Otherwise, it could reinfect you after taking antibiotics.

If the causative pathogens are not known, antibiotic therapy does not make sense.

The antibiotics do not necessarily cure the arthritis, but eliminate the pathogen at the portal of entry (genital organs, urinary tract, intestines , respiratory tract) and thus reduce the risk of later recurrences.

The symptoms can be treated with painkillers and anti-inflammatory drugs . Cortisone-free (non-steroidal) anti-inflammatory drugs (NSAIDs) such as diclofenac and ibuprofen are suitable.

Severe disease progression often requires short-term treatment with glucocorticoids (cortisone). Cortisone can also be injected directly into the joint if a bacterial joint infection has been ruled out.

If the reactive arthritis does not subside within a few months, it is called chronic arthritis. Then treatment with so-called basic therapeutics (basic drugs) may be necessary, also known as “disease-modifying anti-rheumatic drugs” (DMARDs) – ie disease-modifying anti-rheumatic drugs. They can inhibit inflammation and modulate the immune system and generally form the basis of the treatment of inflammatory rheumatic diseases (such as rheumatoid arthritis).

In the case of chronic reactive arthritis, the conventional (classic) basic drug sulfasalazine is usually used. If this does not work sufficiently, the doctor can prescribe methotrexate, for example (also a classic basic therapeutic). In rare cases, this treatment does not work either. Then biological DMARDs such as infliximab or etanercept can be tried. Although these are approved as drugs, they are not directly used for reactive arthritis – their use in this disease is therefore “off-label”.

physical therapy

Physiotherapeutic measures support the drug treatment of reactive arthritis. Cold therapy (cryotherapy, for example in the form of cryopacks) can be used to relieve acute inflammatory processes and pain. Movement exercises and manual therapy can keep joints flexible or make them more flexible and prevent a regression of the muscles.

You can do that yourself

Try to rest the affected joints. However, if your physiotherapist recommends exercises to do at home, you should do them conscientiously.

You can also apply cooling compresses to acutely inflamed, painful joints on your own.

However, patients with high blood pressure should be careful with cold applications and consult their doctor beforehand.

Reactive arthritis: disease course and prognosis

Many sufferers are particularly interested in one question: How long does reactive arthritis last? The reassuring answer: Most reactive arthritis heals on its own after six to twelve months . Until then, medication and physiotherapy can relieve the symptoms.

In 15 to 30 percent of those affected, however, reactive arthritis becomes chronic . The course of the disease becomes more protracted the more joints are affected. The disease is usually persistent, especially in patients with HLA-B27 in their blood. In exceptional cases, the illness can even last ten to 15 years.

In 20 percent of cases, chronic reactive arthritis is associated with the occurrence of other inflammatory spinal diseases (spondyloarthritis), such as psoriatic arthritis or axial spondyloarthritis.

Complications arise, for example, when the joint inflammation permanently impairs the joint function – up to and including destruction of the joint. In the eye , the inflammatory process can spread from the conjunctiva to the iris and the adjacent eye structures. This can permanently impair visual function. A so-called cataract can develop, which can lead to blindness.

In half of the patients, the disease returns after some time ( recurrence ), caused by renewed infection. So if you have had reactive arthritis before, you are at an increased risk of developing it again. Sometimes, however, only individual symptoms such as conjunctivitis occur.

You can protect yourself against a chlamydia infection as a (re)trigger of reactive arthritis by always using condoms during sex – especially if you have different sexual partners.

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