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REACTIVE ARTHRITIS OVERVIEW — Reactive arthritis is a very uncommon type of arthritis in which the joints become painful and swollen within four weeks after an infection in another part of your body. The most common joints affected are those in the lower extremities such as the knees and the ankles. The infection might have been in the gastrointestinal tract, genitals, or urinary tract.
Reactive arthritis is a form of "spondyloarthritis" (SpA), which is a family of arthritis-associated diseases. The pattern of arthritis in the SpA family fall into one of two groups, which sometimes overlap:
●Peripheral SpA – These conditions affect the joints of the arms and legs, fingers and toes, and heels. Almost all people with reactive arthritis have this type of SpA, but it a relatively rare cause of peripheral SpA.
●Axial SpA (axSpA) – These conditions involve the back and the neck. The prime examples of this type are ankylosing spondylitis and nonradiographic axial spondylitis. (See "Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)".)
Besides reactive arthritis, SpA also consists of the following members: ankylosing spondylitis (AS), non-radiographic axial spondyloarthritis (nr-axSpA), SpA associated with psoriasis, Crohn, disease, and ulcerative colitis.
Strictly speaking, a patient who has developed peripheral or axial SpA can be diagnosed as having reactive arthritis only if the development is preceded within four weeks by evidence of an infection such as diarrhea or burning sensation during urination from inflammation in the urethra. In addition, the patient should not have preexisting features of the other members of the SpA family. In the past, clinicians sometimes used the term "Reiter syndrome" instead of "reactive arthritis." The term "Reiter syndrome" is no longer used.
REACTIVE ARTHRITIS CAUSES — Two types of bacteria are regarded as being responsible for most cases of reactive arthritis:
●Bacteria that cause bowel infections – These include the bacterial species Salmonella, Shigella, Campylobacter, and Yersinia. These bacteria often cause food poisoning, leading to diarrhea, which can last up to one month. (See "Patient education: Foodborne illness (food poisoning) (Beyond the Basics)".)
●Bacteria that cause genital infections – These include Chlamydia trachomatis, a sexually transmitted infection. Chlamydia can cause pelvic pain, burning with urination, and a pus-like or watery vaginal or penile discharge. Some people have no symptoms with their infection. (See "Patient education: Chlamydia (Beyond the Basics)".)
GENETIC RISK FACTOR — One of the genetic risk factors is a particular variant of the human leukocyte antigen (HLA)-B gene known as HLA-B27. However, not all patients with reactive arthritis carry the HLA-B27 gene.
REACTIVE ARTHRITIS SYMPTOMS — Typical symptoms of reactive arthritis include joint pain and swelling that develops suddenly, usually one to four weeks after an episode of infection such as diarrhea. Frequently, the pain and swelling involve a small number of joints (three or less), typically including the knee, ankle, or joints of the feet.
Some patients have tendonitis affecting the Achilles tendon, behind the ankle, or the plantar fascia, on the sole of the foot where it attaches to the heel. Some patients develop sausage-like swelling of one or more fingers or toes.
Conjunctivitis (inflammation of the covering of the eyes) can also occur in people with reactive arthritis.
REACTIVE ARTHRITIS DIAGNOSIS — Diagnosis depends first and importantly on the distribution and location of pain and swelling of the extremities, and secondly on a history of recent prior symptoms of diarrhea or a sexually transmitted disease. It is helpful to identify the bacterial cause in the case of genital infections, as this will help guide treatment of the infections.
Laboratory tests, such as stool cultures to test for Salmonella, Shigella, Campylobacter, and Yersinia, can sometimes confirm an infection. However, it is not always necessary or possible; by the time patients develop arthritis, the diarrhea has usually resolved, and the bacteria may no longer be retrievable. Urine and genital swab testing can sometimes detect Chlamydial trachomatis. The erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) may also be tested. However, ESR and CRP may be normal in more than half of the patients. In either form of reactive arthritis, there is no need to do joint biopsy for the purpose of identifying the causative bacteria.
REACTIVE ARTHRITIS TREATMENT
Antibiotics — Antibiotics may be used to treat an active genital infection (see "Patient education: Chlamydia (Beyond the Basics)"). Most acute diarrheal illnesses do not require antibiotics (see "Patient education: Acute diarrhea in adults (Beyond the Basics)"). There is no convincing evidence that standard regimens of antibiotics will improve joint pain or will shorten the course of reactive arthritis after the joint pain has developed.
Nonsteroidal antiinflammatory drugs — Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, or naproxen are usually recommended to reduce joint pain and swelling. Relatively large doses of an NSAID may be needed on a regular basis for up to two weeks to determine if the NSAID is effective. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
Other treatments — If you do not improve with NSAIDs, your clinician may recommend a glucocorticoid (also called a steroid) injection into the joint. Additional treatment with glucocorticoids (taken by mouth) might be necessary for a short period if you have severe pain or joint swelling.
Another medication may be recommended if your symptoms do not improve within two to three months with NSAIDs or glucocorticoid treatment. This may be treatment with one of the disease-modifying antirheumatic drugs (DMARDs; eg, sulfasalazine or methotrexate) or if joint swelling still persists, a medication that interferes with the action of tumor necrosis factor (TNF; a TNF inhibitor or blocker such as etanercept, infliximab, adalimumab, golimumab, and certolizumab). In both cases, you should see a specialist in inflammatory joint diseases (a rheumatologist) to confirm that your symptoms are caused by reactive arthritis. (See "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)" and "Patient education: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics)".)
Eye treatment — Eye inflammation can occur in people with reactive arthritis and is sometimes treated with glucocorticoid eye drops. If you develop eye pain or blurry vision, you should see an ophthalmologist to determine if your symptoms are due to conjunctivitis or a more serious eye problem such as inflammation of the iris (called iritis or anterior uveitis). (See "Uveitis: Etiology, clinical manifestations, and diagnosis".)
WHEN WILL I GET BETTER? — Most people with reactive arthritis have a mild course of joint pain that resolves spontaneously and that never comes back. In some people, the disease will intermittently cause symptoms. In others, the disease is persistent.
If your back becomes painful and stiff and does not improve with time, reactive arthritis may have developed into other forms of axial spondyloarthritis (axSpA). (See "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults" and "Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)
Patient education: Psoriatic arthritis (Beyond the Basics)
Patient education: Crohn disease (Beyond the Basics)
Patient education: Ulcerative colitis (Beyond the Basics)
Patient education: Foodborne illness (food poisoning) (Beyond the Basics)
Patient education: Chlamydia (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)
Patient education: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
The following organizations also provide reliable health information.
●National Library of Medicine
●Spondylitis Association of America
●National Institute of Arthritis and Musculoskeletal and Skin Diseases
●American College of Rheumatology
●The Arthritis Foundation
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges David Yu, MD, who contributed to earlier versions of this topic review.
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