Reactive Arthritis
An Information Booklet
Introduction
This booklet is for anyone who wants to find out more about reactive arthritis. You may be suffering from the condition yourself, or you may have a friend, relative or partner who has reactive arthritis. It explains the main facts about the condition, including the main symptoms and how it is treated, and answers common questions about this type of arthritis.
Near the end of the booklet you will find details of how to contact the Arthritis Research Campaign (arc) and other organizations which can provide further information. We have also included a glossary of medical terms (like antibodies). We have put these terms in italics when they are first used in the booklet.
What is reactive arthritis?
The term 'reactive arthritis' is used to describe inflammation (heat, pain and swelling) in the joints that can develop after you have had a bacterial or viral infection somewhere else in the body. Often reactive arthritis causes only joint inflammation but sometimes joint pain and swelling may be accompanied by symptoms such as red eyes (conjunctivitis), scaly skin rashes over the hands or feet, diarrhoea, mouth ulcers, and inflammation of the genital tract which produces a discharge from the vagina or penis. The main signs of the condition are summarized in Figure 1.
Unlike rheumatoid arthritis or osteoarthritis, reactive arthritis is usually a relatively short-lived condition that may last for up to 6 months and, in most cases, disappears completely leaving no problems in the future.
How do you know if you have reactive arthritis?
Pain and swelling, usually in the lower limbs (knees, ankles or toes), are often the first signs of reactive arthritis. Swelling may happen suddenly or develop over a few days after an initial stiffness in the affected joints. Other joints, including the fingers, wrists, elbows and the joints at the base of the spine (sacroiliac joints), can also become inflamed. In some cases the pain can be severe enough to need time off work, bed rest or even admission to hospital. Reactive arthritis can also cause inflammation of the tendons around the joints, such as the Achilles tendon at the back of the ankle. If both the tendons and joints of the fingers or toes are affected at the same time it can cause a swollen or 'sausage' digit. Conjunctivitis, a scaly skin rash on the palms of the hands or the soles of the feet (known as 'keratoderma blenorrhagica' ) or, in men, a sore rash over the end of the penis can also suggest reactive arthritis.
Inflammation of the joints similar to that seen in reactive arthritis can also occur in other conditions such as rheumatoid arthritis, psoriatic arthritis, Behçet's syndrome or gout. (Separate arc booklets are available on each of these conditions.) Reactive arthritis can be distinguished from these other conditions because people report an infection that occurred a few days or weeks before the joint swelling started. The infection seems to trigger the start of the arthritis. This infection may be food poisoning (e.g. salmonella), which is usually shown by vomiting or diarrhoea, or a viral-like illness with a sore throat, cough or skin rash. Some viral infections may cause only a minor illness yet still be capable of triggering reactive arthritis.
Sexually acquired genital infections, which may show up as a discharge from or discomfort in the penis or vagina, are also associated with the development of reactive arthritis. Examples of such infections are chlamydia and non-specific urethritis (NSU). Some people who suddenly develop arthritis of the knees or ankles and have no previous history of arthritis may be told by their doctor that they have reactive arthritis even when the link with an infection beforehand is unclear. Occasionally some people may develop symptoms similar to reactive arthritis after vaccinations or inoculations.
Reactive arthritis is not caused by an active infection within the joints and should not be confused with a condition known as infective (septic) arthritis where there is an active joint infection. With reactive arthritis, the joints become inflamed because the immune system, while trying to rid the body of infection, causes an inflammatory reaction in the joint lining with pain and swelling as a result. Recent research has suggested that scraps of dead bacteria may travel to the joints and trigger the arthritis.
Who gets reactive arthritis?
People of all ages, including children, can get reactive arthritis. For this reason reactive arthritis generally affects a younger average age group than rheumatoid arthritis or osteoarthritis. In the UK reactive arthritis is most commonly seen following symptoms of a viral infection, often similar to a cold or flu, when inflammation of the knees or ankles may be the only symptoms. School outbreaks of viral illness, especially parvovirus ('slapped cheek' virus), are often associated with reactive arthritis
The second commonest cause is an infection of the gut, such as food poisoning or dysentery. Between 1 and 2% of people involved in any outbreak of food poisoning may suffer joint inflammation afterwards. Often, reactive arthritis will be reported following a tummy upset or diarrhoea. More rarely, reactive arthritis may follow a sexually acquired infection of the urethra or cervix, which may be shown by pain on passing urine or by a discharge from the vagina or penis. The doctor may ask about sexual activity in patients with possible reactive arthritis.
Although there is not a family tendency to develop reactive arthritis, if you have a particular gene, HLA B27, which is carried by about 1 in 14 (7%) of the general population, you may have a greater chance of developing reactive arthritis. Whether you have this gene or not can be checked with a simple blood test, but this test is not usually needed in routine management of reactive arthritis. Having the HLA B27 gene may also increase the likelihood of a person having further episodes of reactive arthritis in the future.
What tests will I have?
Although there is no single specific test for reactive arthritis,
you may be asked to provide a stool sample or have a swab taken
from the throat, or you may need to be examined by a genito-urinary
specialist and have
swabs taken from the penis or vagina. These can be tested for signs
of inflammation or infection. Blood tests may be carried out to
measure the level of inflammation and to check that gout is not
the cause. Blood tests can be carried out for genetic analysis (tests
for the HLA B27 gene) or for antibodies associated with
other forms of arthritis (rheumatoid factor, anti-nuclear antibody). X-rays are rarely useful
in diagnosing reactive arthritis. If your eyes are sore and red
you may be examined by an eye specialist in order to check that
it is not a more serious inflammation of the eye, known as iritis.
What treatments are there?
Treatments for reactive arthritis fall into three groups:
- antibiotics to treat the initial triggering infection if it persists
- treatments to help the joint pain and swelling
- drugs to tackle persistent arthritis.
Treating the infection
If you are found to have a bowel infection, a bacterial throat infection, or a genital tract infection you will probably be given antibiotics by mouth. These will help to eliminate the organism which is causing the infection. However, research suggests that antibiotics given over a long period of time do not help to settle the joint inflammation in reactive arthritis. Conjunctivitis is often treated with eye drops or ointment. More severe eye inflammation, such as iritis, may need steroid eye drops.
Treating the joint pain and swelling
Joint inflammation is treated according to severity. Mild to moderate arthritis may be relieved with non-steroidal anti-inflammatory tablets (NSAIDs) such as ibuprofen, indometacin or diclofenac. NSAIDs may cause indigestion or heartburn, and some, particularly the COX-2-specific drugs ('coxibs'), have been associated with an increased risk of heart attacks or strokes. For more information see the arc leaflet 'Non-Steroidal Anti-Inflammatory Drugs'.
In addition to drug treatments, resting wrist splints, heel and shoe pads, and sometimes bed rest may be helpful in the short term. Ice packs and heat pads can also help to relieve joint pain and swelling. A pack of frozen peas or hot-water bottle can be used, but should be wrapped in a towel to prevent burning the skin.
Treating severe or persistent arthritis
More severe symptoms may need a joint injection to remove fluid ('aspiration') and to put local steroid into the inflamed joint. This is often used to relieve knee pain. Occasionally, severe arthritis may need treatment with intramuscular or intravenous injections of steroids or short courses of low-dose steroid tablets. Steroid treatments given in these ways are both safe and often very effective in the short term. (See arc leaflets 'Steroid Tablets' and 'Local Steroid Injections'.
Cases of reactive arthritis lasting longer than 6 months may need disease-modifying drugs, such as sulfasalazine and, occasionally, methotrexate or azathioprine (see arc leaflets 'Sulfasalazine', 'Methotrexate' and 'Azathioprine').
Should I rest or exercise?
When the joint inflammation is active, it may make you feel tired and produce a general feeling of being unwell. Rest and early nights can play an important role in recovery during the early stages of reactive arthritis. However, it is also important that you try to keep your joints moving and try to maintain muscle strength. You may be advised by a physiotherapist or occupational therapist to do particular exercises, while at the same time avoiding excessive activity that might put too much strain on inflamed joints.
Are there any diets or complementary therapies which help?
There are no diets which are proven to help reactive arthritis, although certain dietary supplements may help to reduce the inflammation (see arc booklet 'Diet and Arthritis'). Complementary and alternative therapies may have a role to play in the control of individual joint symptoms (see arc booklet 'Complementary and Alternative Medicine for Arthritis').
Does reactive arthritis always get better within 6 months?
For the majority of people, reactive arthritis disappears completely within 6 months. During this time, it often runs a fluctuating course, with better and worse days. Gradually, as the arthritis subsides, you will find there are more good days than bad. In 10–20% of people, the symptoms last for longer than 6 months, but only a small number of people go on to develop a persistent arthritis that requires longer-term treatment. Some unlucky people, especially those who have the HLA B27 gene, may have bouts of reactive arthritis which come back at intervals of months or years in response to further triggering infections. When this happens it is described as 'recurrent'. People affected in this way should be especially careful to avoid exposure to food poisoning and to avoid the risk of sexually transmitted infections.
Does having reactive arthritis lead to problems later in life?
Under normal circumstances, when reactive arthritis disappears, the joints make a full recovery and there are no long-term problems as a result. A child with reactive arthritis is not at greater risk of developing other forms of arthritis as an adult.
Research into reactive arthritis
arc continues to support research into reactive arthritis. As a result, we now have a better understanding of how infections can trigger reactive arthritis by over-stimulating the immune system. Many studies have shown the presence of particles of bacteria and viruses within the inflamed joints. Further work is being done to determine whether these germs are present in a live or dead form in the joints. Learning more about the causes of reactive arthritis gives cause for optimism that even more effective treatments can be developed in the future.
Glossary
Antibodies – blood proteins which are formed in response to germs, viruses or any other substances which the body sees as foreign or dangerous. The role of antibodies is to attack foreign substances and make them harmless.
Anti-nuclear antibodies (ANA) – antibodies which are often found in the blood of people with forms of arthritis other than reactive arthritis. A test for anti-nuclear antibodies is sometimes carried out to exclude other conditions which can mimic reactive arthritis.
Chlamydia – the most common sexually transmitted infection (STI) in the UK. It is on the increase especially in young people. It is a bacterium that can remain dormant for years and is a major cause of infertility. It may have no symptoms.
HLA B27 – human leukocyte antigen B27. People who have this gene are more likely to have conditions such as reactive arthritis, psoriatic arthritis or ankylosing spondylitis.
Infective arthritis – also known as septic arthritis, this is very different from reactive arthritis. It occurs when there is an active infection within a joint or joints, usually only one joint initially. It can happen as a complication of an artificial joint replacement or arthritis. Septic arthritis is a medical emergency requiring hospital treatment.
Non-specific urethritis (NSU) – an inflammation of the urethra (the tube which urine passes through) which is not caused by chlamydia or gonorrhoea. It is thought to be caused by unidentified bacteria. It can be treated with antibiotics. Accurate diagnosis needs a sample to be taken on a swab from the urethra. NSU can cause a burning sensation when passing urine, or a discharge, or it may have no symptoms at all.
Parvovirus – the cause of a common childhood illness known as 'fifth' disease or 'slapped cheek' syndrome. Adults in contact with children who have this infection may pick up a mild infection without realizing it. This virus can also trigger reactive arthritis.
Septic arthritis – see infective arthritis.
Useful addresses
The Arthritis Research Campaign (arc)
PO Box 177
Chesterfield
Derbyshire S41 7TQ
Phone: 0870 850 5000
www.arc.org.uk
As well as funding research, we produce a range of free information booklets and leaflets. Please contact the above address for a list of titles or, on this website, see Publications for People with Arthritis.
Arthritis Care
18 Stephenson Way
London NW1 2HD
Phone: 020 7380 6500
Helpline (freephone): 0808 800 4050
www.arthritiscare.org.uk
Offers self-help support, a helpline service, and a range of leaflets on arthritis.
NHS Sexual Health Helplines
Sexual Health Line (freephone): 0800 567123
Sexwise (freephone helpline for under-18s): 0800 282930
www.playingsafely.co.uk
Provides information and helpline services on sexually transmitted infections and sexual health in general. The website includes a search facility to help you find local sexual health clinics.
Information on drugs
Separate arc leaflets are available on many of the drugs used for arthritis and related conditions. We would recommend that you read the relevant leaflets for more detailed information about your medication.
