Reiter’s syndrome (reactive arthritis)

Reiter’s syndrome, also known as reactive arthritis, is a type of inflammatory arthritis that typically develops as a reaction to an infection in another part of the body. This condition is characterized by joint pain, swelling, and stiffness, often accompanied by inflammation in the eyes, urinary tract, or skin. Reiter’s syndrome most commonly affects young to middle-aged adults and can have a significant impact on mobility and quality of life.

Symptoms

The exact cause of Reiter’s syndrome remains unclear, it often develops in response to an infection elsewhere in the body, particularly in the gastrointestinal or genitourinary tract. Recognizing the symptoms of Reiter’s syndrome is essential for early diagnosis and timely intervention to manage the condition effectively.

Joint Symptoms

• Joint pain: One of the hallmark symptoms of Reiter’s syndrome is joint pain, which can range from mild discomfort to severe and debilitating.
• Joint swelling: Affected joints may become swollen, tender, and warm to the touch due to inflammation.
• Joint stiffness: Patients with Reiter’s syndrome often experience stiffness, especially in the morning or after periods of inactivity.

Inflammatory Eye Symptoms

• Conjunctivitis (pink eye): Inflammation of the conjunctiva, the thin membrane covering the white part of the eye, causing redness, irritation, and discharge.
• Uveitis: Inflammation of the uvea, the middle layer of the eye, leading to eye pain, sensitivity to light (photophobia), and blurred vision.
• Keratitis: Inflammation of the cornea, resulting in eye pain, redness, and impaired vision.

Urinary Tract Symptoms

• Urethritis: Inflammation of the urethra, causing pain or discomfort during urination, increased frequency of urination, and discharge from the penis.
• Cystitis: Inflammation of the bladder, leading to urinary urgency, frequency, and discomfort or pain in the lower abdomen.
• Prostatitis: Inflammation of the prostate gland in men, resulting in pelvic pain, urinary difficulties, and discomfort during ejaculation.

Skin Symptoms

• Keratoderma blennorrhagicum: Skin lesions characterized by thickening and scaling, typically on the palms and soles, but can occur on other parts of the body.
• Circinate balanitis: Inflammation of the glans penis, causing redness, swelling, and pain.
• Psoriasis-like rash: Some individuals with Reiter’s syndrome may develop a rash resembling psoriasis, characterized by red, scaly patches on the skin.

Other Symptoms

• Fatigue: Chronic fatigue and malaise are common in individuals with Reiter’s syndrome, affecting their overall energy levels and daily functioning.
• Fever: Low-grade fever may occur, especially during active phases of inflammation or infection.
• Weight loss: Unintentional weight loss may occur due to the systemic inflammatory response associated with Reiter’s syndrome.

Causes

The exact cause of Reiter’s syndrome remains elusive, it is believed to develop in response to certain infections, genetic predisposition, and environmental factors. Understanding the intricate interplay of these factors can provide valuable insights into the pathogenesis of this condition.

Infectious Triggers

• Bacterial Infections: Reiter’s syndrome is commonly triggered by bacterial infections, particularly those caused by organisms such as Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. These infections can initiate an aberrant immune response, leading to the development of reactive arthritis in susceptible individuals.
• Genitourinary and Gastrointestinal Infections: Infections of the genitourinary tract, such as urethritis and cervicitis, and gastrointestinal infections, including gastroenteritis and food poisoning, have been implicated as primary triggers of Reiter’s syndrome. The bacteria involved in these infections can trigger an inflammatory response that affects the joints, eyes, and other organs.

Genetic Factors

• HLA-B27 Gene: Genetic predisposition plays a significant role in the development of Reiter’s syndrome, with a strong association observed with the human leukocyte antigen B27 (HLA-B27) gene. Individuals carrying the HLA-B27 gene have an increased susceptibility to reactive arthritis following certain infections. However, not all individuals with HLA-B27 develop Reiter’s syndrome, suggesting that other genetic and environmental factors contribute to its pathogenesis.
• Other Genetic Markers: In addition to HLA-B27, other genetic factors may influence the risk of developing Reiter’s syndrome. Variations in genes involved in immune regulation, inflammatory pathways, and tissue repair mechanisms have been studied for their potential contribution to the development and progression of this condition.

Environmental Triggers

• Microbial Triggers: Besides specific bacterial infections, other microbial triggers such as viruses and protozoa have been implicated in the development of Reiter’s syndrome. While the exact mechanisms by which these microorganisms induce reactive arthritis remain unclear, they may elicit an abnormal immune response or molecular mimicry, where microbial antigens resemble self-antigens, leading to autoimmunity.
• Environmental Factors: Various environmental factors, including smoking, trauma, and stress, may exacerbate or trigger episodes of Reiter’s syndrome in susceptible individuals. Smoking, in particular, has been associated with an increased risk and severity of reactive arthritis, possibly due to its pro-inflammatory effects and impact on immune function.

Immune Dysregulation

• Dysregulated Immune Response: Reiter’s syndrome is characterized by dysregulated immune responses, including the activation of pro-inflammatory cytokines, infiltration of immune cells into affected tissues, and the production of autoantibodies. Aberrant immune activation and cytokine-mediated inflammation contribute to the pathogenesis of joint, ocular, and genitourinary manifestations in reactive arthritis.

Treatments

There is no cure for Reiter’s syndrome, effective management strategies aim to alleviate symptoms, control inflammation, prevent complications, and improve the overall quality of life for individuals living with this condition. Treatment typically involves a combination of pharmacological interventions, physical therapy, lifestyle modifications, and, in some cases, surgical interventions.

Pharmacological Interventions

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as ibuprofen, naproxen, and indomethacin, are commonly prescribed to relieve pain and reduce inflammation in individuals with Reiter’s syndrome. These medications help alleviate joint pain, stiffness, and swelling by inhibiting the production of prostaglandins, which are inflammatory mediators.
• Disease-Modifying Antirheumatic Drugs (DMARDs): In cases of persistent or severe symptoms, DMARDs like methotrexate, sulfasalazine, or azathioprine may be prescribed to modulate the underlying inflammatory process and slow disease progression. DMARDs are particularly useful in individuals with recurrent or refractory symptoms of reactive arthritis.
• Corticosteroids: Oral or intra-articular corticosteroid injections may be recommended for short-term symptom relief in individuals with severe joint inflammation. However, long-term use of corticosteroids is generally avoided due to the risk of adverse effects, such as osteoporosis, diabetes, and immunosuppression.
• Biologic Therapies: In cases of severe or refractory Reiter’s syndrome, biologic therapies targeting specific inflammatory pathways, such as tumor necrosis factor-alpha (TNF-alpha) inhibitors (e.g., etanercept, adalimumab), may be considered to control disease activity and improve symptoms. Biologic agents are typically reserved for individuals who do not respond adequately to conventional therapies or experience significant functional impairment.

Physical Therapy and Exercise

• Physical therapy: It plays a crucial role in the management of Reiter’s syndrome by improving joint mobility, strength, and function, reducing pain, and preventing deformities. A tailored exercise program, including stretching, strengthening, and aerobic exercises, can help individuals with reactive arthritis maintain joint flexibility and muscle tone.
• Joint Protection Techniques: Occupational therapists can provide guidance on joint protection techniques and ergonomic modifications to minimize stress on affected joints during daily activities, work, and recreational pursuits.

Symptom-Specific Management

• Ocular Symptoms: Individuals with Reiter’s syndrome-related eye inflammation may require topical corticosteroids, cycloplegic agents, or immunosuppressive medications to alleviate symptoms and prevent complications such as vision loss.
• Urinary Tract Symptoms: Treatment of urethritis, cystitis, or prostatitis associated with reactive arthritis typically involves antibiotics to eradicate the underlying bacterial infection. Symptomatic relief may also be achieved with analgesics, antispasmodics, and pelvic floor exercises.
• Skin Manifestations: Topical corticosteroids, emollients, and keratolytic agents may be used to manage skin lesions such as keratoderma blennorrhagicum or circinate balanitis associated with Reiter’s syndrome.

Surgical Interventions

In rare cases of severe joint damage or deformity refractory to conservative measures, surgical interventions such as joint replacement surgery may be considered to restore joint function and alleviate pain. Surgical options depend on the severity and location of joint involvement and should be discussed with a healthcare provider.