Reactive arthritis is an aseptic inflammation affecting the joints, simultaneously or following an extra-articular infection (nasopharyngeal, intestinal, urogenital). Disease is characterized by an asymmetric lesion of joints, tendons, mucous membranes (conjunctivitis, uevitis, erosion in the oral cavity, urethritis, cervicitis, balanitis), skin (keratoderma), nails, lymph nodes, systemic reactions. The diagnosis is based on reliable clinical signs confirmed in the laboratory. Treatment is aimed at eliminating infection and eliminating inflammation. Reactive arthritis has a prognostically favorable course, a complete recovery is possible.
Meaning
The most common cause is a urogenital or intestinal infection. However, the manifestation is not directly related to infection in the joint, and secondary inflammation of the joints does not develop in all patients who have had an infectious disease.
Such selectivity, from the point of view of immunogenetic theory, is explained by the predisposition to reactive arthritis of individuals with hyperreaction of the immune system to microbial agents circulating in the blood and persisting in the articular fluid and tissues. Due to microbial mimicry – the similarity of the antigens of the infectious pathogen and joint tissues – the immune hyper-response is directed not only at microorganisms, but also at the auto-tissues of the joint. As a result of complex immunochemical processes, aseptic (non-purulent) reactive inflammation develops in the joints.
Classification
Taking into account the etiological conditionality , the following groups are distinguished:
- postenterocolitic, caused by pathogens of intestinal infections – yersinia, salmonella, dysentery bacillus, campylobacter, clostridia;
- urogenital, developed as a result of chlamydia, ureaplasma, and other infections.
Symptoms
The classic triad of signs of reactive arthritis includes the development of conjunctivitis, urethritis and arthritis proper. Symptoms of reactive arthritis usually appear 2-4 weeks after the clinic of a venereal or intestinal infection. Initially, urethritis develops, characterized by frequent urination with pain and burning. Then there are signs of conjunctivitis — lacrimation, redness and pain in the eyes. In typical cases, signs of urethritis and conjunctivitis are poorly expressed.
The latter manifests arthritis, manifested by arthralgia, edema, local hyperthermia, redness of the skin of the joints. The onset of arthritis is acute with subfebrility, deterioration of well-being, involvement of 1-2 joints of the lower extremities (interphalangeal, metatarsophalangeal, ankle, heel, knee), less often – joints of the hands. Due to the pronounced swelling and pain, joint functions suffer, vertebralgia is often noted.
The symptoms of reactive arthritis persist for 3-12 months, then there is a complete reverse development of the clinic. The danger of reactive arthritis lies in the high probability of recurrence and chronization of inflammation with gradual damage to an increasing number of joints. Typical forms of reactive arthritis include Reiter’s disease, which combines inflammatory changes in the joints, eyes and genitourinary tract.
Due to the transferred reactive arthritis, some patients (about 12%) develop deformity of the feet. Severe forms of inflammation can cause destruction and immobility (ankylosis) of the joint. Recurrent or untreated uveitis contributes to the rapid development of cataracts.
Diagnostics
Changes in peripheral blood in reactive arthritis are manifested by an increase in the rate of erythrocyte sedimentation; in venous blood, an increase in C-reactive protein is detected against the background of negative tests of rheumatoid factor (RF) and antinuclear factor (ANF). A specific marker indicating the presence of reactive arthritis is the detection of the HLA 27 antigen. For the differential diagnosis of reactive arthritis from arthritis of rheumatic origin, a rheumatologist’s consultation is necessary. Depending on the infection that caused reactive arthritis, the patient is referred to a urologist or venereologist for examination.
PCR examination of biological material (blood, smear from the genital tract, feces) suggests a probable causative agent of infection and the cause of reactive arthritis. At the same time, there are no pathogens in the sowing of articular fluid, which makes it possible to differentiate the diagnosis with bacterial arthritis. In reactive arthritis, radiography of the joints does not have a decisive diagnostic value, however, it often reveals the presence of heel spurs, paravertebral ossification, periostitis of the bones of the feet. Joint puncture or arthroscopy is usually not required.
Treatment
The main principle of reactive arthritis therapy is the elimination of the primary infectious focus in the urogenital or intestinal tract. Etiologically justified antimicrobial therapy is prescribed in optimal dosages for a period of at least 4 weeks. In reactive arthritis caused by chlamydia infection, preparations of groups of macrolides, tetracyclines, fluoroquinolones are used. Sexual partners are subject to simultaneous treatment even with negative tests for chlamydia. In the absence of dynamics after the antibacterial course, drugs of another group are re-prescribed.
To eliminate the inflammatory reaction in the joints, NSAIDs are treated; in severe arthritis – corticosteroids (prednisone), both systemically and with intra-articular and periarticular injections. The introduction of corticosteroids into the sacroiliac joints is carried out under the control of CT. Prolonged course of reactive arthritis may require the appointment of anti–inflammatory therapy with basic drugs – sulfasalazine, methotrexate.
With the help of TNF inhibitors (etanercept, infliximab), even therapy-resistant forms of the disease can be treated, signs of arthritis, spondylitis, acute uveitis are stopped. The introduction of stem cells in reactive arthritis helps to restore the structure of damaged cartilage, normalize metabolism, eliminate inflammation in the joint.
When an inflammatory effusion is formed, it is evacuated from the joint cavity. Locally used anti-inflammatory creams, ointments, gels, applications of dimexide. Of the methods of physiotherapy for reactive arthritis, preference is given to hydrocortisone phonophoresis, sinusoidal modulating currents (SMT), cryotherapy, physical therapy. After the acute degree of inflammation is relieved, procedures are prescribed aimed at restoring the functions of the joints – therapeutic baths (with Dead Sea salts, hydrogen sulfide, hydrogen sulfide), mud therapy.
Prognosis and prevention
The long-term prognosis of reactive arthritis is variable. In 35% of patients, inflammatory signs disappear within six months, and subsequently the disease does not resume. The same number of patients have relapses with the phenomena of arthritis, enteritis, systemic reactions. In 25% of cases, the course of arthritis becomes primarily chronic with a tendency to slight progression. Another 5% of patients have a severe form of reactive arthritis, which eventually leads to destructive and ankylosing changes in the joints and spine.
The main measure to prevent reactive joint inflammation is the prevention of primary intestinal (salmonellosis, yersiniosis, campylobacteriosis, dysentery) and genitourinary (chlamydia) infections.