Reiter's syndrome is a type of arthritis that forms as a reaction to an infection in the body. It involves three conditions: inflammation in and around a joint (arthritis), in the urinary tract (urethritis) and in the lining of the eye (conjunctivitis).
Reiter's syndrome can develop after a person has a gastrointestinal infection or a sexually transmitted disease. However, most people do not develop Reiter's syndrome after having either of these common infections. The reasons that some people develop Reiter's syndrome and others do not are not fully understood.
Two to four weeks after the initial infection, a person with Reiter's syndrome may experience joint pain, commonly in the knees, ankles, feet or lower back. Conjunctivitis makes the eyes red and inflamed. Inflammation in the urinary system causes frequent urges to urinate or a burning sensation during urination. These symptoms may occur together or separately.
There are no specific tests to diagnose Reiter's syndrome. A medical history and description of symptoms can help a physician rule out other conditions and point to Reiter's syndrome.
The infectious symptoms can be treated with antibiotics. The pain and inflammation in the joints may be treated with drugs such as anti-inflammatories. For most patients, treatment resolves symptoms of Reiter's syndrome within several months.
About Reiter's syndrome
Reiter's syndrome is a condition in which a bacterial infection causes inflammation in a joint (arthritis,) in the lining of the eyes (conjunctivitis) and in the urinary tract (urethritis). Some patients may experience skin and mouth lesions as well.
Reiter's syndrome is a type of reactive arthritis, meaning that an infection elsewhere causes inflammation in a joint or joints. Reactive arthritis is similar to infectious arthritis, where an infection directly invades and inflames a joint.
Infections in the gastrointestinal or urogenital systems can trigger Reiter's syndrome. This initial infection may or may not produce symptoms. Several days or weeks later, the infection can cause inflammation in the areas affected by Reiter's syndrome. It may inflame joints in the knee, foot, ankle, hips and lower back, causing pain, swelling or stiffness.
The conjunctiva, the membrane that lines the eye and inside of the eyelid, may become red and inflamed in one or both eyes. The cervix (mouth of the uterus in women) and urethra (in men and women) may become inflamed and cause urgency or burning during urination. Men, women and children may all come into contact with bacterial agents that trigger Reiter's syndrome.
Joint pain caused by Reiter's syndrome is most common in the legs, spine or hands. Reiter's syndrome belongs to a family of diseases known as spondylarthropathies that attack the spine. These diseases include psoriatic arthritis, ankylosing spondylitis and enteropathic arthritis (arthritis related to digestive disorders such as inflammatory bowel disease or celiac disease).
Reiter's syndrome is an uncommon form of arthritis. Other forms of reactive arthritis may also cause joint inflammation triggered by an infection but may not involve the eyes or genitals. Reiter's syndrome can occur in adults and children. Among adults, it is much more common in men than women.
Most people will recover from the initial symptoms after treatment, although some mild arthritis symptoms may remain for up to 12 months. Some patients experience recurrence of symptoms, which may be due to reinfection. A small percentage of patients may develop chronic, severe arthritis that is difficult to control, according to the National Institutes of Health. The frequency is estimated at 3.5 cases per 100,000.
Reiter's syndrome was first described in 1916 when arthritis, urethritis and conjunctivitis were identified in one patient by Hans Reiter, a German military physician later convicted of Nazi war crimes.
Risk factors and causes of Reiter's syndrome
Reiter's syndrome is a reaction to bacterial infection in other body systems. Although many people contract these infections, few of them go on to develop Reiter's syndrome. The mechanism that makes an infection progress to Reiter's syndrome is not well understood.
In the urogenital system, the initial infection may be caused by bacteria such as Chlamydia trachomatis or Ureaplasma urealyticum, which are transmitted through sexual contact. The initial infection may also be caused by the human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS). In the gastrointestinal system, some infections with certain microorganisms, including the Salmonella, Campylobacter or Shigella bacteria, may progress to Reiter's syndrome. These bacteria may enter the body when a person comes into contact with contaminated feces or eats or handles food contaminated with the bacteria, such as raw or undercooked meat.
Elements called risk factors may increase the likelihood of developing a disease or condition. However, not everyone with the disease may exhibit risk factors and not everyone with risk factors may develop the disease. Risk factors associated with Reiter's syndrome include:
Sex and age. Reiter's syndrome is much more common in men than in women, and most common in men between the ages of 20 and 40. Most men with Reiter's syndrome develop it from chlamydia, ureaplasma or HIV/AIDS. Most women with Reiter's syndrome develop it from a gastrointestinal infection.
Genetics. Studies show that a genetic marker called HLA-B27 may indicate a tendency to develop Reiter's syndrome. About 8 percent of healthy people have this gene, according to the National Institutes of Health. However, about 80 percent of people with Reiter's syndrome have the gene. Although the presence of HLA-B27 may indicate a tendency to develop the syndrome, it is not a certainty. Of the people with the gene who are exposed to a triggering infection, only 20 percent develop Reiter's syndrome.
Signs and symptoms of Reiter's syndrome
Reiter's syndrome begins with a bacterial infection in the gastrointestinal or urogenital system. The gastrointestinal bacteria can enter the body through eating or handling contaminated food. It may produce symptoms of fever, diarrhea, vomiting and abdominal pain.
In the urogenital system, bacteria such as chlamydia are transmitted through unprotected sexual contact and may produce pelvic pain or sexual pain. Men and women may experience pain or burning during urination (dysuria). Abnormal discharges, from the penis in men and the vagina in women, may also appear. However, many people experience no symptoms from chlamydia.
If the initial bacterial infection progresses to Reiter's syndrome, the person may experience symptoms two to four weeks after the first infection. Symptoms may include:
Urogenital symptoms in men (inflammation of the urethra or prostate gland - urethritis or prostatitis):
Burning sensation during urination
Increased urges to urinate
Unusual discharge from the penis
Chills and fever
Sores on the penis
Urogenital symptoms in women (inflammation of the urethra or cervix - urethritis or cervicitis):
Burning sensation during urination
Increased urges to urinate
Abnormal vaginal discharge
Bleeding between menstrual periods
Some women can also develop inflammation of other reproductive organs that may produce no symptoms. These include salpingitis (inflammation of the fallopian tubes) or vulvovaginitis (inflammation of the vulva and vagina).
Joint symptoms:
Pain or swelling, commonly in the knees, ankles, feet, lower back or hands.
Sausage digit. A finger or toe that is red and swollen for its entire length.
Inflammation of tendons (tendinitis), especially the Achilles tendon in the lower leg.
Enthesitis. Inflammation and pain where the tendons connect to bones.
Heel and foot pain. Including heel spurs and growths on the bones on the bottom of the foot.
Eye symptoms:
Conjunctivitis. Eye pain, redness and swelling of the conjunctiva, the mucous membrane that lines the eye and inside of the eyelid. It may involve one or both eyes.
Uveitis. An inflammation of the uveal tract, the middle layer of the eye.
These three areas of symptoms (genitals, joints, eyes) define Reiter’s syndrome. Some patients also develop other symptoms of reactive arthritis, including buttock or lower back pain, scaly rash on the penis, red or brown spots on the palms or soles of feet and sores in the mouth or on the genitals.
The symptoms of Reiter's syndrome may flare up for several months and resolve with treatment. Some people may experience recurrence of the joint pain or other symptoms. Recurrence of the arthritis symptoms is much more common when Reiter's syndrome originates from a urogenital infection.
Diagnosis methods for Reiter's syndrome
Reiter's syndrome can be difficult to diagnose because the symptoms may be mild and occur sporadically. No specific laboratory test can confirm the diagnosis. However, episodes of arthritis of one month with urethritis/cervicitis and conjunctivitis are specific and sensitive for this disease.
Diagnosis begins with a physical examination. A medical history, including the recent symptoms of any infection, and a sexual history may also be taken. A patient's history of any unusual symptoms, fever or pain can help the diagnostic process. The patient may be asked to complete a pain assessment form.
Certain blood tests may be used to rule out other form of arthritis. Some of these tests, which frequently yield positive results for many forms of arthritis, are negative for people with Reiter's syndrome. Many laboratory tests are used to screen for specific kinds of arthritis or other disease. Blood tests that used include:
Antinuclear antibody (ANA) test and rheumatoid factor test. These usually yield a positive result for some forms of arthritis. However, patients with Reiter's syndrome usually test negative for both tests.
C reactive protein test. An elevated level of this protein produced by the liver suggests an inflammatory disease.
HLA-B27 test. Presence of this genetic marker in the white blood cells may indicate Reiter's syndrome, or other conditions including ankylosing spondylitis, rheumatoid arthritis or juvenile rheumatoid arthritis.
Erythrocyte sedimentation rate (ESR). This blood test measures how long it takes red blood cells (erythrocytes) to separate from plasma in a blood sample. It is nonspecific: An elevated ESR indicates inflammation that could be caused by many conditions.
Other tests that may be performed include:
Urine tests and stool samples. A physician may test a sample for infections that originated with a gastrointestinal source.
Chlamydia test. A swab of cells from the throat and the urethra in men and women and the cervix in women is used to test for this sexually transmitted disease in cases where it is the suspected originating infection. A more advanced urine test can also test for chlamydia. If a patient tests positive for chlamydia, the physician may test for other sexually transmitted infections, including gonorrhea and the human immunodeficiency virus (HIV).
Synovial fluid analysis. A needle is used to remove fluid from an inflamed joint. Testing the fluid may indicate several forms of arthritis, such as gout, infectious arthritis or juvenile rheumatoid arthritis.
Most patients with Reiter's syndrome do not show any joint damage on x-rays in the early stages of the disease. The use of x-rays may serve to rule out other forms of arthritis. X-rays that show bony outgrowths or changes in the size of joint spaces may indicate such diseases as osteoarthritis. If Reiter's syndrome is more advanced at diagnosis, the patient may show some joint changes, especially if the joints in the lower back are affected.
The combination of the patient's medical history and test results may enable a physician to diagnose Reiter's syndrome or continue investigating other potential conditions.
Treatment options for Reiter's syndrome
Once Reiter's syndrome is diagnosed, each aspect of the condition may be treated by a different specialist. A rheumatologist specializes in inflammatory diseases and may treat the arthritis. An ophthalmologist specializes in eye diseases and may treat the conjunctivitis (inflammation of the eyelid and lining of the eye). A gynecologist may treat any genital symptoms for women, and a urologist may treat urinary or genital symptoms for men or women.
The aim of treatment is to reduce the symptoms, prevent or limit joint damage and restore the function of damaged joints.
Several forms of medication are used to treat Reiter's syndrome. These include:
Antibiotics. A bacterial infection, either from the original source or in the joints, eyes or genital system, may be treated with antibiotics. This may be in several forms, including oral, injection or eye drops. Some patients may require long courses of antibiotics (up to three months). However, the use of antibiotics without a known source of infection is controversial and usually not recommended.
Nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are used to reduce pain and inflammation. They come in prescription and non-prescription forms. Some may affect renal or gastrointestinal function. COX-2 inhibitors may be prescribed if other NSAIDs are not effective.
Corticosteroids. These anti-inflammatories may be given as pills or injections to reduce inflammation. If only a few joints are inflamed, a physician can give an injection. If many joints are inflamed, oral corticosteroids may be prescribed. Long-term use of corticosteroids can have many side effects, including osteoporosis and diabetes.
Disease-modifying antirheumatic drugs (DMARDs). These drugs are more commonly prescribed for patients with rheumatoid arthritis but may be used for Reiter's syndrome patients who have not experienced relief from NSAIDs. Side effects include liver and kidney complications and repression of immune responses to infection.
Tumor necrosis factor (TNF) blockers. Protein blockers that inhibit the body's inflammatory response. This class of biologic response modifiers (BRMs) may help to reduce inflammation, pain and stiffness.
People with more damage to joints may also benefit from physical therapy to improve joint function and range-of-motion exercises and exercise programs that strengthen muscles and add support to the joints. Sometimes splints are needed to decrease joint pain.
Most people with Reiter's syndrome recover fully from the initial flare-up of symptoms and are able to return to regular activities within two to six months.
Prevention methods for Reiter's syndrome
Prevention of Reiter's syndrome involves avoidance of the initial bacterial infections. Gastrointestinal infections may not be completely avoided, but they can be minimized by ensuring that food is stored at the proper temperatures (refrigerated when necessary) and cooked at temperatures high enough to kill any bacteria. People should ensure they handle uncooked food properly by not transmitting fluids from uncooked meat to the mouth or to other foods.
Reiter's syndrome triggered by chlamydia and other sexually transmitted diseases (STDs) may be prevented by practicing safe sex. These methods include limiting the number of sexual partners, always using latex condoms during sex and getting tested regularly for STDs.
Prompt treatment of the initial symptoms of infection (e.g., diarrhea, vomiting, unusual genital discharge) may prevent the progression of the infection to Reiter's syndrome.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about Reiter's syndrome:
Could my symptoms be due to Reiter's syndrome?
What else could explain my symptoms?
What diagnostic tests might I need to undergo?
How is this diagnosis confirmed?
How is Reiter's syndrome different from other kinds of arthritis?
Can I transmit Reiter's syndrome to another person?
What are the potential risks of these treatments?
What are the risks if I do not use these treatments?
Do I need to see an ophthalmologist, urologist, rheumatologist or other specialist?
Does having Reiter's syndrome put me at risk for other conditions?
If my symptoms go away now, can I get reinfected later?
