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Reactive arthritis and ankylosing spondylitis

Clinical presentation

Reactive arthritis

The main symptoms of reactive arthritis are pain and swelling of fairly sudden onset in the knees, ankles or toes. The fingers, wrists, elbows and sacroiliac joints (base of spine) may also be affected. In Reiter's syndrome arthritis is accompanied by inflammation of the eyes (iritis, uveitis and or conjunctivitis), a scaly skin rash on the palms of the hands, soles of the feet or tip of the penis (keratoderma blenorrhagica), and signs of urethritis. Reactive arthritis may be triggered by an episode of food poisoning (1 - 2% of people), by parvovirus or by a sexually transmitted infection, particularly C. trachomatis. Reactive arthritis primarily occurs in people who are positive for the  HLA B27 gene. This tissue typing and histocompatability gene is carried by approximately 1 in 14 of the population in the UK [see: genotypic determinants of chlamydial disease]. Reactive arthritis usually resolves within 6 months and, unlike septic arthritis, bacteria are rarely grown from the affected joints. In a few people with reactive arthritis the disease recurs, sometimes triggered by an episode of food poisoning or genital tract infection.  

Until recently there was no agreement on how to classify and diagnose reactive arthritis, or what kind of specific clinical and laboratory investigations are appropriate. However, a group of experts at the 4th International Workshop on Reactive Arthritis, in Berlin, July 1999, determined that the term "reactive arthritis" should only be used if the clinical picture involved the human HLA-B27 genotype and typical, spondyloarthropathy -associated microorganisms (Chlamydia, Yersinia, Salmonella, Shigella, Campylobacter species). The term "infection related arthritis" was recommended for arthritides associated with other infections. 

Acute and chronic reactive arthritis were regarded as being disease of respectively less or more than six months duration. The interval between symptoms and arthritis was proposed to be from a minimum1 - 7 days to a maximum  4 weeks, with particular, often asymmetric involvement of the lower limbs. [Comment: This strict definition has not been used in most studies of reactive arthritis]. Recommended investigations included a search for chlamydiae (particularly C. trachomatis) in urine/urethra/cervix using nucleic acid based tests, while in the case of diarrhea, pathogenic gut bacteria should be searched for in stool specimens or by serology. [Braun et al., 2000].  

For further information on the clinical presentation of reactive arthritis see the Arthritis Research Campaign guide.

Ankylosing Spondylitis

This is a painful, progressive rheumatic disease in which the bones of the spine and other joints fuse. Usually the condition is partial and often limited to just the pelvic bones. There is inflammation at the sites where ligaments and tendons attach to bone (enthesis). Inflammation causes erosion of the bone at the sites of attachment (enthesopathy). Healing of the eroded areas causes laying down of new bone visible on X-ray. Usually the pelvis is affected first, followed by the lower back, chest wall and neck. In Britain the condition affects 1 in 200 men and 1 in 500 women.

The disease is usually characterized by a slow and gradual onset of back pain. Stiffness and pain is particularly noticeable on waking up and usually feels better after exercise. There may be night sweats and fever. In Britain more than 90% of sufferers of this condition are HLA B27 positive and there is a clear relationship to bowel or genital tract infection. For further information on the clinical presentation see the National ankylosing spondylitis society guide.

Temperomandibular joint. 

In patients undergoing surgical treatment for a deranged temperomandibular joint, a variety of of sexually transmitted bacteria have been recovered from excised joint tissue. From a total of 26 specimens examined, DNA from C. trachomatis or Mycoplasma genitalium were recovered from 42% and 35% of specimens respectively. Enteric pathogens commonly associated with reactive arthritis were not detected in this joint. It was suggested that inflammation as a result of the long term presence of bacteria from sexually transmitted infection caused derangement of the joint eventually requiring surgical correction [Henry et al., 2000]. 

[MEW] March 2002

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References

Arthritis Research Campaign (UK). (2001, regularly updated).  [Useful web site of a UK charity which funds a lot of research on arthritic and rheumatic diseases. Good on-line guide for patients and others on reactive arthritis]. Full guide.

Braun, J., Kingsley, G., van der Heijde, D. & Sieper, J. (2000). On the difficulties of establishing a consensus on the definition of and diagnostic investigations for reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3-6, 1999. Journal of Rheumatology 27, 2185 - 2192.

Henry, C. H., Hughes, C. V., Gerard, H. C., Hudson, A. P. & Wolford, L. M. (2000). Reactive arthritis: preliminary microbiologic analysis of the human temporomandibular joint. Journal of Oral and Maxillofacial Surgery 58, 1137 - 1142. [Also discussion pp 1143 - 1144]. 

National Ankylosing Spondylitis Society, UK. (2001, regularly updated). [An excellent site. The frequently asked questions give a good introduction to this condition. There is also an excellent on-line guide book for patients on ankylosing spondylitis]. Full guide.

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