This fact sheet contains general information about Reiter's syndrome. It describes what Reiter's syndrome is and how it develops. It also explains how Reiter's syndrome is diagnosed and treated. If you have further questions after reading this fact sheet, you may wish to discuss them with your doctor.

What Is Reiter's Syndrome?

Reiter's syndrome is a disorder that causes three seemingly unrelated symptoms: arthritis, redness of the eyes, and urinary tract signs. Doctors sometimes refer to Reiter's syndrome as a seronegative spondyloarthropathy because it is one of a group of disorders that cause inflammation throughout the body, particularly in parts of the spine and at other joints where tendons attach to bones. (Examples of other seronegative spondyloarthropathies include psoriatic arthritis, ankylosing spondylitis, and inflammatory bowel syndrome arthritis.) Inflammation is a characteristic reaction of tissues to injury or disease and is marked by four signs: swelling, redness, heat, and pain.

Reiter's syndrome is also referred to as reactive arthritis, which means that the arthritis occurs as a "reaction" to an infection that started elsewhere in the body. In many patients, the infection begins in the genitourinary tract (bladder, urethra, penis, or vagina). The infection is most commonly passed from one person to another by sexual intercourse. This form of the disorder is sometimes called genitourinary or urogenital Reiter's syndrome. Another form of the disorder, called enteric or gastrointestinal Reiter's syndrome, develops when a person eats food or handles substances that are tainted with bacteria.

What Causes Reiter's Syndrome?

When a preceding infection is recognized, symptoms of Reiter's syndrome appear about 1 to 3 weeks after the infection. Chlamydia trachomatis is the bacteria most often associated with Reiter's syndrome acquired through sexual contact. Several different bacteria are associated with Reiter's syndrome acquired through the digestive tract, including Salmonella, Shigella, Yersinia, and Campylobacter. People may become infected with these bacteria after eating or handling improperly prepared food, such as meats that are not stored at the correct temperature.

Doctors do not know exactly why some people exposed to these bacteria develop the disorder and others do not, but they have identified a genetic factor (HLA-B27) that increases a person's chance of developing Reiter's syndrome. About 80 percent of people with Reiter's syndrome are HLA-B27 positive. Only 6 percent of people who do not have the syndrome have the HLA-B27 gene.

Is Reiter's Syndrome Contagious?

Reiter's syndrome is not contagious; that is, a person with the disorder cannot pass it to somebody else. However, the bacteria that can trigger it can be passed from one person to another, although not all people infected with the bacteria will develop Reiter's syndrome. Rather, it is likely that people who develop the disease have inherited a trait that makes them susceptible.

Who Gets Reiter's Syndrome?

Men between the ages of 20 and 40 are most likely to develop Reiter's syndrome. It is the most common type of arthritis affecting young men. Among men under age 50, about 3.5 per 100,000 develop Reiter's syndrome each year. Three percent of all men with a sexually transmitted disease develop Reiter's syndrome. Women can also develop the disorder, though less often than men, with features that are often milder and more subtle.

What Are the Symptoms of Reiter's Syndrome?

The symptoms can affect many different parts of the body, but most typically affect the urogenital tract, the joints, and the eyes. Less common symptoms are mouth ulcers, skin rashes, and heart-valve problems. The signs may be so mild that patients do not notice them. They usually come and go over a period of several weeks to several months.

Urogenital Tract Symptoms

Reiter's syndrome often affects the urogenital tract, including the prostate, urethra, and penis in men and the fallopian tubes, uterus, and vagina in women. Men may notice an increased need to urinate, a burning sensation when urinating, and a discharge from the penis. Some men with Reiter's syndrome develop prostatitis, inflammation of the prostate gland. Symptoms of prostatitis can include fever, chills, increased need to urinate, and a burning sensation when urinating.

Women with Reiter's syndrome also develop signs in the urogenital tract, such as inflammation of the cervix (cervicitis) or inflammation of the urethra (urethritis), which can cause a burning sensation during urination. In addition, some women also develop salpingitis (inflammation of the fallopian tubes) or vulvovaginitis (inflammation of the vulva and vagina). These conditions may or may not cause any symptoms.

Joint Symptoms or Arthritis

The arthritis associated with Reiter's syndrome typically affects the knees, ankles, and feet, causing pain and swelling. Wrists, fingers, and other joints are less often affected. Patients with Reiter's syndrome commonly develop inflammation where the tendon attaches to the bone, a condition called enthesopathy. Enthesopathy may result in heel pain and the shortening and thickening of fingers and toes. Some people with Reiter's syndrome also develop heel spurs, bony growths in the heel that cause chronic or long-lasting foot pain.

Arthritis in Reiter's syndrome can also affect the joints in the back and cause spondylitis (inflammation of the vertebrae in the spinal column) or sacroiliitis (sa-kro-il-e-i-tes), inflammation of the joints in the lower back that connect the spine to the pelvis. People with Reiter's syndrome who have the HLA-B27 gene have a greater chance of developing sacroiliitis and spondylitis.

Eye Involvement

Conjunctivitis, an inflammation of the mucous membrane that covers the eyeball and eyelid, develops in about 50 percent of people with urogenital Reiter's syndrome and 75 percent of people with enteric Reiter's syndrome. A few people may develop uveitis, an inflammation of the inner eye. Conjunctivitis and uveitis can cause redness of the eyes, eye pain and irritation, and blurred vision. Eye involvement typically occurs early in the course of Reiter's syndrome, and symptoms may come and go.

Other Symptoms

About 20 to 40 percent of men with Reiter's syndrome develop small, shallow, painless sores or lesions, called balanitis circinata, on the end of the penis. A small percentage of men and women develop rashes of small hard nodules on the soles of the feet, and less often on the palms of the hands or elsewhere. These rashes are called keratoderma blennorrhagica. In addition, some people with Reiter's syndrome develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed.

About 10 percent of people with Reiter's syndrome, usually those with prolonged disease, develop heart problems including aortic regurgitation (leakage of blood from the aorta into the heart chamber) and pericarditis (inflammation of the membrane that covers and protects the heart).

How Is Reiter's Syndrome Diagnosed?

Diagnosing Reiter's syndrome is often difficult because there is no specific test to confirm that a person has it. When a patient reports symptoms, the doctor must examine him or her carefully and rule out other causes of arthritis.

The doctor will take the patient's complete medical history, noting current symptoms as well as any previous diseases, problems, and infections. Because the symptoms of Reiter's syndrome can be vague, it is sometimes useful for the patient to keep a log of the symptoms that occur, when they occur, and for how long. It is especially important to report any flulike symptoms, such as fever, vomiting, or diarrhea, even if they were mild, because they may be associated with the initial bacterial infection.

The doctor may use various blood tests to help rule out other conditions and confirm a suspected diagnosis of Reiter's syndrome. Tests may be done to determine the presence of rheumatoid factor or antinuclear antibodies. Results of these tests are abnormal in patients with other types of arthritis such as rheumatoid arthritis or lupus, but they typically are normal in patients with Reiter's syndrome. Doctors may determine the erythrocyte sedimentation rate, or sed rate, which is the rate at which red blood cells settle at the bottom of a test tube of blood. An elevated sed rate indicates inflammation somewhere in the body. Typically, people with rheumatic diseases, including Reiter's syndrome, have an elevated sed rate. In some patients with suspected Reiter's syndrome, the doctor may do a blood test to determine the presence or absence of HLA-B27.

The doctor is also likely to perform tests for infections that might be associated with Reiter's syndrome. Patients are generally tested for a Chlamydia infection because recent studies have shown that early treatment in Chlamydia-induced Reiter's syndrome may ameliorate the course of the disease. In many people with Reiter's syndrome, there is no clear evidence of infection at the time they are seen, although antibodies may be detected in the blood, indicating that an infection was present in the past. The doctor may test samples of cells taken from the patient's throat as well as the urethra in men or cervix in women. Urine and stool samples may also be tested. The synovial fluid (the fluid that lubricates the joints) or the membrane (synovium) that lines the joint may be removed from the joint affected by arthritis. Studies of the fluid or the synovium can help the doctor make certain there is no infection in the joint.

Doctors sometimes use X rays to help establish a diagnosis of Reiter's syndrome and rule out other causes of arthritis. Common findings on X rays of patients with Reiter's syndrome include spondylitis, sacroiliitis, swelling of soft tissues, damage to cartilage or bone margins of the joint, and bone deposits where the tendon attaches to the bone.

What Type of Doctor Treats Reiter's Syndrome?

A patient probably will see different doctors because Reiter's syndrome affects different parts of the body. It may be helpful to the doctors and the patient for one doctor to manage the complete treatment plan. This doctor can coordinate treatments and monitor the side effects from the various medicines the patient may take. A rheumatologist (doctor specializing in arthritis) often manages a patient's treatment and treats the joint disease. The following specialists treat other features that affect different parts of the body.

• Ophthalmologist—treats eye disease.
• Gynecologist—treats urogenital symptoms in women.
• Urologist—treats urogenital symptoms in men.
• Dermatologist—treats skin symptoms.
• Orthopaedist—performs surgery on severely damaged joints.
• Physiatrist—supervises exercise regimens.

How Is Reiter's Syndrome Treated?

Although there is no cure for Reiter's syndrome, treatments that effectively relieve the symptoms are available. Many symptoms may even disappear for long periods of time. The doctor is likely to use one or more of the following treatments:

• Bed rest—Short periods of bed rest are sometimes effective in reducing the pain and inflammation of arthritis. Lying down can reduce the pressure of the body's weight on a painful joint and provide relief for some patients.
• Exercise—Even before symptoms disappear, some strengthening and gentle range-of-motion exercises will maintain or improve joint function. Strengthening exercises build up the muscles around the joint to better support it. Isometric tightening of muscles without moving the joints can be used even in active, painful disease. Range-of-motion exercises improve movement and flexibility and reduce stiffness in the affected joint. Before beginning an exercise program, patients should talk to the doctor, who can recommend appropriate exercises.
• Nonsteroidal anti-inflammatory drugs (NSAID's)—This type of medicine effectively reduces joint inflammation and is commonly used to treat patients with Reiter's syndrome. Some NSAID's, such as aspirin and ibuprofen, are available without a prescription. Many others require a doctor's prescription.
• Corticosteroid injections—For people with severe joint inflammation, injections of corticosteroids directly into the affected joint may effectively reduce inflammation. Doctors typically use this treatment only after trying to control arthritis with NSAID's. Corticosteroid injections are most commonly used for severe knee or ankle inflammation.
• Topical corticosteroids—This type of medicine can be put directly on the skin lesions associated with Reiter's syndrome. Topical corticosteroids reduce inflammation and promote healing.
• Antibiotics—Antibiotics may be prescribed to eliminate the bacterial infection that triggered Reiter's syndrome. The specific antibiotic prescribed depends on the type of bacterial infection that has to be treated. Patients must carefully follow the doctor's instructions about how much medicine to take and for how long; if the medicine is not taken correctly, the infection may not go away. Often, an antibiotic is taken once or twice a day for 7 to 10 days or longer. Some doctors may recommend that a person with Reiter's syndrome take antibiotics for a long period of time (up to 3 months). Current research shows that this practice usually has no effect on the course of the disease and is therefore unnecessary. However, in cases when Chlamydia triggers Reiter's syndrome, prolonged antibiotic treatment is effective in shortening the length of time that a person has symptoms.
• Immunosuppressive medicines—A small percentage of patients with Reiter's syndrome have severe symptoms that cannot be controlled with the treatments described earlier. For these people, medicine that suppresses the immune system, such as sulfasalazine or methotrexate, may be effective.

What Is the Prognosis for People Who Have Reiter's Syndrome?

Most people with Reiter's syndrome recover fully from the initial flare of symptoms and are able to return to regular activities within 2 to 6 months after the first symptoms appear. Arthritis may last up to 6 months, although the symptoms are usually very mild and do not interfere with daily activities. Only 20 percent of people with Reiter's syndrome will have chronic arthritis, which is usually mild. Some patients experience symptom recurrence. Studies show that about 15 to 50 percent of patients will develop symptoms sometime after the initial flare has disappeared. Back pain and arthritis are the symptoms that most commonly reappear. A small percentage of patients will have deforming arthritis and severe symptoms that are difficult to control with treatment.

What Are Researchers Trying To Learn About Reiter's Syndrome?

Researchers continue to investigate the causes of Reiter's syndrome and study treatments for the condition. For example:

• Researchers are trying to better understand the relationship of infection to Reiter's syndrome. In particular, they are trying to determine why an infection triggers arthritis and why some people who develop infections get Reiter's syndrome and others do not. Scientists have identified a genetic link—people who are positive for HLA-B27 are more susceptible to Reiter's—and are studying why these people are more at risk than others.
• Researchers are trying to develop methods to detect the location of the triggering bacteria in the body. Some scientists suspect that after the bacteria enter the body, they are transported to the joints, where they can remain in small amounts indefinitely.
• Researchers are studying new treatments for Reiter's syndrome; for example, prolonged treatment with antibiotics or a combination of antibiotics and other drugs such as methotrexate or sulfasalazine. Several recent studies have shown that prolonged treatment with antibiotics may reduce the duration of symptoms in some patients with Reiter's syndrome caused by Chlamydia infection.

Where Can People Get More Information About Reiter's Syndrome?

Spondylitis Association of America
P.O. Box 5872
Sherman Oaks, CA 91413
818/981-1616
800/777-8189
World Wide Web address: http://www.spondylitis.org/

This is the main voluntary organization devoted to all forms of spondylitis, including Reiter's syndrome. The association publishes patient and professional materials and a newsletter for members.

Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
404/872-7100
800/283-7800
World Wide Web address: http://www.arthritis.org/

This is the main voluntary organization devoted to arthritis. The foundation publishes a free pamphlet on Reiter's syndrome and can also provide physician/clinic referrals.

American College of Rheumatology
60 Executive Park South, Suite 150
Atlanta, GA 30329
404/633-3777
World Wide Web address: http://www.rheumatology.org/

This professional organization of rheumatologists, both physicians and scientists, is dedicated to treating and studying all forms of arthritis and can also provide a list of rheumatologists by State.

National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse (NAMSIC)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
301/495-4484
Fax: 301/718-6366
TTY: 301/565-2966
World Wide Web address: http://www.niams.nih.gov/

This clearinghouse, a public service sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), provides information about various forms of arthritis and rheumatic disease. The clearinghouse distributes patient and professional education materials and also refers people to other sources of information.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of John Klippel, M.D., of NIAMS; Daniel Clegg, M.D., University of Utah School of Medicine, Salt Lake City; and Ralph Schumacher, M.D., VA Medical Center, Philadelphia, PA, in the preparation and review of this fact sheet.

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