Reiter's syndrome

• Reiter's syndrome is characterized by arthritis (swollen and painful joints), eye inflammation and irritation, and urinary tract problems. It is generally a temporary condition, but symptoms may come back repeatedly for a few patients.
• Reiter's syndrome is considered a type of reactive arthritis because the joints become painful and swollen in response to an infection in the body. Symptoms of Reiter's syndrome typically develop one to three weeks after the initial infection develops. Reiter's syndrome may develop even if the infection is treated quickly or does not last long.
• In many patients, the initial infection develops in the genitourinary tract, which includes the bladder, urethra, and penis or vagina. Genitourinary infections are usually passed from person to person through sexual intercourse. This form of the disorder is also called genitourinary or urogenital Reiter's syndrome.
• In other patients, the infection develops in the gastrointestinal, or digestive, tract. This form, called enteric or gastrointestinal Reiter's syndrome, develops when an individual consumes food or beverages that are contaminated with bacteria.
• Although the infections that cause Reiter's syndrome can be passed to other people, Reiter's syndrome itself is not contagious or sexually transmitted.
• Reiter's syndrome is most common among males who are between the ages of 20 and 40. It is considered the most common type of arthritis to affect young men. Researchers estimate that about 3.5 out of 100,000 American males who are younger than 50 years of age develop Reiter's syndrome each year. An estimated three percent of all males with sexually transmitted diseases develop Reiter's syndrome.
• Although less common, women can also develop the disorder. For unknown reasons, women typically experience milder symptoms than males.
• There is currently no cure for Reiter's syndrome. Treatment is available to help reduce symptoms, and it is necessary to prevent serious complications such as blindness. For most patients, symptoms of Reiter's syndrome go away after two to six months. Only about 20% of patients will have long-term arthritis after the infection is cured. In such cases, the arthritis is typically very mild and does not interfere with daily activities. In about 15-50% of patients, symptoms may go away and come back for several years, which require long-term treatment. A small percentage of patients will have deforming arthritis and severe symptoms that are difficult to control with treatment.

• General: Certain genitourinary and gastrointestinal infections have been shown to cause Reiter's syndrome. This occurs when the disease-causing bacteria travel to other areas of the body, where they cause inflammation.
• It remains unknown why only some patients get Reiter's syndrome after they are exposed to these bacteria. However, researchers have discovered a genetic (biological) factor that increases an individual's chance of developing the disorder. About 80% of patients with Reiter's syndrome have a mutated gene that leads to the development of an abnormal human leukocyte antigen (HLA) called HLA-B27.
• It remains unknown exactly how the HLA-B27 molecule triggers the inflammatory response in the body. It has been suggested that it occurs when an infectious organism that looks similar to HLA-B27 enters the body. In such cases, researchers believe that the immune system mistakes the patient's own cells that contain the HLA-B27 molecule for the disease-causing bacteria. In essence, the immune system attacks itself (a condition called autoimmunity) and symptoms of Reiter's syndrome appear. It has also been suggested that the HLA-B27 molecules attach to the infectious bacteria. This may cause the immune system to attack itself and trigger the disease. A third theory is that the HLA-B27 molecule is linked to an unidentified gene that triggers the immune response.
• Genitourinary tract infection: A sexually transmitted genitourinary tract infection, called chlamydia, is the most common cause of Reiter's syndrome. This infection is caused by a bacterium called Chlamydia trachomatis. Most cases of chlamydia are transmitted from person to person through oral, anal, or vaginal sex. Less commonly, Reiter's syndrome may be caused by gonorrhea (another common STD).
• Gastrointestinal tract infection: Many types of bacteria known to cause infections in the gastrointestinal tract have been linked to Reiter's syndrome. The most common bacteria to cause Reiter's syndrome include salmonella, shigella, yersinia, and campylobacter. People become infected after consuming food or beverages that are contaminated with these bacteria. This type of infection may occur if produce is not properly washed or meat is not stored or cooked at the appropriate temperature.

• General: The most common symptoms of Reiter's syndrome include arthritis, eye inflammation and irritation, and urinary tract problems. Individuals may have received treatments for the initial infection several weeks before Reiter's syndrome develops. In general, symptoms of Reiter's syndrome usually start to appear one to three weeks after the patient has developed a genitourinary or gastrointestinal infection. Symptoms of Reiter's syndrome typically come and go over the course of several weeks to months. The severity of symptoms varies among patients. Women typically experience milder symptoms than men.
• Arthritis: Patients typically develop arthritis, which causes pain and inflammation of the joints. Pain typically worsens when the patient moves the joints. Swelling typically develops where a tendon attaches to a bone, a condition called enthesopathy. The knees, ankles, and feet are most commonly affected. The wrists, fingers, and other joints are less commonly affected. Symptoms typically develop on both sides of the body. In addition, some patients may develop bony growths in the heels of the feet (called heel spurs) that cause long-lasting foot pain.
• In some cases, arthritis may develop in the back and cause inflammation of the bones in the spine (a condition called spondylitis) or inflammation of the joints in the lower back that connect the spine to the pelvis (called sacroiliitis). Patients who have HLA-B27 are the most likely to experience arthritis of the back.
• Arthritis may last anywhere from two to six months. For most patients, the symptoms are usually mild and do not interfere with daily activities. Most patients do not experience permanent joint damage.
• Eye irritation and inflammation: About 50% of patients with urogenital Reiter's syndrome and 75% of patients with gastrointestinal Reiter's syndrome develop a condition called conjunctivitis, which causes inflammation of the transparent membrane that covers the eyeball. Conjunctivitis may cause the eyes to become red, irritated, and painful.
• Although less common, some patients may develop more serious eye conditions called iritis and uveitis. Iritis occurs when the colored portion of the eye becomes inflamed. Uveitis describes inflammation of the inner layers of the eye. Iritis and uveitis may cause eye pain, redness, and blurred vision. If left untreated, patients may experience permanent vision loss or blindness. Iritis and uveitis are most likely to occur in individuals with the HLA-B27 tissue type.
• Urinary tract: Reiter's syndrome typically affects the urinary tract. Symptoms may develop in the prostate, urethra, and penis in men and the fallopian tubes, uterus, cervix, vagina, and urethra in women. Common symptoms in males include a burning sensation during urination, increased urge to urinate, and penile discharge. Some men may develop an inflamed prostate, a condition called prostatitis. Symptoms of prostatitis may include chills, fever, burning sensation during urination, difficulty urinating, and increased urge to urinate.
• Common symptoms in women include inflammation of the cervix and inflammation of the urethra, which may lead to a burning sensation during urination. Some women may experience inflamed fallopian tubes (called salpingitis) or inflammation of the vulva and vagina (called vulvovaginitis). Salpingitis and vulvovaginitis may not cause any symptoms.
• Other: Some male patients may also develop painless sores, called balanitis circinata, on the tip of their penises. Less commonly, patients may develop small hard bumps, called nodules, on the bottoms of their feet. In some cases, nodules may develop on the palms of the hands or other areas of the body. A few patients may also develop mouth sores that come and go. These mouth sores may or may not be painful.

• General: There are no specific tests available to diagnose Reiter's syndrome. Instead, the healthcare provider will take a detailed medical history and perform a physical examination.
• Culture swab: A culture swab may be used to determine if chlamydia is causing symptoms of Reiter's syndrome. For females, the healthcare provider may swab the discharge from the cervix. For males, the healthcare provider inserts a thin swab into the tip of the penis to retrieve a sample of fluid from the urethra. In some cases, the healthcare provider may swab the anus. The sample is then rubbed on a petri dish. If the patient has chlamydia, Chlamydia trachomatis will grow on the petri dish.
• Blood tests: Blood tests may be performed to diagnose a bacterial infection that may have caused Reiter's syndrome.
• A blood test may also be performed to determine if the patient has the HLA-B27 tissue type. Having this tissue type does not necessarily mean that the patient has Reiter's syndrome. This is because the HLA-B27 molecule has also been linked to other conditions, including rheumatic diseases and acute anterior uveitis. However, testing positive for the molecule means that the patient has an increased risk of developing the condition.
• Eye exam: An eye exam may also be performed to determine if the patient has conjunctivitis, uveitis, or iritis. An eye doctor may use a microscope, called a slit lamp, to determine if parts of the eye are inflamed or irritated. However, if the patient does not have eye problems it does not rule out the possibility of Reiter's syndrome. This is because only 50% of patients with Reiter's syndrome have conjunctivitis, and even fewer develop uveitis or iritis.

• Heart problems: An estimated 10% of patients with Reiter's syndrome develop heart problems, which may include leakage of blood from the aorta into the heart chamber (called aortic regurgitation) and inflammation of the membrane that surrounds the heart (called pericarditis). These conditions can be serious. For instance, severe aortic regurgitation may lead to a life-threatening infection of the heart lining or congestive heart failure. Heart problems are most common among patients who have chronic Reiter's syndrome. Individuals who already have heart disease may have an increased risk of developing heart problems associated with Reiter's syndrome.
• Permanent vision loss: If patients with iritis and/or uveitis do not receive immediate medical treatment, they may suffer from permanent vision loss. Therefore, it is important for patients to visit their doctors as soon as symptoms develop.
• Infertility: Patients may experience temporary infertility if the genitourinary organs, such as the prostate or fallopian tubes, become inflamed. However, fertility problems generally resolve once inflammation subsides.
• Transmitting infections: If the infection that causes Reiter's syndrome is not treated, it may be spread to others, including sexual partners and babies during vaginal childbirth. However, Reiter's syndrome itself is not contagious or sexually transmitted.

• General: There is currently no cure for Reiter's syndrome. Treatment is available to help reduce symptoms, and it is necessary to prevent serious complications such as blindness. For many patients, symptoms of Reiter's syndrome start to go away after four to five months. However, in about 15-50% of patients, symptoms may spontaneously go away and come back for several years and require long-term treatment.
• Antibiotics: Medications, called antibiotics, are typically taken to treat the bacterial infection that caused Reiter's syndrome. The specific antibiotic and length of treatment varies depending on the type and severity of the infection.
• Patients should take their medications exactly as prescribed. Even if symptoms go away, patients should not stop taking medications early because the bacteria may still be present in the body. If the medication is stopped too early, the remaining bacteria in the body may mutate and become resistant to treatment. Once the bacteria are resistant to a medication, the antibiotic is no longer effective.
• Bed rest: Patients may benefit from short periods of bed rest. Lying down periodically reduces the pressure put on the joints, and it may help relieve pain and inflammation caused by arthritis.
• Exercise: Regular moderate exercise may help patients maintain and/or improve joint function. Strength training with weights is important because having strong muscles around the joint helps make the joint more stable. Exercises and stretches that increase the joint's range of motion are also important because they help increase flexibility and reduce stiffness in the joints. Regular exercise also help individual maintain healthy body weight, which puts less pressure on the joints. Not all types of exercise are safe for everyone. Therefore, individuals should talk to their healthcare providers before starting a new exercise program.
• Apply warm and cool packs: Applying warm packs to affected joints may help relax the muscles, reduce pain, and increase blood flow to the joint. It may also be an effective treatment before exercise. Alternatively, patients may take a hot shower or bath before exercise to help reduce pain.
• Applying cool packs to affected joints may help reduce swelling and pain caused by arthritis. A cool compress that is applied to the eyes may help alleviate mild symptoms of conjunctivitis. Cool packs should not be applied for longer than 10 minutes at a time. Individuals may also experience temporary pain relief by alternating between warm and cool packs.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to relieve pain and inflammation throughout the body. Commonly used over-the-counter NSAIDs include ibuprofen (Advil® or Motrin®) and naproxen sodium (Aleve®). Higher doses of these drugs are also available by prescription from a doctor. Commonly prescribed NSAIDs include diclofenac (Cataflam® or Voltaren®), nabumetone (Relafen®), and ketoprofen (Orudis®). NSAIDs may be taken by mouth, injected into a vein, or applied to the skin.
• The frequency and severity of side effects may vary. The most common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the digestive system. Patients can reduce the risk of experiencing gastrointestinal side effects by taking medications with food and a full glass of water.
• Disease modifying anti-rheumatic drugs (DMARDs): Disease-modifying anti-rheumatic drugs (DMARDs) may be prescribed for patients who experience joint inflammation for longer than six weeks or when many joints are affected. These drugs are taken to limit the amount of permanent joint damage. Because these drugs may take weeks to months before they begin to take effect, they are often used in combination with NSAIDs. Commonly prescribed DMARDs include the gold compound auranofin (Ridaura®), hydroxychloroquine (Plaquenil®), minocycline (Dynacin® or Minocin®), sulfasalazine (Azulfidine®), and methotrexate (Rheumatrex®).
• Side effects may include mouth sores, diarrhea, and nausea. Serious side effects may include liver damage, decreased white blood cell count (which leads to an increased risk of infection), and decreased platelet count (which causes an increased risk of bleeding).
• Corticosteroid injections: Patients who have severe joint inflammation may receive corticosteroid injections into the affected joints. Injections are typically used if other treatments, including NSAIDs, are unable to effectively relieve pain and inflammation.
• These drugs are generally very effective when used short-term. However, if these drugs are used for many months to years, they may become less effective and serious side effects may develop. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face, and diabetes.
• Topical corticosteroids: Topical corticosteroids, such as hydrocortisone, may be applied to the skin to help skin sores heal and reduce inflammation.
• Common side effects include thinning of the skin, telangiectasia, temporary loss of skin pigment, as well as burning, dryness, or itching of skin.
• Immunosuppressants: A few patients may have symptoms that do not respond to any of the treatments mentioned above. These patients may benefit from medications called immunosuppressants. These drugs weaken the body's immune system, which may help reduce inflammation and pain throughout the body. Commonly prescribed immunosuppressants include leflunomide (Arava®), azathioprine (Imuran®), cyclosporine (Neoral® or Sandimmune®), and cyclophosphamide (Cytoxan®).
• Immunosuppressants may have serious side effects, including increased risk of infections, kidney problems, high blood pressure, and decreased levels of red blood cells. Other side effects may include increased hair growth, loss of appetite, vomiting, and upset stomach.
• Steroidal eye drops: Steroidal eye drops, such as prednisolone (AK-Pred®, Pred Forte®), may help to reduce inflammation of the eyes. These eye drops are only available by prescription and should be taken under the strict supervision of a qualified healthcare provider. These drops may increase the risk of cataracts (clouding of the eye lens), which can cause long-term damage and impaired vision. Common side effects include temporary stinging, burning of the eyes, or blurred vision.

Note
: Currently, there is a lack of scientific data on the use of integrative therapies for the treatment or prevention of Reiter's syndrome.
The integrative therapies listed below should be used only under the supervision of a qualified healthcare provider, and should not be used in replacement of other proven therapies or preventive measures.

B

Good scientific evidence

• Bromelain
  : Some physicians use bromelain, an enzyme derived from pineapple, to help reduce inflammation. It is sometimes recommended to be taken with turmeric (Curcuma longa), which may enhance the effects of bromelain.
• Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceae
  family. Use cautiously with a history of bleeding disorders, stomach ulcers, or heart, liver, or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.

C

Unclear or conflicting scientific evidence

• Cat's claw
  : Several laboratory and animal studies suggest that cat's claw may reduce inflammation. Large, high-quality human studies are needed before a conclusion can be drawn.
• Avoid if allergic to cat's claw or Uncaria plants or plants in the Rubiaceae family such as gardenia, coffee, or quinine. Avoid with a history of conditions affecting the immune system (such as AIDS, HIV, some types of cancer, multiple sclerosis, tuberculosis, rheumatoid arthritis, lupus). Use cautiously with bleeding disorders or a history of stroke, or if taking drugs that may increase the risk of bleeding. Discontinue use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Cat's claw may be contaminated with other Uncaria species. Reports exist of a potentially toxic, Texan grown plant, Acacia gregii being substituted for cat's claw. Avoid if pregnant, breastfeeding, or trying to become pregnant.
• Dandelion
  : Research in laboratory animals suggests that dandelion root may possess anti-inflammatory properties. There is a lack of well-conducted human studies currently available in this area.
• Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Potassium blood levels should be monitored. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
• Eyebright
  : Several iridoid glycosides isolated from eyebright, particularly aucubin, may possess anti-inflammatory properties comparable to those of indomethacin (a nonsteroidal anti-inflammatory drug). However, there is currently insufficient evidence to recommend for or against eyebright as an anti-inflammatory agent.
• Avoid with a known allergy or hypersensitivity to eyebright. Hypersensitivity to members of the Scrophulariaceae family may lead to a cross-sensitivity reaction. Use cautiously as an eye treatment, particularly homemade preparations, due to the risk of infection if not sterile. Use cautiously with diabetes and drugs that are broken down by the liver. Avoid if pregnant or breastfeeding.
• Licorice
  : Because licorice may affect the metabolism of steroids, licorice is sometimes used to help decrease inflammation. Additional study is needed to make a conclusion.
• Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
• Turmeric
  : Turmeric is a perennial plant native to India and Indonesia, and it is often used as a spice in cooking. Laboratory and animal studies show anti-inflammatory activity of turmeric and its constituent curcumin, however, reliable human research is lacking.
• Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with history of bleeding disorders, immune system deficiencies, liver disease or gallstones. Use cautiously with blood-thinners (e.g. warfarin). Use cautiously if pregnant or breastfeeding.

• General: Patients who have been diagnosed with Reiter's syndrome should be extra cautious of sexually transmitted infections (STIs) and gastrointestinal infections because they may trigger an episode of Reiter's syndrome.
• Safe sex: Individuals may wish to use a barrier method of contraception, such as a condom, if having vaginal, anal, and oral sex with an infected person or with someone who has not been tested for sexually transmitted infections (STIs), such as chlamydia.
• Patients should limit the number of sexual partners they have. Having multiple sexual partners increases a patient's risk of developing STIs.
• Reduce exposure to STIs: Wear gloves when in contact with blood or other body fluids that could possibly contain blood, such as urine, feces, or vomit. Wearing a protective barrier helps reduce the risk of exposure to STIs.
• Good hygiene: Practicing good hygiene and regularly washing the hands with soap and water may help reduce the risk of acquiring gastrointestinal infections, the other main infection that can cause Reiter's syndrome.
• Thoroughly wash all fruits and vegetables before eating. This also helps reduce the risk of acquiring gastrointestinal infections.
• Protect the joints: Patients who have been diagnosed with Reiter's syndrome should take steps to protect their joints in order to reduce joint pain. Rest the joints after doing heavy work or exercising the joints for an extended period of time. Use proper form when lifting heavy objects in order to prevent putting too much strain on certain joints. For instance, when lifting something heavy, individuals should bend their legs so the weight is being lifted primarily with the legs instead of the back. If needed, use assistive devices, such as a cane or walker.