Reactive arthritis in children - diagnosis and treatment

Reactive arthritis poses a threat to the younger generation and can even affect infants. It is one of the acute spondyloarthropathies, i.e., it is an acute inflammatory process that spreads to the spine, ligaments, various organs and skin. Reactive arthritis mainly affects peripheral joints: knees, hips, necks, interphalangeal joints of the hands and feet, wrists and others. In rare cases, it can lead to inflammation of the aorta, kidneys, pleurisy, damage to the nervous system, even meningoencephalitis.

What is reactive arthritis (ReA)

The term “reactive arthritis” was first used more than 50 years ago to name arthritis that develops after yersiniosis in the absence of infectious agents in the joints. But after a few years, this name began to be associated with certain infections of the gastrointestinal tract, genitourinary organs and nasopharynx.

Currently, reactive arthritis is considered to be non-purulent inflammation of the joints, developing no later than 6 to 8 weeks after a urogenital, intestinal or nasopharyngeal infection. ICD-10 code M02.

Young men aged 17–40 years are more likely to get sick after suffering from sexually transmitted infections (women get sick much less often). In children, adolescents, as well as people of any age and gender, reactive arthritis can develop after intestinal infections, as well as infections of the nasopharynx.

The prevalence of ReA in our country among adults is about 43 per 100,000 population, among children - 99, among adolescents - 172. The incidence is growing, which is largely due to genetic predisposition, asymptomatic infections and untimely administration of adequate treatment.

There is also Reiter's syndrome, which develops after a urogenital infection and manifests itself in the form of three main symptoms: arthritis, conjunctivitis and urethritis.

Causes of the disease

The main causes of reactive arthritis are past infection and genetic predisposition. Infections that can cause ReA include:

• urogenital form of ReA
  – chlymydia, ureaplasmosis, mycoplasmosis;
• intestinal form of ReA
  – shigenellosis (dysentery), salmonellosis, yersiniosis, intestinal infection caused by Escherichia coli;
• nasopharyngeal form
  – previous nasopharyngeal infections caused by staphylococcal, streptococcal and other infections.

A previous infection is a trigger (triggering factor) that starts a chain of immuno-allergic and inflammatory reactions. This occurs predominantly in genetically predisposed individuals who have the HLA-B27 antigen in their body, which causes an imbalance in the immune system, which leads to increased formation of prostaglandins and cytokines - biologically active substances that cause inflammation.

A long-term inflammatory process is also supported by incompletely removed infectious pathogens and the appearance of antibodies to them. Reactive arthritis caused by urogenital infection (chlamydia, mycoplasma, ureaplasma), which penetrates cells and remains viable for a long time, takes a particularly long time. Failures in the immune system cause allergic and autoimmune (allergy to the body's own tissues) processes, which also support long-term inflammation.

Causes of infectious arthritis

The most likely cause of infectious arthritis is the metastatic route of joint damage, which involves direct penetration of infection into the joint tissue through the blood or lymph.

Another route of infection can be injury or an open wound, as well as the spread of pathogens from nearby foci of another disease, for example, osteomyelitis.

Arthritis caused by infectious pathogens in childhood is usually provoked by staphylococcus, enterobacteria or Haemophilus influenzae. However, at the same time, other arthritis, quite specific for this age category, may occur, caused by tuberculosis, gonorrhea or syphilis.

Symptoms of reactive arthritis

Regardless of the cause of the disease, reactive arthritis develops in the same way. By the time the first symptoms of reactive arthritis appear, all manifestations of the trigger infection end or go unnoticed.

Pain, swelling and redness over the affected joint are some of the first symptoms of reactive arthritis.

The first signs of ReA

The disease begins 3 to 30 days (sometimes more) after the infection, acutely with an increase in body temperature, headache, malaise, and the appearance of an inflammatory process in the joints. More often one or more asymmetrically located joints of the lower extremities are affected. Most often these are the knee, ankle and toe joints.

The skin and subcutaneous tissue over the affected joint are red, swollen, and painful. Sometimes pain immediately appears in the lower back - a sign of damage to the sacroiliac joints and joints of the spine. When the first signs of joint inflammation appear, you should consult a doctor. The Paramita clinic will definitely help you.

Obvious symptoms

Reactive arthritis can occur in the form of:

• acute inflammatory process
  – up to 3 months;
• subacute
  – for 3 – 6 months;
• protracted
  – 6 – 12 months;
• chronic
  – more than 12 months;
• recurrent
  – ​​with relapses and remissions.

In addition to the symptoms of reactive arthritis with pain and dysfunction of the affected joints, damage to periarticular tissues - ligaments, tendons, periarticular capsules (enthesitis) is also characteristic. Particularly characteristic is damage to the heel (subcalcaneal bursitis), accompanied by severe pain and inflammation of the periarticular tissues, as well as the 1st toe with redness and swelling of the tissues - “sausage toe”. Such symptoms can completely disrupt the function of the lower extremities - it becomes impossible to move due to pain.

ReA of urogenital origin is often combined with long-term urethritis in men or cervicitis in women, as well as eye damage (Reiter's syndrome). Eye damage can occur in the form of mild conjunctivitis, but in some cases the deeper membranes of the eye are also affected.

Sometimes with reactive arthritis, psoriasis-like rashes appear on the skin, palms and soles, as well as psoriatic-like lesions on the nails. Painless erosions appear on the oral mucosa. There may also be enlargement of the lymph nodes in the groin area.

Dangerous symptoms

The most dangerous is reactive arthritis associated with urogenital infection. This form of the disease is prone to a long-term relapsing course followed by the formation of a rheumatoid-like course. Therefore, it is very important to promptly and adequately treat arthritis.

Recommendations for infectious arthritis

To maintain the effectiveness of therapy, as well as achieve the most favorable results, it is important to follow a number of recommendations for infectious arthritis, including:

1. Movement is an integral part of therapy.
2. Maximum limitation of sudden movements and forces that create additional stress on the affected joints.
3. Improving power sensations.
4. Simplifying everyday processes through the use of modern technological solutions.
5. Increasing personal safety by installing additional handrails in the apartment, using anti-slip mats, etc.

How dangerous is the disease?

The danger of reactive arthritis is that it can develop into a long-term chronic recurrent disease that is difficult to treat.

Stages of ReA

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The inflammatory process in the joints occurs in several stages:

• initial
  - with an acute onset, general symptoms appear: fever, headache, malaise, as well as inflammation, swelling and tenderness of the joints; At first, the ankle joints and joints of the 1st toe are most often affected;
• expanded
  - asymmetrical damage to the joints of the legs (from bottom to top), starting from the ankle joints to the knees; pain appears in the lower back associated with damage to the joints of the spine, skin rashes, erosions on the mucous membranes, enlarged lymph nodes; with Reiter's syndrome - conjunctivitis and urethritis;
• final
  - with intestinal and nasopharyngeal forms of reactive arthritis, the inflammatory process ends after 3 months with recovery; in a subacute course, the process can last up to 6 months and also end in recovery; The urogenital form of ReA often occurs chronically.

Possible complications

Chronic reactive arthritis can cause lameness

Reactive arthritis should be treated as early as possible.

Prolonged inflammation can lead to chronic pain, especially in the heel, foot and toes, leading to lameness.

With a long chronic course of Reiter's syndrome, damage to the optic nerve and blindness is possible, as well as damage to the reproductive system and infertility.

What to do during an exacerbation

If the inflammatory process has taken a chronic, relapsing course, then it is necessary to carry out long-term treatment under the supervision of a physician. When the first signs of relapse of reactive arthritis appear, you should:

• limit physical activity;
• take a medicine from the group of NSAIDs (non-steroidal anti-inflammatory drugs) - Diclofenac, Ibuprofen, Meloxicam; a tablet of any product can be taken orally, and a cream, gel or ointment with the same composition can be applied externally to the area of ​​the affected joint;
• Urgently contact your doctor to prescribe adequate treatment.

Possible localization of inflammation

In intestinal and urogenital forms of reactive arthritis, the joints of the lower extremities are most often affected. In the nasopharyngeal form - the joints of the upper extremities and the temporomandibular joint.

Arthritis of the lower extremities

Affection of the lower extremities predominantly begins with the big toes and moves upward (staircase sign), affecting the overlying joints asymmetrically. In reactive arthritis, one to five joints become inflamed:

• interphalangeal toes; Most often the first toe is affected, it swells and turns red - the “sausage toe” symptom;
• ankles with damage to surrounding tissues; Particularly characteristic is damage to the tendons and ligaments in the heel area with the formation of loose heel spurs, which causes constant pain that intensifies when walking and stepping on the heel;
• knee – this location is characterized by the formation of a large amount of exudate (inflammatory fluid in the joint), which leads to the formation of popliteal cysts; rupture of cysts leads to the development of thrombophlebitis and impaired venous circulation;
• hip – rarely affected, occurs in the form of moderate joint pain.

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Arthritis of the upper extremities

Localization of reactive arthritis in the joints of the upper extremities is much less common. This mainly occurs in diseases of the nasopharynx and dental infectious and inflammatory processes.

The most common joints affected by ReA are:

• elbow - the elbow swells, turns red, becomes painful, the arm has difficulty bending and unbending;
• wrist with damage to the ligaments and tendons of the hand - pain in the joint is transmitted to the hand; severe pain does not allow you to squeeze and unclench your hand or hold objects in it;
• shoulder – rarely affected, characterized by swelling and pain.

Temporomandibular arthritis

Reactive arthritis affects the joints of the lower and upper extremities, temporomandibular joints

Triggers include infections of the nasopharynx, ear and mouth. Characterized by slight swelling, redness and swelling in the area of ​​development of reactive arthritis. When opening the mouth, there is a slight asymmetry; the chewing process may be disrupted and become painful. The disease occurs acutely or subacutely, is well treated, and the prognosis is favorable.

Diagnostics

Diagnosis of reactive arthritis includes identifying characteristic manifestations of the disease and confirming the diagnosis with the following studies:

• Laboratory diagnostics:
  general clinical blood and urine tests - these studies reveal the presence of an inflammatory process, anemia;
• biochemical blood tests - total protein and protein fractions, the presence of C-reactive protein (a sign of an inflammatory reaction);
• immunological studies - rheumatoid factor, antibodies to cyclic citrullinated peptides to exclude rheumatoid arthritis; markers of systemic lupus erythematosus;
• detection of the HLA-B27 antigen by testing blood using the PCR (polymerase chain reaction) method, which allows identifying the smallest DNA particles of this protein;
• identification of urogenital, intestinal infections and foci of nasopharyngeal infections using microscopic, microbiological (culture on nutrient media), immunological studies;
• To exclude purulent arthritis, synovial fluid is sometimes examined.
• X-ray of the joints, during which the degree of their damage is revealed.
• Ultrasound - allows you to identify changes in the periarticular tissues.
• Arthroscopy is the examination of the inner articular surface using optical equipment. Rarely used in ReA.

Forecasts and prevention of infectious arthritis

Considering the prognosis of the disease, it is worth noting that only one third of patients with arthritis of infectious origin at the end of treatment are faced with unpleasant residual effects, which are expressed by joint immobility.

The most dangerous types of the disease are septic arthritis, because despite fairly favorable prospects, the fatal outcome is 5-15%

.

The risk group for developing infectious arthritis includes people of different ages who have ailments such as:

• rheumatoid arthritis;
• osteoarthritis;
• bad habits;
• weakened immune system;
• obesity of varying degrees.

For the purpose of prevention, it is recommended to follow the basics of dietary nutrition, attend prescribed therapeutic events, promptly treat existing diseases and, of course, monitor the general health of the body.

Treatment of reactive arthritis

Only a doctor can cure reactive arthritis after an examination and taking into account its results. Basic principles of treatment of reactive arthritis:

• elimination of inflammation and joint pain;
• suppression of infectious-allergic and autoimmune processes;
• eliminating the trigger infection.

The following types of treatment for reactive arthritis are carried out:

• medicinal;
• non-medicinal;
• using folk remedies.

Drug therapy

Crunching in joints - when to worry

Intra-articular injections of hyaluronic acid

Treatment for reactive arthritis begins with eliminating inflammation, swelling and pain. For this purpose, patients are prescribed NSAID drugs. The most effective medications include Diclofenac, Aceclofenac, Ibuprofen and others in the form of injections, tablets or externally (gels, ointments).

In case of severe swelling and inflammation that cannot be eliminated by NSAIDs, glucocorticoid hormones are prescribed. They are prescribed in courses in the form of tablets orally (Prednisolone), in the form of pulse therapy - short intensive courses intravenously (Methylprednisolone), and also by injection into the joint or periarticular tissue (Hydrocortisone, Diprospan).

If there is a risk of transition to a chronic course, basic therapy is prescribed - drugs that suppress immune reactions: Sulfasalazine, Methotrexate, Azathioprine, etc. Biological agents are also prescribed - biologically active substances (antibodies, cytokines, etc.) that take part in immune reactions ( Mabthera).

For trigger urogenital infections, a long course of antibacterial therapy must be prescribed: antibiotics from the group of macrolides (Clarithromycin), tetracyclines (Doxycycline) or fluoroquinolones (Ciprofloxacin) for a month or more.

For intestinal infections, antibacterial therapy is considered inappropriate. For nasopharyngeal and dental infections, the decision to prescribe antibiotics is made by the doctor individually.

Medicines for the treatment of reactive arthritis

Non-drug treatment

Non-drug treatments include:

1. Diet. There is no special diet, but given the allergic component of the disease, foods that cause allergies (eggs, nuts, citrus fruits, red and orange vegetables and fruits, etc.), spicy seasonings, fried, canned, smoked foods, sweets and baked goods are excluded from the diet.
2. Physiotherapeutic procedures. In the acute period, to eliminate swelling and pain, electrophoresis with Hydrocortisone is prescribed, and then laser and magnetic therapy. At the recovery stage, sanatorium-resort treatment with balneo and mud therapy is recommended.
3. Reflexology courses.
4. PRP therapy is the stimulation of the body’s regenerative abilities by introducing the patient’s own plasma enriched with platelets.
5. Therapeutic exercises and massage are carried out after eliminating the acute inflammatory process.

Folk remedies

Treatment of reactive arthritis with folk remedies is often included in complex treatment to enhance the effectiveness of drugs and reduce the drug load on the patient’s body. Folk remedies are selected for each patient individually, depending on the nature of the disease.

Self-treatment of reactive arthritis with folk remedies is ineffective.

Stages of development of infectious arthritis

In order to understand how to treat infectious arthritis and what measures will be most effective, it is important to understand at what stage the disease is.

In total, it is customary to distinguish 4 main stages of arthritis:

• Stage 1
  – accompanied by the development of osteoporosis (chronically progressive decrease in bone density of the joint), without destructive changes;
• Stage 2
  – the initial stage of destruction of cartilage tissue, reduction of the joint space, the occurrence of single usurs (destructions on the surface) of the bone;
• Stage 3
  – significant damage to articular tissues, pronounced reduction in the joint space, the presence of subluxations and deviations (deviations from the norm) of the bones;
• Stage 4
  – symptoms of stage 3 + complete immobility of the joint.

Approach to treating the disease in our clinic

When a patient is admitted to the clinic with symptoms of reactive arthritis, a mandatory comprehensive examination is carried out before prescribing complex treatment. At the same time, the patient undergoes emergency procedures to eliminate inflammation and pain. This includes drug treatment, acupuncture, physiotherapy, etc. After the examination, a comprehensive treatment is prescribed, which includes:

• modern Western methods of treatment using the latest drugs, treatment regimens and non-drug methods aimed at eliminating the symptoms of reactive arthritis;
• traditional oriental treatment methods aimed at restoring the health of the entire body, including joint function.

This approach allows you to quickly and effectively completely cure reactive arthritis.

Surgical method of treatment

In a situation where complex therapy is unable to cope with the existing degree of damage to the joint, radical methods come to the rescue, including surgery.

Surgical treatment of arthritis is used only in severe cases. Among the types of surgical intervention there are such measures as:

• arthroscopy
  is a low-traumatic operation that involves the removal of bone processes;
• endoprosthetics
  – replacement of articular elements with implants;
• arthrodesis
  – absolute fixation of the joint;
• osteotomy
  - excision of part of the bone tissue of the affected joint in order to reduce pressure on it;
• arthroplasty
  is a complete replacement of the affected joint.

General clinical recommendations

In the acute and subacute course of ReA, after a course of treatment, the patient should be under the supervision of a rheumatologist for six months with clinical and laboratory monitoring every 3 months.

In the chronic course of the disease, dispensary observation is longer with the prescription of courses of anti-relapse therapy until a state of stable remission appears.

After an illness, it is recommended to avoid heavy physical activity and strength sports. Swimming is a good way to restore joint function.

Persons with a genetic predisposition (presence of the HLA-B27 antigen) to reactive arthritis are recommended to have one proven sexual partner.

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FAQ

Is reactive arthritis contagious?

No. But the urogenital infection that caused it can persist for a long time and be contagious.

Are there any peculiarities of the course, diagnosis, treatment in children?

In children, ReA is more acute and rarely becomes chronic.

What prognosis do doctors usually give?

The prognosis for reactive arthritis is favorable; in most cases, complete recovery occurs. But if left untreated, it becomes chronic with a long course and constant pain in the joints.

Reactive arthritis is a complex, incompletely studied infectious-allergic disease that mainly affects genetically predisposed people and requires timely and adequate treatment. It's not worth running.

But if you were unable to seek medical help in time, do not despair, modern technologies make it possible to provide assistance and relieve pain at any stage of the disease. The Paramita clinic (Moscow) will always help you.

Literature:

1. Agababova ER, Bunchuk NV, Shubin SV, etc. Criteria for the diagnosis of reactive arthritis (draft). Scientific and Practical Rheumatology 2003;(3):82–3.
2. Kovalev YN, Ilyin NI. Reiter's disease. Chelyabinsk: Option-book; 1993. 240 p.
3. Zeidler H, Hudson AP. New insights into Chlamydia and arthritis. Promise of a cure? Ann Rheum Dis. 2014;73:637–44. doi:1136/annrheumdis-2013-204110.
4. Ford D.K. Natural history of arthritis following venereal urethritis. Ann Rheum Dis. 1953;12(3):177–97. doi: 10.1136/ard.12.3.177.

Themes

Arthritis, Joints, Pain, Treatment without surgery Date of publication: 10/13/2020 Date of update: 12/14/2020

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