The Don Julio Salmonella outbreak, which has claimed more than 59 victims–possibly hundreds–will cause many to develop a condition called reactive arthritis. Here is some additional information for any of the victims who do, in fact, develop this long-term, and in some cases permanent, condition:
Diagnosis of Reactive Arthritis:
Diagnosis of reactive arthritis (including the condition formerly called Reiter’s syndrome) is mainly clinical. There are no validated diagnostic criteria, however some guidance for diagnosis is available (Braun et al., 1999; Hannu et al., 2006; Kingsley & Sieper, 1996; Petersel & Sigal, 2005). In 1995, the Third International Workshop on Reactive Arthritis established criteria for diagnosing reactive arthritis. The main criteria involve the pattern of joint involvement and the timing of the onset of the condition (such as soon after an infection). Diagnosis of Reiter’s syndrome has essentially been replaced with diagnosis of the broader category in which it resides: Reactive Arthritis.
The diagnostic criteria of the Third International Workshop on Reactive Arthritis are:
- The arthritis should predominantly involve the lower limb, involve one or only a few joints and not equally involve both sides of the body (asymmetric).
- There should be evidence or a history of preceding infection. Although it is ideal to have a culture that is positive for an infectious agent that is recognized to be associated with this condition (such as Salmonella or Chlamydia), if the patient has documented diarrhea or urethritis in the prior 4 weeks, laboratory confirmation is not required.
- If there is no clear clinical infection, then laboratory confirmation (perhaps with serology or a culture) is essential.
- The patient should not have evidence that the joint itself is infected (i.e., septic arthritis). Also, other causes of monoarthritis (such as gout) or oligoarthritis (such as rheumatoid arthritis) should be ruled out.
Interestingly, the above criteria do not require laboratory tests (such as HLA-B27). Features that have been considered part of Reiter’s syndrome such as conjunctivitis, iritis, skin lesions, noninfectious urethritis, and certain types of cardiac and neurological abnormalities are not required for a diagnosis of reactive arthritis.
Treatment of Reactive Arthritis:
Testing for and treating any underlying infection is often attempted but in many cases the underlying infection is self limited or can no longer be found. If the inciting infectious can be determined it must be treated aggressively with antibiotics.
Symptomatic treatment with high doses of a nonsteroidal anti-inflammatory drug (NSAID) and steroid injections into affected joints can be helpful (Barth & Segal, 1999). NSAIDs can reduce joint inflammation and are commonly used to treat patients with reactive arthritis. Some traditional NSAIDs, such as aspirin and ibuprofen, are available without a prescription, but others that are more effective for reactive arthritis, such as indomethacin and voltaren, must be prescribed by a doctor. Less is known about whether a new class of NSAIDs, called COX-2 inhibitors, is effective for reactive arthritis, but they may reduce the risk of gastrointestinal complications associated with traditional NSAIDs (National Institutes of Health, 2004). For people with severe joint inflammation, injections of corticosteroids directly into the affected joint may reduce inflammation. Doctors usually give these injections only after trying unsuccessfully to control arthritis with NSAIDs. In some cases, short courses of oral steroids, such as methylprednisolone or prednisone, may also be required.
A small percentage of patients with reactive arthritis have severe symptoms that cannot be controlled with any of the above treatments. For these people, medicine that suppresses the immune system, such as sulfasalazine or methotrexate, may be effective (Clegg, et al., 1996; Creemers et al., 1994; National Institutes of Health, 2004). If the symptoms do not respond to these agents a newer group of medications, called biologics, can often be very effective. Biologic agents can be either injectables (such as etanercept or adalimumab) or given intravascularly (such as infliximab or rituximab). These agents can be very immunosuppressive and are very expensive so are not used as first-line treatments.
Topical corticosteroids, which come in a cream or lotion, can be applied directly on the skin lesions associated with reactive arthritis. Topical corticosteroids reduce inflammation and promote healing (National Institutes of Health, 2004).
Antibiotics to eliminate the bacterial infection that triggered the reactive arthritis may be prescribed. The specific antibiotic prescribed depends on the type of bacterial infection present. It is important to follow instructions about how much medicine to take and for how long; otherwise the infection may persist. Typically, an antibiotic is taken for 7 to 10 days or longer (National Institutes of Health, 2004). Currently, however, there is no evidence to suggest that antibiotic treatment is beneficial once reactive arthritis has occurred (Hill Gaston & Lillicrap, 2003).
Exercise, when introduced gradually, may help improve joint function. In particular, strengthening and range-of-motion exercises will maintain or improve joint function. Strengthening exercises builds up the muscles around the joint to better support it. Muscle-tightening exercises that do not move any joints can be done even when a person has inflammation and pain. Range-of-motion exercises improve movement and flexibility and reduce stiffness in the affected joint. For patients with spine pain or inflammation, exercises to stretch and extend the back can be particularly helpful in preventing long-term disability. Aquatic exercise also may be helpful. Before beginning an exercise program, patients should talk to a health professional who can recommend appropriate exercises (National Institutes of Health, 2004).