Reactive Arthritis: Symptoms, Diagnosis, and Treatment Options

Q: Reactive Arthritis: Symptoms, Diagnosis, and Treatment Options

Hello, thank you for your inquiry. <br>Here are my responses：<br>1. <br>My first symptom is pain in the Achilles tendon at the calcaneus, which appears normal externally. <br>However, after sitting for a long time, I experience brief pain when I stand up and walk, which subsides

Leigh syndrome

Hello Doctor, I have normal blood test results, but my symptoms have led my physician to suspect reactive arthritis.
I would like to ask you the following questions:
1.
My first symptom was pain in the Achilles tendon at the heel, which appears normal externally.
However, after sitting for a long time, I experience brief pain when I stand up and walk, which goes away after walking for a bit.
About three months later, it became "occasional" pain when standing up.
The same location on the other foot started to hurt after six months, but it only hurts occasionally when standing or walking.
Are these symptoms indicative of enthesitis? Is there any way to differentiate enthesitis from other muscular issues?
2.
Some of my joint pain appears suddenly, but may resolve after a few hours or days, and there is no redness or swelling.
I find this confusing and sometimes struggle to articulate these symptoms.
Doctor, is there actual inflammation occurring in these areas?
3.
I also have chronic conjunctivitis in my eyes.
Initially, my ophthalmologist thought it was an allergy, but after learning that I was seeing a rheumatologist, they performed a Schirmer test, which showed only 3mm in one eye, indicating dry eye syndrome.
If the conjunctivitis is related to reactive arthritis, how long is it likely to last? Can dry eye syndrome be a complication of reactive arthritis?
4.
The immunologist prescribed me Mobic 15 mg for one month, and I have been taking it for 10 days with seemingly no improvement in pain.
Previously, my family doctor prescribed Diclofenac enteric-coated tablets 25 mg, which significantly improved my pain within a few days.
Is Mobic less effective than Diclofenac, and is it more suitable for long-term use? If the pain does not improve, can I switch back to Diclofenac? Thank you for your response.

Jade, 30~39 year old female. Ask Date: 2023/03/22

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your inquiry.
Here are my responses:
1.
My first symptom is pain in the Achilles tendon at the calcaneus, which appears normal externally.
However, after sitting for a long time, I experience brief pain when I stand up and walk, which subsides after walking for a bit.
After about three months, it changed to "occasional" pain when I stand up.
The same area on the other foot also started to hurt after six months, but it only occasionally hurts suddenly when standing or walking.
Are these symptoms indicative of enthesitis? Is there any way to differentiate enthesitis from other muscle issues? --> Typically, the classic locations for enthesitis are at the attachment of the Achilles tendon to the heel or the plantar fascia to the heel.
These areas are easier to assess and differ from muscle inflammation.
Initially, the pain may fluctuate, but over time it can become persistent, sometimes severe and sometimes mild.
However, the diagnosis of enthesitis still requires evaluation by a physician.
2.
Some of my joint pains appear suddenly but may resolve within a few hours or days, without any visible redness or swelling.
I find these symptoms confusing and sometimes struggle to articulate them.
Doctor, are these areas truly inflamed? --> As mentioned, when arthritis first occurs, symptoms may come and go and last for a short time.
With repeated inflammation over time, it may gradually evolve into persistent pain.
3.
I also have chronic conjunctivitis.
Initially, my ophthalmologist thought it was an allergy, but later, after learning that I was seeing a rheumatologist, they performed a Schirmer test, which showed only 3mm in one eye, indicating dry eye syndrome.
How long does conjunctivitis associated with reactive arthritis typically last? Can dry eye syndrome be a complication of reactive arthritis? --> The duration of conjunctivitis can vary, but it usually does not last long and typically improves quickly after seeing an ophthalmologist.
Dry eye syndrome can also be a complication of reactive arthritis.
4.
The immunologist prescribed me Mobic 15 mg for one month.
After taking it for 10 days, there seems to be no improvement in pain.
Previously, my family physician prescribed Diclofenac enteric-coated tablets 25 mg, which significantly improved my pain within a few days.
Is Mobic less potent than Diclofenac, and is it more suitable for long-term use? However, if the pain does not improve, can I switch back to Diclofenac? --> Mobic is indeed milder and more suitable for long-term use; however, if you are not responding well to Mobic, switching medications is an option.
Diclofenac may be effective, but it can be harsher on the stomach, so if you choose to use it long-term, be mindful of gastrointestinal symptoms.
Best regards from the Allergy, Immunology, and Rheumatology Department of Changhua Hospital, Ministry of Health and Welfare.

Reply Date: 2023/03/22

More Info

Understanding reactive arthritis (ReA) is crucial for effective diagnosis and treatment. Reactive arthritis is a form of inflammatory arthritis that occurs as a reaction to an infection in another part of the body, often following a genitourinary or gastrointestinal infection. It can lead to joint pain and swelling, typically affecting the knees, ankles, and feet, and may also involve the Achilles tendon, as you've described.

1. Symptoms and Differentiation: Your initial symptom of pain in the Achilles tendon area, particularly after prolonged sitting, aligns with common presentations of enthesitis, which is inflammation at the site where tendons attach to bones. This can indeed be a symptom of reactive arthritis or other conditions like ankylosing spondylitis or psoriatic arthritis. The intermittent nature of your pain, where it appears suddenly and then resolves, is characteristic of inflammatory joint pain. To differentiate between reactive arthritis and other musculoskeletal issues, a thorough clinical evaluation is essential. This may include imaging studies, such as X-rays or MRIs, to assess for inflammation or damage in the joints and tendons. Additionally, a detailed history of any preceding infections or other symptoms can provide clues.

2. Inflammation and Symptoms: The sudden onset of joint pain without visible swelling or redness can still indicate inflammation. Inflammatory arthritis can present with pain that fluctuates in intensity and may not always show external signs. The absence of swelling does not rule out inflammation; thus, it is important to communicate these symptoms to your healthcare provider, who may consider further diagnostic tests, such as blood tests for inflammatory markers (e.g., ESR, CRP) or imaging studies.

3. Ocular Symptoms: Your chronic conjunctivitis and dry eye symptoms, particularly with a low Schirmer test result, suggest a possible connection to an underlying inflammatory condition. Reactive arthritis can be associated with ocular manifestations, including conjunctivitis. The duration of conjunctivitis related to reactive arthritis can vary, but it typically improves with the management of the underlying arthritis. Dry eye syndrome can indeed be a complication of reactive arthritis, as systemic inflammation can affect tear production.

4. Medication and Treatment: Regarding your medication, Mobic (meloxicam) is a nonsteroidal anti-inflammatory drug (NSAID) that is generally milder than diclofenac (the active ingredient in the delayed-release medication you mentioned). If you have not experienced significant pain relief with Mobic after a reasonable trial period, it is reasonable to discuss with your physician the possibility of switching back to diclofenac or exploring other treatment options. Long-term use of NSAIDs should be monitored for gastrointestinal side effects, especially with medications like diclofenac, which can be harsher on the stomach.

In summary, reactive arthritis can present with a variety of symptoms, including enthesitis and ocular issues. Differentiating it from other forms of arthritis requires careful clinical evaluation and possibly imaging or laboratory tests. If your current treatment is not effective, it is essential to communicate this with your healthcare provider to adjust your management plan accordingly. Regular follow-ups and open communication with your healthcare team will be key in managing your symptoms effectively.

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