Continuing Medical Education: Spondyloarthropathies.
Edited By: Gregory C. Gardner, M.D.
Last updated Friday, January 07, 2005
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Reiter's syndromeHistory This disorder takes its name from Professor Hans Reiter who is given
credit for first describing the features of the disease that bears his
name in a young officer in the Prussian army. Classically, the disease
has been defined by the triad of arthritis, conjunctivitis, and
urethritis. More recently the disease has been defined more broadly.Definition The present criteria for defining Reiter's syndrome are listed below.
Table III. Definition of Reiter's Disease*
| Seronegative asymmetric arthritis |
|---|
| PLUS one or more of the following: |
- Urethritis/cervicitis
- Dysentery
- Inflammatory eye disease
- Mucocutaneous disease
|
|---|
| Exclusions include: |
- Ankylosing spondylitis
- Psoriatic arthritis
- Other rheumatic diseases
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|---|
| * Adopted from Calin A: Textbook of Rheumatology, 3rd Edition, W. B. Saunders Co. |
Reiter's syndrome affects men more often than women with the ratio
of about 5:1. It can occur at any age but is principally seen among the
20 to 30 year old age group.
Reiter's syndrome has also been termed a reactive arthritis because
it appears to be closely linked to various infectious agents. The
notion has been that there is a molecular mimicry between antigens on
the organism and the enthesis of the HLA B27 positive host leading to
inflammation directed against the host as well as the organism. More
recently, some investigators have felt that they have been able to
identify chlamydia like organism in patients with Reiter'
disease/reactive arthritis suggesting persistent synovial presence of
organisms thought responsible for this disorder. Below is listed the
agents presently recognized to be associated with Reiter's syndrome.
The manifestations of Reiter's disease typically begin two to six weeks
after such an infection.
Recently it has been recognized that Reiter's syndrome/psoriatic
arthritis occur with an increased frequency in patients with HIV
infection. This may be due to the various enteric infections that occur
or to CD8 T cell activity.
Table IV. Organisms Associated with Reiter's Syndrome
| Postdysentery | Postvenereal |
|---|
| Shigella | Chlamydia |
| Salmonella | Mycoplasma |
| Yersenia |
| Campylobacter |
Clinical features - Peripheral Arthritis
The pattern seen with Reiter's syndrome is characteristically an
asymmetric pauciarticular or polyarticular arthritis predominantly
affecting the lower extremities. These patients may have very large
effusions. "Sausage digits" may be seen at the fingers or toes similar
to those in the other spondyloarthropathies. - Axial Arthritis
Patients may complain of low back pain during the course of an
attack but development of spondylitis usually occurs in patients with
long standing persistent disease. - Enthesitis
Similar in location to other spondyloarthropathies. Patients may
have significant swelling of the Achilles tendons and the involvement
at this location has been termed in the past "lovers heel" due to the
association with venereal disease. - Eye Disease
Conjunctivitis is the most common manifestation at the eye and may
go unnoticed by the patient. Uveitis may occur and can be more serious
than that seen in AS. Iridocyclitis and even optic neuritis have been
described in Reiter's syndrome. - Urogenital Disease
The urethritis seen in Reiter's can occur from postvenereal
infection but also after infection from the enteric organisms. This has
raised the question of the mechanism of urethritis in Reiter's
syndrome. Prostatitis may occur in some degree in up to 80% of patients. - Mucocutaneous Disease
There are several characteristic lesions that occur in Reiter's
disease. Keratodermia blennorrhagicum occurs typically on the soles but
may be seen on the palms, scalp, trunk, or scrotum. They begin as
vesicles the form hyperkeratotic plaques that coalesce. Microscopically
they are identical to psoriasis. Keratodermia is found in less than a
third of patients. Ulcers and erosions can occur in the mouth and are
typically not painful. Circinate balanitis is a superficial erosion on
the glans penis and is seen in 20-50% of patients. Finally, nail
changes can occur with accumulation of hyperkeratotic material beneath
the nail. - Miscellaneous
Cardiac involvement can occur in up to 10% of patients with either
conduction problems or aortic insufficiency. Rarely, peripheral or
cranial neuropathies can occur.
Radiographic features The basic features have been alluded to with discussion of the other
spondyloarthropathies. The spine involvement is similar to that seen in
psoriatic spondylitis with more asymmetric involvement of the
sacroiliac joints and non-marginal syndesmophytes. Reactive periostitis
also occurs particularly around the calcaneous. Plantar spurs are very
characteristic of Reiter's syndrome.Treatment Medications used to treat Reiter's syndrome include NSAIDs,
intra-articular steroids, occasionally oral steroids, sulfasalazine,
methotrexate, and azathioprine. Methotrexate is presently felt to be
contraindicated in patients with Reiter's syndrome and HIV infection
due to data that suggests that methotrexate may hasten the progression
of the HIV disease. All patients with Reiter's syndrome should be
considered for HIV testing.
Antibiotics may have a role in preventing the development of a
chronic disease state but this is presently not fully elucidated. One
should consider a prolonged course (2-4 weeks ?) of tetracycline or
another antichlamydia agent in patients with postvenereal Reiter's
syndrome. Prognosis Unfortunately, Reiter's syndrome tends to be a recurrent disease. A
minority of patients may have a single episode and another small group
may develop severe persistent disease. Most episodes last less than six
months. Patients with HIV infection and Reiter's syndrome/psoriatic
arthritis often have more severe persistent form of disease.Surgery for arthritis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 to make an appointment. Our clinical center is located in Seattle Washington, USA
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