Reiter's Syndrome

Aka: Reiter's Syndrome, Reiter's Disease, Reactive Arthritis, Circinate Balanitis, Urethro-oculo-articular Syndrome

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II. Definition

  1. Spondyloarthropathy
  2. Aseptic inflammatory Polyarthritis

III. Epidemiology

  1. Most common inflammatory Polyarthritis in young men
    1. Incidence: as high as 33 in 100,000 males
  2. More commonly affects men by ratio of 9:1 to 5:1
  3. Age of onset as early as 13 years

IV. Pathophysiology

  1. Associated with HLA-B27 Genotype in >66% of patients
  2. Reactive Arthritis may be initial presentation of HIV
  3. First described by Hans Reiter in 1916
    1. Reference case was Prussian Soldier with Diarrhea

V. Causes: Infectious Agents in Reiter's Syndrome

  1. Diarrheal Illness
    1. Shigella flexneri
    2. Shigella dysenteriae
    3. Clostridium difficile
    4. Salmonella typhimurium
    5. Salmonella enteritidis
    6. Yersinia enterocolitica
    7. Campylobacter jejuni
  2. Nonspecific Urethritis
    1. Chlamydia trachomatis
    2. Ureaplasma Urealyticum
  3. Immunodeficiency
    1. Human Immunodeficiency Virus (HIV)

VI. Differential Diagnosis

  1. Poststreptococcal Reactive Arthritis
  2. Viral Arthritis
  3. Ankylosing Spondylitis
  4. Colitic Arthritis (associated with Ulcerative Colitis)
  5. Gonococcal Arthritis (NeisseriaGonorrhea)
  6. Systemic Lupus Erythematosus
  7. Lyme Disease
  8. Psoriatic Arthritis (Associated with Psoriasis)
  9. Rheumatic Fever
  10. Rheumatoid Arthritis
  11. Juvenile Rheumatoid Arthritis (Still's Disease)
  12. Gouty Arthritis

VII. Signs

  1. Arthritis onset 1-4 weeks after GI or GU infection
  2. Classic Clinical Triad (infrequently present)
    1. Arthritis
    2. Conjunctivitis
    3. Non-Gonococcal Urethritis
  3. Asymmetric Oligoarticular Arthritis (2-4 joints)
    1. Affects lower extremities most commonly
    2. Large Knee Effusion
    3. Dactylitis (Sausage-shaped fingers and toes)
      1. Also seen in Psoriatic Arthritis
    4. Enthesitis (ligament, tendon insertion inflammation)
      1. Achilles Tendonitis
      2. Plantar Fasciitis
      3. Patellofemoral Syndrome
    5. Low Back Pain from inflammatory Sacroiliitis
    6. Other musculoskeletal involvement
      1. Anterolateral ribs
      2. Pubic Symphysis
      3. Iliac crest
  4. Constitutional symptoms
    1. Weight loss
    2. Fever up to 102 F
  5. Gastrointestinal (precedes Arthritis by 1-4 weeks)
    1. Acute Diarrhea
  6. Genitourinary (precedes Arthritis by 1-4 weeks)
    1. Urethritis
    2. Cervicitis
    3. Cystitis
    4. Hematuria
    5. Hydronephrosis
    6. Circinate Balanitis (10-20% of cases)
      1. Shallow, painless gray-border ulcer of glans penis
      2. More common in uncircumcised men
  7. Skin changes
    1. Keratoderma blenorrhagica
      1. Hyperkeratotic, waxy Papules and Plaques on the palms and the plantar foot surface
      2. Similar to lesions in Pustular Psoriasis
    2. Painless, shallow Oral Ulcers
      1. Tongue ulceration
      2. Lip Ulceration
      3. Pharyngeal ulceration
      4. Palate and Buccal mucosa ulcerations (similar to the glans ulcers, Circinate Balanitis)
  8. Eye changes
    1. Conjunctivitis
    2. Acute Anterior Uveitis (in up to 37% of cases)
  9. Cardiovascular changes (rare)
    1. Aortitis
    2. Aortic Insufficiency
    3. Conduction abnormality with potential Heart Block

VIII. Labs

  1. Complete Blood Count
    1. Anemia
  2. Erythrocyte Sedimentation Rate (ESR) increased
  3. C-Reactive Protein (CRP) increased
  4. Joint Fluid exam
    1. Synovial Fluid WBC: 15,000 to 30,000 per mm3
    2. Neutrophils predominate on differential (>66%)
    3. Normal Joint FluidGlucose
    4. No Synovial Fluid Crystals on Polarized Microscopy
  5. HIV Test

IX. Precautions

  1. Rule-out Septic Arthritis as cause!
    1. Obtain Synovial Fluid as above
    2. Consider Antistreptolysin-O Antibody Test

X. Management: Similar to Ankylosing Spondylitis

  1. First Line Medications
    1. NSAIDs: Indomethacin SR 75 mg PO bid to tid
    2. Doxycycline 100 mg PO bid for three months
      1. Indicated for suspected Chlamydia etiology
    3. Intra-articular Corticosteroid Injection
      1. Indicated for large Knee Effusions
  2. Second line agents for persistent disease
    1. Sulfasalazine 1 gram PO bid to tid
  3. Third line agents for chronic Disability (avoid in HIV)
    1. Methotrexate 7.5 to 25 mg per week
    2. Azathioprine (Imuran) 100 to 150 mg PO qd

XI. Course

  1. Self-limited: Resolves over 3-12 months
  2. Chronic Arthritis may develop in up to 30% of cases

XII. References

  1. Tak Yan Yu in Ruddy (2001) Kelley's Rheum, p. 1055-67
  2. Arnett in Klippel (1997) Primer Rheumatic, p. 184-88
  3. Barth (1999) Am Fam Physician 60:499-507 [PubMed]
  4. Kataria (2004) Am Fam Physician 69:2853-60 [PubMed]
  5. Kirchner (1995) Postgrad Med 97(3): 111-22 [PubMed]

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