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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Related Studies

Ontology: Reiter Syndrome (C0035012)

Definition (MSHCZE) Chorobný stav řazený k reaktivním artritidám (spondylartritidám) charakterizovaný nehnisavým zánětem kloubů při současném zánětlivém postižení močové trubice (uretritida), oční spojivky (konjunktivitida), následující obv. po střevním zánětu, klasicky po dysenterii. Může být při venericky získané chlamydiové infekci močových cest. Často je přítomen histokompatibilní antigen HLA-B27. Klasická triáda je spíše vzácná. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) A rare, reactive inflammatory disorder seen following bacterial infection. It predominantly affects males aged 20-40. Individuals with HLA-B27 antigen are estimated to have a 50 % increased risk. The disorder is characterized by arthritis, conjunctivitis, uveitis, iritis and ulceration of the oral cavity, genitals and volar surfaces of the hands and feet. The clinical course is self-limited with resolution of clinical disease usually within six months of onset.
Definition (CSP) triad of nongonococcal urethritis followed by conjunctivitis and arthritis.
Definition (MSH) Historically characterized by a triad of inflammation involving the eye (CONJUNCTIVITIS), the bone (POST-INFECTIOUS ARTHRITIS), and the urethra (URETHRITIS), it is now thought to be nearly synonymous with reactive arthritis.
Concepts Disease or Syndrome (T047)
MSH D016918
ICD9 099.3
ICD10 M02.3 , M02.30, M02.39
SnomedCT 67224007, 154390002, 266212009, 154389006
English Fiessinger-Leroy-Reiter syndrome, REITER'S SYNDROME, REITERS DISEASE, Reiters Disease, REITER DIS, Disease, Reiter's, Reiter Disease, Syndrome, Reiter, Disease, Reiter, REITERS DIS, Reiter's Disease, Fiessinger Leroy Reiter syndrome, Reiter's syndrome with arthropathy, Reiter's syndrome with arthropathy (diagnosis), Reiter's syndrome (diagnosis), Reiter's Syndrome, Reiters disease, Reiter syndrome, Reiter disease, Reiter Syndrome, Reiter's disease, unspecified site, Reiter's disease, site unspecified, reiters disease, reiter syndrome, reiters syndrome, syndrome reiter, syndrome reiter's, reiter's disease, disease reiters, reiter disease, reiter's syndrome, Urethrooculoarticular syndrome, Reiter's syndrome, Reiter's disease, Reiter's disease (disorder), arthritis; urethritica, Reiter; triad, Reiter, syndrome; urethro-oculo-articular, triad; Reiter, urethritica; arthritis, urethro-oculo-articular; syndrome, uroarthritis; infectious, Reiters syndrome
Dutch ziekte van Reiter, Reiter-syndroom, syndroom van Fiessinger-Leroy-Reiter, Reiter; trias, artritis; urethritica, syndroom; urethro-oculo-articulair, trias; Reiter, urethritica; artritis, urethro-oculo-articulair; syndroom, uroartritis; infectieus, Ziekte van Reiter, syndroom van Reiter
German Reiter-Syndrom, Fiessinger-Leroy-Reiter-Syndrom, Reiter-Krankheit, Morbus Reiter, Urethro-okulo-synoviales Syndrom, MORBUS REITER
Italian Sindrome di Fiessinger-Leroy-Reiter, Malattia di Reiter, Sindrome di Reiter
Portuguese Síndrome de Fiessinger-Leroy-Reiter, Doença de Reiter, SINDROME DE REITER, Síndrome de Reiter
Spanish Enfermedad de Reiter, Síndrome de Fiessinger-Leroy-Reiter, SINDROME DE REITER, enfermedad de Reiter (trastorno), enfermedad de Reiter, síndrome de Reiter, síndrome uretrooculoarticular, Síndrome de Reiter
Japanese ライター病, ライター症候群, ﾗｲﾀｰｼｮｳｺｳｸﾞﾝ, ﾗｲﾀｰﾋﾞｮｳ
French Syndrome conjonctivo-urétro-synovial de Fiessinger-Leroy-Reiter, Syndrome conjonctivo-uréthro-synovial de Fiessinger-Leroy-Reiter, Syndrome de Fiessinger-Leroy-Reiter, Syndrome de Reiter, Maladie de Reiter, Syndrome oculo-urétro-synovial, SYNDROME DE REITER
Czech Reiterova choroba, Fiessinger-Leroy-Reiterův syndrom, Reiterova nemoc, Reiterův syndrom
Korean 라이터병
Hungarian Reiter-syndroma, Fiessinger-Leroy-Reiter syndroma, Reiter-betegség, Reiter syndroma, Reiter betegség
Norwegian Reiters syndrom, Reiters sykdom
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Arthritis, Reactive (C0085435)

Definition (MSH) An aseptic, inflammatory arthritis developing secondary to a primary extra-articular infection, most typically of the GASTROINTESTINAL TRACT or UROGENITAL SYSTEM. The initiating trigger pathogens are usually SHIGELLA; SALMONELLA; YERSINIA; CAMPYLOBACTER; or CHLAMYDIA TRACHOMATIS. Reactive arthritis is strongly associated with HLA-B27 ANTIGEN.
Concepts Disease or Syndrome (T047)
MSH D016918
ICD10 M02.3
SnomedCT 67224007, 239783001, 201736002, 239784007, 129133005
English Arthritides, Postinfectious, Arthritides, Reactive, Arthritis, Postinfectious, Postinfectious Arthritides, Postinfectious Arthritis, Reactive Arthritides, Arthritis, Post-Infectious, Post-Infectious Arthritis, Arthritides, Post-Infectious, Arthritis, Post Infectious, Post Infectious Arthritis, Post-Infectious Arthritides, Arthritis occurr after infect, ARTHRITIS POSTINFECT, ARTHRITIS POST INFECT, POST INFECT ARTHRITIS, POSTINFECT ARTHRITIS, Reactive Arthritis, Arthritis reactive, reactive arthritis, reactive arthritis (diagnosis), Reactive arthritis, Arthritis, Reactive, Arthritis, Reactive [Disease/Finding], Reactive arthritis (disorder), Arthritis occurring after infection, Post-infective arthritis, Post-infective arthropathy, Post-bacterial arthropathy (disorder), Post-bacterial arthropathy, Post-infective arthritis (disorder), infectious; arthritis, postinfective reaction (etiology), infectious; arthritis, postinfective reaction (manifestation)
Dutch reactieve artritis, infectieziekte; artritis, postinfectieuze reactie, artritis reactief, Artritis, reactieve, Artrtis, postinfectieuze, Reactieve artritis
German reaktive Arthritis, Arthritis reaktiv, Arthritis, reaktive, Arthritis, postinfektiöse, Postinfektiöse Arthritis
Swedish Artrit, reaktiv
Japanese ﾊﾝﾉｳｾｲｶﾝｾﾂｴﾝ, Reiter症候群, Reiter病, ライター症候群, ライター尿道炎, 尿道関節症候群, ライテル病, 関節炎-反応性, ライター病, 反応性関節炎, 感染後関節炎, 関節炎-感染後
Czech artritida poinfekční, Artritida reaktivní, Reaktivní artritida, reaktivní artritida, postinfekční artritida, artritida reaktivní
Finnish Reaktiivinen artriitti
French Rhumatisme post-infectieux, Arthrite post-infectieuse, Arthrite réactionnelle
Italian Artrite postinfettiva, Artrite post-infettiva, Artrite reattiva
Russian ARTRIT POSTINFEKTSIONNYI, РЕЙТЕРА СИНДРОМ, РЕЙТЕРА БОЛЕЗНЬ, ARTRIT REAKTIVNYI, REITERA SINDROM, REITERA BOLEZN', АРТРИТ ПОСТИНФЕКЦИОННЫЙ, АРТРИТ РЕАКТИВНЫЙ
Polish Zapalenie stawów poinfekcyjne, Choroba Reitera, Zapalenie stawów reaktywne, Poinfekcyjne zapalenie stawów, Zespół Reitera
Hungarian Reaktív arthritis, Arthritis reactiva
Norwegian Reaktiv artritt, Artritt, reaktiv, Reaktiv leddbetennelse, Postinfeksiøs artritt, Artritt, postinfeksiøs, Leddbetennelse, reaktiv
Spanish artritis reactiva (trastorno), artritis reactiva, artritis posinfecciosa (trastorno), artritis posinfecciosa, artritis postinfecciosa (trastorno), artritis postinfecciosa, artritis que ocurre después de una infección, artropatía posbacteriana (trastorno), artropatía posbacteriana, artropatía postinfecciosa, Artritis reactiva, Artritis Postinfecciosa, Artritis Reactiva
Portuguese Artrite reactiva, Artrite Pós-Infecciosa, Artrite Reativa
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Circinate balanitis of Reiter's disease (C0403762)

Concepts Disease or Syndrome (T047)
SnomedCT 236744002
English Circin balanitis-Reiter's dis, penis lesion circinate balanitis, circinate balanitis, circinate balanitis (physical finding), Circinate balanitis of Reiter disease, Circinate balanitis of Reiter's disease, Circinate balanitis of Reiter's disease (disorder)
Spanish balanitis circinata en el síndrome de Reiter (trastorno), balanitis circinata en el síndrome de Reiter
Derived from the NIH UMLS (Unified Medical Language System)

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