Reiters Syndrome

REITERS SYNDROME A triad of features including arthritis, conjunctivitis, and urethritis or cervicitis. It occurs most commonly in young men, is associated with HLA-B27 in 80% of white patients and 50-60% of blacks, Epidemiologically -Similar to other reactive arthritis syndromes characterized by sterile inflammation of joints from infections originating at non-articular sites. -A fourth feature may be buccal ulceration or balanitis. (It is possible for only two features to be present.) Two forms: -Sexually transmitted; symptoms usually begin 7-14 days after exposure -Chlamydia trachomatis or perhaps Ureaplasma urealyticum). -Post-dysentery-infection (with shigella, salmonella, yersinia, campylobacter) System(s) affected: Musculoskeletal, Skin/Exocrine, Renal/Urologic Genetics: HLA-B27 tissue antigen present in 60-80% of patients Incidence/Prevalence in USA: 0.24-1.5% incidence after epidemics of bacterial dysentery; complicates 1-2% cases of non-gonococcal urethritis Predominant age: 20-40 years Sex: Male > Female Clinical presentation a) Musculoskeletal: -Asymmetric arthritis (especially knees, ankles, MTP joints). -Enthesopathy (inflammation at tendinous insertion into bone) such as plantar fasciitis, digital periostitis, Achilles tendinitis -Spondyloarthropathy (spine and sacroiliac joint involvement) b) Urogenital tract: -Urethritis -Prostatitis -Occasionally cystitis -Balanitis -Cervicitis - usually asymptomatic c)Eye: - Conjunctivitis of one or both eyes -Occasionally scleritis, keratitis, corneal ulceration.Rarely uveitis and iritis. d)Skin: -Mucocutaneous lesions (small, painless, superficial ulcers on oral mucosa, tongue, glans penis) -Keratoderma blennorrhagica (hyperkeratotic skin lesions of palms and soles and around nails) Constitutional: Fever, malaise, anorexia, weight loss Can appear seriously ill (fever, rigors, tachycardia, exquisitely tender joints) Others may be involved Cardiovascular:-Occasionally pericarditis, murmur, conduction defects, aortic incompetence Nervous system:-Rarely peripheral neuropathy, cranial neuropathy, meningoencephalitis, neuropsychiatric changes Management -Treatment is symptomatic -No treatment necessary for conjunctivitis. Iritis may require treatment. - Treatment unnecessary for mucocutaneous lesions -Physical therapy during recovery phase -Arthritis may be prominent and disabling during the acute phase MEDICATIONS · Symptomatic management NSAIDs have been the mainstay of therapy. Antibiotics may also have some role. Antibiotics given at the time of a nongonococcal sexually transmitted infection reduce the chance that the individual will develop Reiter's

CAUSES: · Chlamydia trachomatis the usual causative organism of postvenereal variety. Male: female ratio 9:1 · Dysenteric form following enteric bacterial infection due to Shigella, Salmonella, Yersinia, and Campylobacter organisms. This form more likely in women, children and the elderly. RISK FACTORS: · Sexual intercourse 7-14 days prior to illness · Food poisoning or bacterial dysenteric outbreak DIFFERENTIAL DIAGNOSIS: · For specific diagnosis, arthritis associated with urethritis for longer than one month · Rheumatoid arthritis · Ankylosing spondylitis · Arthritis associated with inflammatory bowel disease Psoriatic arthritis · Juvenile rheumatoid arthritis · Bacterial arthritis including gonococcal LABORATORY: · Blood à WBC 10,000-20,000 à Neutrophilic leukocytosis à Elevated erythrocyte sedimentation rate à Moderate normochromic anemia à Hypergammaglobulinemia · Synovial fluid WBC 1000-8000 cells/mm3 à Bacterial culture negative · Collaborative tests à Cultures or serology positive for Chlamydia trachomatis, or stools positive for Salmonella, Shigella, Yersinia or Campylobacter support the diagnosis PATHOLOGICAL FINDINGS: · A seronegative spondyloarthropathy (similar to ankylosing spondylitis, enteric arthritis and psoriatic arthritis) · Villous formation in joints · Joint hyperemia · Joint inflammation · Prostatitis · Seminal vesiculitis Skin biopsy similar to psoriasis · Non-specific conjunctivitis SPECIAL TESTS: Histocompatibility antigen HLA-B27 positive in 60-80% of cases in non-HIV related Reiter's IMAGING: · X-ray Periosteal proliferation, thickening à Spurs à Erosions at articular margins à Residual joint destruction à Syndesmophytes (spine) à Sacroiliitis