Reiter's syndrome

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'A differential diagnosis revealed that the rash on the bottom of this individualís feet, known as keratoderma blennorrhagica, was due to Reiter's syndrome, not a syphilitic infection as was initially suspected' - CDC/ Dr. M. F. Rein

Reiter's syndrome is the combination of three seemingly unlinked symptoms—an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis) and urethritis. It is named after Hans Reiter, a German military physician, who in 1916 described the disease in a World War I soldier who had recovered from a bout of diarrhea. It is also known as arthritis urethritica, venereal arthritis, reactive arthritis and polyarteritis enterica.

Hans Reiter during World War Two committed inhumane experimentation on Jews and other prisoners in the concentration camps, and there is some debate amongst those inflicted with the syndrome on whether they want the syndrome to be named after the physician.

Reiter's is a seronegative, HLA-B27-linked spondyloarthropathy (autoimmune damage to the cartilages of joints) often precipitated by genitourinary or gastrointestinal infections. It is more common in men than in women and more common in white men than in black men. People with HIV have an increased risk of developing Reiter's as well.

It is set off by a preceding infection, the most common of which would be a genital infection with Chlamydia trachomatis. Other bacteria known to cause Reiter's are gonococcus, Ureaplasma Urealyticum, Salmonella, Shigella, Yersinia, and Campylobacter. A bout of food poisoning or a gastrointestinal infection may also set off Reiter's (those last four bacteria mentioned are enteric bacteria). Reiter's usually manifests about 1-3 weeks after a known infection.

Contents

Signs and symptoms

Symptoms generally appear within 1-3 weeks but can range from 4-35 days from onset of inciting episode of disease.

The classical presentation is that the first symptom experienced is a urinary symptom such as burning pain on urination (dysuria) or an increased need to urinate (polyuria or frequency). Other urogenital problems may arise such as prostatitis in men, and cervicitis, salpingitis and/or vulvovaginitis in women.

The arthritis that follows usually affects the large joints such as the knees causing pain and swelling with relative sparing of small joints such as the wrist and hand.

Eye involvement occurs in about 50% of men with urogenital Reiter's and about 75% of men with enteric Reiter's. Conjunctivitis and uveitis can cause redness of the eyes, eye pain and irritation, and blurred vision. Eye involvement typically occurs early in the course of Reiterís syndrome, and symptoms may come and go.

Roughly 20 to 40 percent of men with Reiterís syndrome develop penile lesions called balanitis circinata on the end of the penis. A small percentage of men and women develop small hard nodules called keratoderma blennorrhagica on the soles of the feet, and less often on the palms of the hands or elsewhere. In addition, some people with Reiterís syndrome develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed.

About 10 percent of people with Reiterís syndrome, especially those with prolonged disease, will develop cardiac manifestations including aortic regurgitationand pericarditis.

Diagnosis

There are countless clinical symptoms, but the clinical picture is dominated by polyarthritis. There is pain, swelling, redness, and heat in the joints.

Swabs of the urethra, cervix and throat may be done looking for the causative organisms. Cultures may be done on urine and stool samples. An aspiration of synovial fluid from an affected knee may be done to look at the fluid under the microscope and for culture.

Treatment

The goal of treatment is firstly to identify and eradicate the underlying infectious source with the appropriate antibiotics. Otherwise, treatment is symptomatic for each problem. Steroids and analgesics may be given for severe joint inflammation. Immunosuppressants may be needed for patients with severe Reiter's which do not respond to any other treatment.

Prognosis

Reiter's syndrome may be self limiting, frequently recurring or develop continually. Most patients have severe symptoms lasting weeks to six months. Approximately 15-50 percent of cases have recurrent bouts of arthritis. Chronic arthritis or sacroiliitis occurs in 15-30 percent of cases. Repeated attacks over many years is common, and more than 40 percent of the patients end up with chronic and disabling arthritis, heart disease or impaired vision. However, most people with Reiter's syndrome can expect to live normal life spans and maintain a near-normal lifestyle with modest adaptations to protect the involved joints.

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