Reiter's syndrome

Introduction

Ref equates Reiter's syndrome with reactive arthritis.

Etiology

• Chlamydia trachomatis recovered from urethra in 70% of untreated men
• Salmonella, Shigella, Campylobacter can produce identical syndrome
• hypersensitivity to bacterial antigens

Genetics

HLA-B27 is positive in 80% of patients

Clinical manifestations

-..........-

• arthritis ......|
• conjunctivitis..| classic triad
• urethritis .....|

• buccal/palatal ulcerations (generally painless)
• balanitis
• cervicitis in women
• sacroiliitis is a strong confirmatory sign, but may not be present
• arthritis is asymmetric, average of 5-6 joints involved, heal & Achilles tendon commonly involved
• keratoderma blennorrhagicum (indistinguishable from psoriasis)
• asymmetric joint involvement
  • toes
  • large joints of lower extremities
• erosions or scales on penis
• iritis (acute anterior uveitis)
• disease is characteristically episodic

Laboratory

• increased erythrocyte sedimentation rate (ESR)
• rheumatoid factor (RF) is negative
• tests for Chlamydia
  • culture
  • ELISA for chlamydial antigens
  • Chlamydia trachomatis DNA
• HLA-B27 genotyping

Differential diagnosis

• Behcet syndrome: genital ulcers, not urethritis, not infectious

Management

• pharmaceutical agents
  • doxycycline, tetracycline or erythromycin for treatment of Chlamydia
  • NSAIDS 1st line: indomethacin
  • glucocorticoid joint injections
  • DMARDS if NSAID ineffective
    • sulfazalazine may be agent of choice
    • methotrexate, start with 7.5 mg PO QD
    • TNF-alpha inhibitor
• prognosis
  • disease remains episodically active in 75% of patients
  • disability is a frequent outcome

More general terms

• reactive arthritis
• syndrome