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165 REACTIVE ARTHRITIS AND REITER’S SYNDROME

165 REACTIVE ARTHRITIS AND REITER’S SYNDROME
Harrison’s Manual of Medicine

165

REACTIVE ARTHRITIS AND REITER’S SYNDROME

Definition
Pathogenesis
Clinical Manifestations
Evaluation
Differential Diagnosis
Outcome
Bibliography

Definition
Reiter’s syndrome describes the triad of arthritis, conjunctivitis, and nongonococcal urethritis. This term is largely of historic interest and is now considered to be part of the spectrum of reactive arthritis, an acute nonpurulent arthritis complicating an infection elsewhere in the body (usually genitourinary or enteric) that may be accompanied by extraarticular features.
Pathogenesis
Up to 85% of pts possess the HLA-B27 alloantigen. It is thought that in individuals with appropriate genetic background, reactive arthritis may be triggered by an enteric infection with any of several Shigella, Salmonella, Yersinia, and Campylobacter species; by genitourinary infection with Chlamydia trachomatis; and possibly by other agents.
Clinical Manifestations
The sex ratio following enteric infection is 1:1, but genitourinary acquired reactive arthritis is predominantly seen in young males. In a majority of cases Hx will elicit Sx of genitourinary or enteric infection 1–4 weeks prior to onset of other features.

Constitutional—fatigue, malaise, fever, weight loss.

Arthritis—usually acute, asymmetric, oligoarticular, involving predominantly lower extremities; sacroiliitis may occur.

Enthesitis—inflammation at insertion of tendons and ligaments into bone; “sausage digit,” plantar fasciitis, and Achilles tendinitis common.

Ocular features—conjunctivitis, usually minimal; uveitis, keratitis, and optic neuritis rarely present.

Urethritis—discharge intermittent and may be asymptomatic.

Other urogenital manifestations—prostatitis, cervicitis, salpingitis.

Mucocutaneous lesions—painless lesions on glans penis (circinate balanitis) and oral mucosa in approximately a third of pts; keratoderma blenorrhagica: cutaneous vesicles that become hyperkerotic, most common on soles and palms.

Uncommon manifestations—pleuropericarditis, aortic regurgitation, neurologic manifestations, secondary amyloidosis.

Reiter’s syndrome is associated with and may be the presenting Sx of HIV.
Evaluation

Pursuit of Chlamydia infection by culture, DFA, or EIA of secretions from throat, urethra, cervix.

Stool cultures may secure Dx of enteric pathogen.

Rheumatoid factor and ANA negative.

Mild anemia, leukocytosis, elevated ESR may be seen.

HLA-B27 may be helpful in atypical cases.

HIV screening should be performed in all pts.

Synovial fluid analysis—often very inflammatory; negative for crystals or infection.

Radiographs—erosions may be seen with new periosteal bone formation, ossification of entheses, sacroiliitis (often unilateral).
Differential Diagnosis
Includes septic arthritis (gram +/–), gonococcal arthritis, crystalline arthritis, psoriatic arthritis (Fig. 161 -1).

TREATMENT

Prolonged administration of antibiotics may benefit Chlamydia-induced disease.

NSAIDs (e.g., indomethacin 25–50 mg PO tid) benefit most pts.

Intraarticular glucocorticoids.

Sulfasalazine up to 3 g/d in divided doses may help some pts with persistent arthritis.

Cytotoxic therapy, such as azathioprine [1–2 (mg/kg)/d] or methotrexate (7.5–15 mg/week) may be considered for debilitating disease refractory to other modalities; contraindicated in HIV disease.

Uveitis may require therapy with ocular or systemic glucocorticoids.

Outcome
Prognosis is variable; a third will have recurrent or sustained disease, with 15–25% developing permanent disability.
Bibliography

For a more detailed discussion, see Taurog JD, Lipsky PE: Ankylosing Spondylitis, Reactive Arthritis, and Undifferentiated Spondyloarthropathy, Chap. 315, p. 1949, in HPIM-15.

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