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Reiter's syndrome

Ref [4] equates Reiter's syndrome with reactive arthritis. Etiology: 1) Chlamydia trachomatis recovered from urethra in 70% of untreated men 2) Salmonella, Shigella, Campylobacter can produce identical syndrome 3) hypersensitivity to bacterial antigens Genetics: HLA-B27 is positive in 80% of patients. Clinical manifestations: 1) arthritis ......| 2) conjunctivitis..| classic triad 3) urethritis .....| 4) buccal/palatal ulcerations (generally painless) 5) balanitis 6) cervicitis in women 7) sacroiliitis is a strong confirmatory sign, but may not be present 8) arthritis is asymmetric, average of 5-6 joints involved, heal & Achilles tendon commonly involved 9) keratoderma blennorrhagicum (indistinguishable from psoriasis) 10) asymmetric joint involvement a) toes b) large joints of lower extremities 11) erosions or scales on penis 12) iritis (acute anterior uveitis) 13) disease is characteristically episodic Laboratory: 1) increased erythrocyte sedimentation rate (ESR) 2) rheumatoid factor (RF) is negative 3) tests for Chlamydia a) culture b) ELISA for chlamydial antigens c) Chlamydia trachomatis DNA 4) HLA-B27 genotyping Differential diagnosis: - Behcet syndrome: genital ulcers, not urethritis, not infectious Management: 1) pharmaceutical agents a) doxycycline, tetracycline or erythromycin for treatment of Chlamydia b) NSAIDS 1st line: indomethacin [5] c) glucocorticoid joint injections d) DMARDS if NSAID ineffective - sulfazalazine may be agent of choice [4] - methotrexate, start with 7.5 mg PO QD - TNF-alpha inhibitor 2) prognosis - disease remains episodically active in 75% of patients - disability is a frequent outcome

General

reactive arthritis syndrome

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1057
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 865
  3. Guide to Physical Examination & History Taking, 6th edition, Bates B, JB Lippincott, Philadelphia, 1995, pg 57
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 18. American College of Physicians, Philadelphia 1998, 2012, 2018
  5. NEJM Knowledge+ Question of the Week. Oct 29, 2019 https://knowledgeplus.nejm.org/question-of-week/703/
  6. Hannu T. Reactive arthritis. Best Pract Res Clin Rheumatol 2011 Nov 22; 25:347. PMID: 22100285
  7. Carter JD, Hudson AP. The evolving story of Chlamydia-induced reactive arthritis. Curr Opin Rheumatol 2010 May 7; 22:424 PMID: 20445454
  8. University of Maryland Medical Center Reiter syndrome http://umm.edu/health/medical/altmed/condition/reiter-syndrome