Reiter`s syndrome M02.3

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 04.10.2022

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Synonym(s)

Fiessinger-Leroy Reiter disease; Fiessinger-Leroy Syndrome; Postdysenteric syndrome; Reiter's disease; Reiter's syndrome; Urethro-oculo-synovial syndrome

History
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Fiessinger and Leroy, 1916; Reiter, 1916

Definition
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Psoriasiform pustular systemic anchorage with the classic symptom triad of:

Oligosymptomatic courses are not uncommon. The relationship to psoriasis is controversial.

Occurrence/Epidemiology
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Incidence: 3-5/100.000 inhabitants/year. The incidence after non-specific urethritis or shigella enteritis is about 1%, but for carriers of HLA antigen-B27 it is over 20%.

Etiopathogenesis
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Unsolved. Discussed are genetic factors (familial accumulation) as well as association to HLA-B27 (positive in 70-90% of patients). Possible infection-allergic reaction after urethritic or enteric (about 25%) infections with e.g. mycoplasma, Yersinia, Chlamydia, Neisseria gonorrhoeae, viruses.

Manifestation
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Occurring in 90-98% of young men.

Clinical features
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Onset usually 10-30 days after enteritic or urethritic infection.

Classic symptom triad ("can`t see, cant`t pee, can`t climb a tree"):

  • Urethritis: Usually onset with acute, nonspecific, purulent to bloody discharge, pain on urination. In dysenteric form first secondary urethritis.
  • Conjunctivitis: Usually occurring bilaterally in varying degrees.
  • Arthritis: Oligoarthritis, especially of the lower extremities, e.g. knee and ankle joints. Often symmetrical, alternating affection with swollen, warm, painful joints. Less commonly, the costosternal joints are also affected. Arthritis of Reiter's disease is quite slow to heal.

Also:

Laboratory
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BSG acceleration, leukocytosis; alpha 1- and alpha 2-globulin proliferation in serum electrophoresis; leukocyturia; cultural or serological detection of chlamydia, mycoplasma (postvenereal) or shigella, salmonella, yersinia or campylobacter (postdysenteric). Rheumatoid factors and ANA are always negative!

General therapy
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During acute attacks and in the case of a disturbed general condition, bed rest, analgesics, paracetamol (e.g. Ben-u-ron Tbl.) 0.5-1 g/day and careful positioning to maintain joint mobility.

External therapy
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Balanitis: Therapy of balanitis parakeratotica circinata with drying measures such as lotio alba and application of gauze compresses. In addition, application of glucocorticoid-containing creams/lotions such as 0.25% prednicarbate cream(e.g. Dermatop cream), 0.1% methylprednisolone cream (e.g. Advantan) or 0.5% hydrocortisone cream R121.

Keratoderma blenorrhagicum or/and psoriasiform skin lesions: Medium-strength glucocorticoids such as 0.1% triamcinolone cream R259 or 0.1% mometasone furoate (e.g. Ecural fat cream/ointment), in combination with calcipotriol-containing externals (e.g. Psorcutan ointment) 2 times/day.

Radiation therapy
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For therapy-resistant Keratoderma blenorrhagicum selective PUVA bath therapy of Palmae and/or Plantae: 8-MOP concentration in the bath water 0.5-1.0 mg/l, water temperature 37 °C, duration of the medication bath 20 minutes, immediately after the bath UVA irradiation with initial e.g. 0.2 J/cm2 UVA, increase of the UVA dose by about 0.2 J/cm2 with every 3rd treatment.

Internal therapy
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Intestinal or urethral infection: If infection of urethra or intestine is still detectable, antibiotic therapy with doxycycline (e.g. Doxy Wolff) 2 times 100 mg/day for 7 days.

Arthritides: Non-steroidal anti-inflammatory drugs such as acetylsalicylic acid 2-4 g/day (e.g. Aspirin Tbl.), especially also indometacin (e.g. Ammuno) 75-150 mg/day, diclofenac (e.g. Voltaren) 75-150 mg/day, ibuprofen (e.g. Ibuprofen-ratiopharm) 600-1200 mg/day. If necessary, also use systemic glucocorticoids, e.g. prednisolone (e.g. Decortin H Tbl.) initially 100 mg/day, reduction to lowest possible maintenance dose. If necessary, also combination therapy with azathioprine (e.g. Imurek 50), starting with 100 mg/day. Reduction depending on the acute nature and course of the disease.

Notice. Exclusion of HIV infection before use of cytostatics or immunosuppressants, since Reiter's disease can be an expression of a late stage of HIV infection (0.5-11% of patients)!

After exhaustion of these possibilities in severe disease methotrexate (e.g. Methotrexat Lederle) 1 time/week 7,5-15 mg p.o. (is preferable to long-term peroral administration of glucocorticoids). An attempt at therapy is also possible with retinoids such as acitretin (Neotigason) 30-50 mg/day (in women only under strict anticonception)!

Ciclosporin A (Sandimmun) is also indicated for severe skin and mucosal changes. See also Psoriasis vulgaris, Psoriasis pustulosa generalisata or Psoriasis arthropathica.

Good therapeutic success is achieved with the use of TNF-alpha antagonists . They are now considered to be the first-choice therapeutic agents.

Rheumatological and ophthalmological consultation.

Progression/forecast
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Subacute (2-6 months) to chronic (months, years) course. Rarely persistent defects. The symptoms subside under treatment after several months to years. Recurrences caused spontaneously or by infections are frequent. In 80% of patients, disease-specific symptoms are still detected after 5 years.

Literature
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  1. Catteral RD (1983) Clinical aspects of Reiter's disease. Br J Rheumatol 22: 151
  2. Edirisinghe DN et al (2002) Reiter's syndrome and keratoderma blennorrhagica on glans penis--is this unusual? Int J STD AIDS 13: 133-134
  3. Fiessinger N, Leroy E (1916) Contribution à l'étude d'une épidemie de dysenterie dans la somme. Bull Soc méd Hòp (Paris) 40: 2030.
  4. Fox R, Calin A, Gerber R, Gibson D (1979) The chronicity of symptoms and disability in Reiter's syndrome: an analysis of 131 consecutive patients. Ann Intern Med 91: 190
  5. García-Kutzbach A et al (2018) Reactive arthritis: update 2018. Clin Rheumatol 37:869-874.
  6. Gaylis N (2003) Infliximab in the treatment of an HIV positive patient with Reiter's syndrome. J Rheumatol 30: 407-411.
  7. Kiss S, Letko E et al (2003) Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome. Ophthalmology 110: 1764-1769
  8. Lotery HE et al (2003) Ulcerative vulvitis in atypical Reiter's syndrome. J Am Acad Dermatol 48: 613-616.
  9. Rahman MU, Schumacher HR, Hudson AP (1992) Recurrent arthritis in Reiter's syndrome: a function of inapparent chlamydial infection of the synovium? Sem Arthr Rheum 21: 259-266
  10. Reiter H (1916) On a hitherto unrecognized spirochete infection (spirochaetosis arthritica). Dtsch med Wschr 42: 1535
  11. Schneider JM et al (2003) Reiter's syndrome. Cutis 71: 198-200
  12. Wollina U et al (1999) Nail changes in rheumatic disease. Dermatologist 50: 549-555
  13. Wu IB et al (2008) Reiter`s syndrome: the classic triad and more. J Am Acad Dermatol 59: 113-121.

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 04.10.2022