Reiter`s syndrome M02.3

Psoriasiform pustular systemic anchorage with the classic symptom triad of:

• Urethritis
• conjunctivitis and
• arthritis.

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

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.

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:

• Integument(25% of Reiter's patients have skin symptoms): In particular, there are exudative, psoriasiform skin lesions, especially symmetrical on palmae and plantae(keratoderma blenorrhagicum), erythemato-squamous foci, especially on capillitium and in the umbilical region.
  • Nail changes: pustular paronychia, onycholysis, pitting, longitudinal rippling, splitting, nail dystrophy, nail loss, subungual hyperkeratosis.
• Mucous membrane: redness, erythematous macules and papules, erosions, hemorrhages, exfoliatio areata linguae.
• Genitourinary: balanitis parakeratotica circinata, chronic prostatitis, cystitis, pyelonephritis.
• Eyes: eyelid and corneal edema, keratitis, iritis, iridocyclitis, uveitis.
• Joints: tendinitis, fasciitis, synoviitis, sacroileitis, ankylosing spondylitis.

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.

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.

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13. Wu IB et al (2008) Reiter`s syndrome: the classic triad and more. J Am Acad Dermatol 59: 113-121.