Reiter`s syndrome M02.3

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 13.10.2023

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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 & Leroy, 1916; Reiter, 1916

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

Oligosymptomatic courses are not rare. The relationship to (pustular)psoriasis is controversial.

Occurrence/Epidemiology
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Incidence: 3-5/100,000 population/year. The incidence after nonspecific urethritis or shigella enteritis is about 1%, but in carriers of HLA antigen-B27(HLA-B27)it is >20%.

Etiopathogenesis
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Unresolved. Genetic factors (familial clustering) and association with HLA-B27 (positive in 70-80% of patients) are discussed. Possible infectious allergic reaction after urethritic or enteric (about 25%) infections with e.g. mycoplasma, yersinia, chlamydia, Neisseria gonorrhoeae, viruses. An etiologic feature concerns post-COVID reactive arthritis.

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.

In addition:

A clinical variant is "Post-COVID-19 Reactive Arthritis (Post-COVID-19 ReA )". It can occur at any age, apparently affects both sexes equally. Some post-COVID-10 ReA present with arthritis of the small joints, others with a spondyloarthritis phenotype - either with peripheral or axial involvement, while some have only tenosynovitis or dactylitis. The occurrence of inflammatory arthritis after COVID-19 vaccination suggests an analogous pathophysiology. Most patients did not experience associated extra-articular manifestations. Few patients reported associated psoriasis , bilateral conjunctivitis, myalgia, balanitis, and symmetric vasculitis. Additional symptoms such as fever, cough, nausea, diarrhea, and taste disturbance occurred irregularly (Bekaryssova D et al. 2022).

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.

Keratoderma blenorrhagicum or/and psoriasiform skin lesions: Medium-strength glucocorticoids such as 0.1% triamcinolone cream triamcinolone acetonide cream hydrophilic 0.025/0.05/0.1% (NRF 11.38.) 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 mucous membrane changes. See also Psoriasis vulgaris, Psoriasis pustulosa generalisata or Psoriasis arthropathica.

Good therapeutic results are achieved with the use of TNF-alpha antagonists . They are now considered the first-choice therapeutic agents.

Progression/forecast
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In the majority of patients, the disease is "self-limiting" (2-6 months). However, some patients develop a chronic course and require immunomodulatory therapy (Jubber A et al. 2021). Rarely, permanent defects persist. Spontaneous recurrences or recurrences triggered by infections are common.

Disease-specific symptoms are still detected in 80% of patients after 5 years.

Literature
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  1. Bekaryssova D et al (2022) Reactive arthritis before and after the onset of the COVID-19 pandemic. Clin Rheumatol 41:1641-1652.
  2. Catteral RD (1983) Clinical aspects of Reiter's disease. Br J Rheumatol 22: 151
  3. Edirisinghe DN et al (2002) Reiter's syndrome and keratoderma blennorrhagica on glans penis--is this unusual? Int J STD AIDS 13: 133-134
  4. Fiessinger N, Leroy E (1916) Contribution à l'étude d'une épidemie de dysenterie dans la somme. Bull Soc méd Hòp (Paris) 40: 2030.
  5. 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
  6. García-Kutzbach A et al (2018) Reactive arthritis: update 2018. Clin Rheumatol 37:869-874.
  7. Gaylis N (2003) Infliximab in the treatment of an HIV positive patient with Reiter's syndrome. J Rheumatol 30: 407-411.
  8. Jubber A et al (2021) Reactive arthritis: a clinical review. J R Coll Physicians Edinb 51:288-297.
  9. 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
  10. Lotery HE et al (2003) Ulcerative vulvitis in atypical Reiter's syndrome. J Am Acad Dermatol 48: 613-616.
  11. 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
  12. Reiter H (1916) On a hitherto unrecognized spirochete infection (spirochaetosis arthritica). Dtsch med Wschr 42: 1535
  13. Schneider JM et al (2003) Reiter's syndrome. Cutis 71: 198-200
  14. Wollina U et al (1999) Nail changes in rheumatic disease. Dermatologist 50: 549-555
  15. 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: 13.10.2023