Urethro-conjunctival synovial syndrome M02.3

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 02.02.2021

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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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Psoriasiforme system ankle with the classic symptom triad from:

Oligosymptomatic courses are not rare. 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 triad of symptoms ("can`t see, cant`t pee, can`t climb a tree"):

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

Also:

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

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 cremes/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 and/or psoriasiform skin changes: Medium glucocorticoids such as 0.1% triamcinolone cream R259 or 0.1% mometasone furoate (e.g. Ecural fat cream/ointment), in combination with calcipotriol-containing topicals (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 urethra infection: If infection of the urethra or intestine is still detectable, antibiotic therapy with doxycycline (e.g. Doxy Wolff) 2 times 100 mg/day for 7 days.
  • Arthritis: Non-steroidal anti-inflammatory drugs such as acetylsalicylic acid 2-4 g/day (e.g. Aspirin Tbl.), especially 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.) initial 100 mg/day, reduction to the lowest possible maintenance dose. If necessary, combination therapy with azathioprine (e.g. Imurek 50), starting with 100 mg/day. Reduction depending on the acuteity and course of the disease.

Remember! Exclusion of an HIV infection before application of cytostatics or immunosuppressive drugs, because the M. Reiter can be an expression of a late stage of an HIV infection (0.5-11% of patients)!

  • After exhaustion of these possibilities with severe clinical picture methotrexate (e.g. methotrexate Lederle) 1 time per week 7.5-15 mg p.o. (is preferable to the long-term peroral administration of glucocorticoids). A therapy trial is also possible with retinoids such as Acitretin (Neotigason) 30-50 mg/day (in women only under strict anti-conception)!
  • Ciclosporin A (sandimmune) is also indicated for severe skin and mucous membrane changes. S.a.u. Psoriasis vulgaris, Psoriasis pustulosa generalisata or Psoriasis arthropathica.
  • 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. Gaylis N (2003) Infliximab in the treatment of an HIV positive patient with Reiter's syndrome. J Rheumatol 30: 407-411
  6. 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
  7. Lotery HE et al (2003) Ulcerative vulvitis in atypical Reiter's syndrome. J Am Acad Dermatol 48: 613-616
  8. 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
  9. Reiter H (1916) On a previously unrecognized spirochaetosis infection (spirochaetosis arthritica). Dtsch med Wschr 42: 1535
  10. Schneider JM et al (2003) Reiter's syndrome. Cutis 71: 198-200
  11. Wollina U et al (1999) Nail changes in rheumatic disease. dermatologist 50: 549-555
  12. Wu IB et al (2008) Reiter's syndrome: the classic triad and more. J Am Acad Dermatol 59: 113-121

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Last updated on: 02.02.2021