Urethro-conjunctival synovial syndrome M02.3

Psoriasiforme system ankle with the classic symptom triad from:

• urethritis
• Conjunctivitis and
• Arthritis.

Oligosymptomatic courses are not rare. 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 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.

• 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.

• 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.

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