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Reiter's syndrome - Causes, Symptoms and Treatments

A self-limiting syndrome associated with polyarthritis (dominant feature), urethritis, balanitis, conjunctivitis, and mucocutaneous lesions, Reiter's syndrome appears to be related to infection, either venereal or enteric. This disease, also called reactive arthritis, usually affects young men (ages 20 to 40) but can be seen in women and children.

Causes of Reiter's syndrome:

The cause of Reiter's syndrome is unknown, but most cases follow venereal or enteric infection. Because 75% to 85% of patients with Reiter's syndrome test positive for the human leukocyte antigen B27, genetic susceptibility is likely. Reiter's syndrome has followed infections caused by Mycoplasma, Shigella, Salmonella, Yersinia, and Chlamydia organisms. More common in patients who are infected with the human immunodeilciency virus (HIV), it may precede or follow acquired immunodeficiency syndrome.

Signs and symptoms of Reiter's syndrome:

The patient with Reiter's syndrome may complain of dysuria, hematuria, urgent and frequent urination, and mucopurulent penile discharge, with swelling and reddening of the urethral meatus. Small painless ulcers may erupt on the glans penis (balanitis) and coalesce to form irregular patches that cover the penis and scrotum. He may also experience suprapubic pain, fever, anorexia with weight loss, and other genitourinary (GU) complications, such as prostatitis and hemorrhagic cystitis. Female patients may complain of suprapubic pain, dysuria, and vaginal discharge. Enteric infections may manifest as fever, abdominal cramps, and loose stools.

Arthritic symptoms usually follow GU or enteric symptoms and last from 2 to 4 months, although some patients may go on to have chronic monoarthritis or oligoarthritis. Asymmetrical and extremely variable polyarticular arthritis is most common and tends to develop in weight-bearing ing joints of the legs and sometimes in the low back or sacroiliac joints. The arthritis is usually acute, with warm, erythematous, and painful joints, but it may be mild, with minimal synovitis. Muscle wasting is common near affected joints. Fingers and toes may swell and appear sausagelike.

Ocular symptoms include mild bilateral conjunctivitis, possibly complicated by keratitis, iritis, retinitis, or optic neuritis. In severe cases, burning, itching, and profuse mucopurulent discharge are possible.

In 30% of patients, skin lesions (keratoderma blennorrhagicum) develop 4 to 6 weeks after onset of other symptoms and may last for several weeks. These macular to hyperkeratotic lesions commonly resemble those of psoriasis. They usually occur on the palms and soles but can develop anywhere on the trunk, extremities, or scalp. Nails become thick, opaque, and brittle; keratic debris accumulates under the nails. In many patients, painless, transient ulcerations erupt on the buccal mucosa, palate, and tongue.

Diagnosis of Reiter's syndrome:

Many patients with Reiter's syndrome test positive for the HLA-B27 antigen and have an elevated white blood cell (WBC) count and erythrocyte sedimentation rate. Mild anemia may develop. Urethral discharge and synovial fluid contain many WBCs, mostly polymorphonuclear leukocytes; synovial fluid is high in complement and protein and is grossly purulent. Cultures or smears of discharge and synovial fluid rule out other causes, such as gonococci or chlamydia.

Examination of urethral, cervical, or nasopharyngeal swabs may have proved helpful in the diagnosis of new-onset Reiter's syndrome because they provide a way to identify early-stage infections with Chlamydia trachomatis, which are often subtle and may go unnoticed.

During the first few weeks, X-rays are normal and may remain so, but some patients may show osteoporosis in inflamed arcas. If inflammation persists, X-rays may show erosions of the small joints, periosteal proliferation (new bone formation) of involved joints, and calcaneal spurs.

Treatment of Reiter's syndrome:

No specific treatment exists for Reiter's syndrome. Most patients recover in 2 to 16 weeks. About 50% of patients have recurring acute attacks, while the rest follow chronic course, experiencing continued synovitis and sacroiliitis. In acute stages, limited weight bearing may be necessary.

Anti-inflammatory agents, the primary treatment, can be given to relieve discomfort and fever. Steroids may be used for persistent skin lesions; gold therapy, sulfasalazine, methotrexate, or azathioprine, for bony erosion. Testing for HIV is also indicated. Physical therapy inclndes range-of-motion and strengthening exercises and the use of padded or supportive shoes to prevent contractures and foot deformities .

Special considerations of Reiter's syndrome:

  • Explain Reiter's syndrome. Discuss the medications and their possible adverse effects. Warn the patient to take medications with meals or milk to prevent Gl bleeding.
  • Encourage normal daily activity and moderate exercise. Suggest a firm mattress and encourage good posture and body mechanics.
  • Arrange for occupational counseling if the patient has severe or chronic joint impairment.

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