Diagnosis and

Management 2
Presentation Topic :
Reiter’s Syndrome

Name: Choo Yee Ting

Student ID: 00000014201

 Introduction1

– Reiter’s syndrome is a systemic autoimmune disorder, described as a classic

triad of conjunctivitis, urethritis and arthritis.
– Mneumonic: “can’t see, can’t pee, can’t climb a tree”
– However, a majority of patients do not present with the classic triad.
– Also known as Reactive arthritis, an inflammatory arthritis which manifests
after several days to weeks after a gastrointestinal or genitourinary infection.
Epidemiology

– Reactive arthritis is relatively rare, and the incidence in population-based studies

is reported to be 0.6 to 27 per 100,000.1
– Age of Onset: 20-40 year-old
– Gender Predominance: Male to female ratio = 5:1 to 50:1 depending on study4
– Very common in HIV individuals
– Overall, higher disease activity and worse functional capacity are seen in the
lower socioeconomic populations.1
Etiology

– Associated with the HLA-B27 gene on chromosome 6 and by the presence of enthesitis
as the basic pathologic lesion
– Triggered by bacterial infection, particularly:
– Genitourinary (Chlamydia trachomatis, Neisseria gonorrhea, and Ureaplasma
urealyticum)
– Gastrointestinal (GI) tract (Salmonella enteritidis, Shigella, Yersinia enterocolitica,
Campylobacter jejuni, Clostridium difficile)
– The incidence is about 2% to 4% after a genitourinary infection mainly with chlamydia
trachomatis and varies from 0% to 15% after gastrointestinal infections with
Salmonella, Shigella, Campylobacter, or Yersinia4
– The symptoms of negative rheumatoid factor arthritis identify the syndrome with
seronegative arthritis. 3
Pathophysiology 2
Clinical course 3
– Each individual patients experiments Reiter’s symptoms differently. However, within
the range of signs, it is possible to identify them as below and in different locations.
When patients present partial symptoms, the condition is known as Partial Reiter's
Syndrome.
– Risk factors related to Reiter's syndrome include:
– A history of sexually transmitted infections.
– Patients aged between 20 and 40 years old.
– Family relatives affected by Reiter's syndrome.
– Genetic traces associated with HLA-B27 Reiter's Syndrome.
– Digestion of contaminated foods.
– Male patients.
– Frequent change of sexual partners.
History and Physical1
– Patients typically present with acute onset oligo-arthritis, mainly involving the lower
extremities, sacroiliac joint, and the lumbar spine.
– Other extra-articular manifestations involve:
– Skeletal system (enthesitis, dactylitis)
– Eye (conjunctivitis, anterior uveitis episcleritis, and keratitis)
– Genitourinary (urethritis, cervicitis, prostatitis, salpingo-oophoritis, cystitis or
circinate balanitis)
– Mucosal and skin involvement (mucosal ulcers, keratoderma blennorrhagica and
erythema nodosum)
– Cardiac (carditis, aortic, conduction and valvular abnormalities)
– Nail changes (onycholysis, subungual keratosis, or nail pits)
– These symptoms manifest several days to weeks after the initial infection.
– Diarrhea or other symptoms caused by the offending agents are usually resolved
by the time the patient develops arthritis.
– ReA can be self-limiting, recurrent or continuous
– About 20% to 25% of the patients may progress to have chronic articular, ocular
and cardiac complications.
– Very common in HIV individuals, patients with new-onset disease must have
HIV ruled out.
– HIV Individuals with ReA often develop severe psoriasiform dermatitis on the
scalp, soles, palms, and flexures. 3
Physical Examination 1

– Sausage shaped finger, toe or heel pain

– Asymmetric oligoarthritis- usually of the lower extremities
– Conjunctivitis or iritis
– Acute diarrhea or cervicitis within 4 weeks of the onset of arthritis
– Urethritis or genital ulcers

Two or more of the above features plus involvement of the skeletal system
establishes the diagnosis.
– Joint and entheses
– The involvement is asymmetric and affects the weight bearing joint. The
joints are often warm, painful and swollen. Tendinitis is a common feature of
the disease.
– Earliest manifestation of joint disorder : entesitis, normally in the Achilles
tendon and in the plantar fascia of the calcaneus, causing shortening or
lengthening of fingers and toes resembling "sausage fingers and toes".
– Skin and mucocutaneous changes are also common and may include
hyperkeratotic skin and erythematous dermatitis.
– Nail dystrophy is common.
– Eye involvement is common and may include conjunctivitis or uveitis.
 keratodermia blennorrhagica Nail changes include nail dystrophy, subungual
debris, and periungual pustules

Radiography of the pelvis reveals bilateral, Uveitis

asymmetrical sacroiliitis.
Differential diagnosis3

– The most common differential diagnosis should include:

– Gonococcal arthritis
– Gouty arthritis
– Still's disease
– Septic arthritis
– Rheumatic fever
– Psoriatic arthritis
– Rheumatoid arthritis
– Immunotherapy/immunization–related arthropathy
– Secondary syphilis
 Diagnosis3

– There are no specific examinations for Reiter’s syndrome.

– Diagnosis can be drawn using risk factors, a history of enteric or sexually
transmitted infections, as well as symptoms and physical examination.
– Other methods that can be used are:
– Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
– Chlamydia testing
– Leukocyte count. In a chronic phase, hemograms can show anemia.
– Arthrocentesis
– X-rays, ultrasonography or magnetic resonance imaging (MRI)
Healthcare team management3

– There is no cure for reactive arthritis and the treatment is supportive. All patients
should be encouraged to become physically active and a physical therapy consult
should be obtained.
– Rheumatologist, ophthalmologist, gastroenterologist, physical therapist, and
pharmacist, dermatologist
– Ophthalmologist: high risk for visual problems.
– Pharmacist: educate the patient on the types of drugs used, their benefits and side
effects.
– Dermatologist: assess skin lesions and recommend treatment.
Treatment1,4
– Most researchers agree that Reiter's syndrome has no cure. Even if symptoms
may disappear in two to six months, most patients present recurrent symptoms
for several years.
– Goal of therapy: - provide symptomatic relief
- prevent chronic complications
– Caution with rheumatoid conditions is unpredictable flare-ups. Given that some
of the therapies employed by chiropractic care are mechanical, including
adjustments and soft-tissue therapy, it is important to keep in mind that this is
an inflammatory condition and can be exacerbated by these therapies. 4
– Recommended treatments include resting whilst the joint inflammation
persists, the use of crutches when the knee is swollen.
– This can be followed by physiotherapy, with moderate exercises to ameliorate
flexibility and to strengthen muscles in order to improve joint support. All
patients should participate in regular exercises to improve exercise endurance
and prevent joint stiffness.3
– Medical management includes:1,4
– Antibiotic therapy: active infection
– NSAIDs: acute
– Disease-modifying antirheumatic drugs (DMARDs) mainly Sulphasalazine:
acute and chronic
– Other agents such as methotrexate and azathioprine: chronic
– Intra-articular or local glucocorticoids: mono/oligoarthritis
– Systemic use of glucocorticoids: severe polyarthritis, cardiac and ocular
manifestations.
– Biologicals such as tumor necrosis factor (TNF) blocking agents (e.g.
infliximab and etanercept)
* However, further studies are needed to determine their role in treatment of ReA.
References

1. Cheeti A, Chakraborty R, Ramphul K. Reactive Arthritis (Reiter Syndrome)

[Internet]. Ncbi.nlm.nih.gov. 2019 [cited 9 November 2019]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499831/
2. Colmegna I, Cuchacovich R, Espinoza L. HLA-B27-Associated Reactive
Arthritis: Pathogenetic and Clinical Considerations. Clinical Microbiology
Reviews [Internet]. 2004 [cited 9 November 2019];17(2):348-369. Available
from: https://cmr.asm.org/content/17/2/348#T1
3. Llorente Molina D, Cedeño S. Reiter's Syndrome. Archives of Medicine
[Internet]. 2009 [cited 9 November 2019];1(1.1). Available from:
http://www.archivesofmedicine.com/medicine/reiters-syndrome.pdf
4. Souza T. Differential diagnosis management for the chiropractor. 3rd ed.
Sudbury, Mass.: Jones and Bartlett Publishers; 2005.