Description

A classic triad of features, including arthritis, conjunctivitis/iritis, and either urethritis or cervicitis:

• The epidemiology is similar to other reactive arthritis syndromes, characterized by sterile inflammation of joints associated with infections originating at nonarticular sites. A fourth feature of dermatologic manifestations may include buccal ulceration or balanitis or a psoriaform skin eruption. (Having only 2 features present does not rule out the diagnosis.)
• It has 2 forms: Sexually transmitted, in which symptoms generally emerge between 7 and 14 days after exposure to Chlamydia trachomatis and other urethral/cervical pathogens acquired during sexual contact and postdysenteric or other bacterial enteric infections.
• System(s) affected: Musculoskeletal; Renal/Urologic; Dermatologic/Exocrine
• Synonym(s): Idiopathic blennorrheal arthritis; Arthritis urethritica; Urethro-oculosynovial syndrome; Fiessinger-Leroy-Reiter disease

Geriatric Considerations
In a demographic group associated with new or frequent sexual partners, the antecedent triggering infection is more likely to be sexually transmitted than enteric.

Pediatric Considerations
With a preceding history of enteric illness, the antecedent triggering event is more likely to be a bacterial enteric infection than sexually transmitted.

Pregnancy Considerations
No special considerations, except as related to the usual precautions concerning pharmaceutical therapies

Epidemiology

• Predominant age: 20–40 years
• Predominant sex: Male > Female
• 0.24–1.5% incidence after epidemics of bacterial dysentery
• Complicates 1–2% of all cases of nongonococcal urethritis (1,2)

Risk Factors

• New or high-risk sexual contacts occurring 7–14 days before the onset of clinical presentation; for sexually acquired precipitants of Reiter syndrome, the primary infection may be subclinical and undiagnosed.
• Food poisoning or bacterial dysentery

Genetics
HLA-B27 tissue antigen present in 60–80% of patients

General Prevention

• The immune-response characteristics of this syndrome make specific avoidance of infectious precipitants the most important general precaution and potentially the most difficult to achieve.
• Safer sexual exposures and good food and water handling for personal consumption are essential for all persons at all times to maintain health and to avoid infections and the chronic inflammatory consequences of a previous infection.
• A family history of seronegative or reactive arthritis syndromes may suggest a genetic predisposition.

Pathophysiology

• The pathophysiology of all the seronegative reactive arthritis syndromes and the immunologic role of infectious diseases as precipitants for clinical illness remain incompletely understood.
• Avoidance of precipitant infections and early management of the multiorgan system inflammatory consequences are important. Scientific evidence does not suggest that antibiotic treatment following onset of syndrome will benefit inflammatory joint, eye, or urinary tract symptoms.

Etiology

• Chlamydia trachomatis is the usual causative organism of the postvenereal variety.
• Dysentery-associated form follows enteric bacterial infection owing to Shigella, Salmonella, Yersinia, and Campylobacter spp. This form is more likely to be seen in women, children, and the elderly than is the postvenereal form.

Commonly Associated Conditions

Recent case of:

• Enteric disease from:
  • Shigellosis or,
  • Salmonellosis or,
  • Campylobacteriosis or,
  • Enteric infection with Yersinia spp.
• Urogenital infection from:
  • Mycoplasma or Ureaplasma spp. or,
  • Chlamydia urethritis
• Infection with HIV