Reactive Arthritis (Reiter Syndrome)
Reiter syndrome is a seronegative, multisystem, inflammatory disorder classically involving joints, the eye, and the lower genitourinary (GU) tract, and skin. It is a postinfectious autoimmune process. Axial joint (e.g., spine, sacroiliac joints) and dermatologic manifestations are common (1)[C],(2)[C].
The classic triad includes arthritis, conjunctivitis/iritis, and either urethritis or cervicitis (“can’t see; can’t pee; can’t bend my knee”).
- The epidemiology is similar to other reactive arthritides, characterized by sterile joint inflammation associated with infections originating at nonarticular sites. A fourth feature (dermatologic involvement) may include buccal ulceration, balanitis, or a psoriasiform skin eruption. (Having only two features does not rule out the diagnosis.)
- Two forms of Reiter syndrome:
- Sexually transmitted: Symptoms emerge 7 to 14 days after exposure to Chlamydia trachomatis and other sexually acquired pathogens.
- Postenteric infection (including traveler’s diarrhea)
- In individuals with new or frequent sexual partners, the triggering infection is likely sexually transmitted (rather than enteric).
- In individuals with a history of recent enteric illness, the triggering event is more likely to be a bacterial enteric infection than sexual transmission.
- System(s) affected: musculoskeletal, renal/urologic, dermatologic/exocrine
- Synonym(s): idiopathic blennorrheal arthritis; arthritis urethritica; urethro-oculo-synovial syndrome; Fiessinger-Leroy-Reiter disease; reactive arthritis
Juvenile rheumatoid arthritis (RA) has many of the same clinical features as Reiter syndrome.
No special considerations; usual drug precautions
- Predominant age: 20 to 40 years
- Predominant sex: male > female
- 0.2–1% incidence after bacterial dysentery outbreaks
- Complicates 1–2% of nongonococcal urethritis cases
- ~3 to 5 cases per 100,000 individuals per year
Etiology and Pathophysiology
- The pathophysiology of all the seronegative reactive arthritis syndromes and the immunologic role of infectious diseases as precipitants for clinical illness are incompletely understood. Proinflammatory cytokines lead to synovitis. Toll-like receptors (TLR) have been implicated in the recognition of gram-negative lipopolysaccharide as part of the disease cascade.
- Avoiding precipitant infections and early management of multiorgan inflammation is important. Antibiotic treatment following onset of syndrome does not appear to benefit inflammatory joint, eye, or urinary tract symptoms.
- C. trachomatis is the most common sexually transmitted infection associated with Reiter syndrome.
- Dysentery-associated Reiter syndrome follows infection with Shigella, Salmonella, Yersinia, and Campylobacter spp. Enteric-associated Reiter syndrome is more common in women, children, and the elderly than the postvenereal form.
HLA-B27 tissue antigen present in 60–80% of patients, suggesting a genetic predisposition
- New or high-risk sexual contacts 1 to 4 weeks before the onset of clinical presentation; the primary infection may be subclinical and undiagnosed.
- Food poisoning or bacterial dysentery
- The immune-response characteristics of this syndrome make avoidance of infectious precipitants the most important general precaution (and potentially the most difficult to achieve).
- Safe sexual practices; proper food and water hygiene
Commonly Associated Conditions
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