Reactive Arthritis (Reiter Syndrome)

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Basics

Reiter syndrome is a seronegative, multisystem, inflammatory disorder classically involving joints, the eye, and the lower genitourinary (GU) tract. It is a postinfectious autoimmune process. Axial joint (e.g., spine, sacroiliac joints) and dermatologic manifestations are common (1)[C],(2)[C].

Description

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

Pediatric Considerations
Juvenile rheumatoid arthritis (RA) has many of the same clinical features as Reiter syndrome.

Pregnancy Considerations
No special considerations; usual drug precautions

Epidemiology

Incidence
  • 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
  • ~3–5 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.

Genetics
HLA-B27 tissue antigen present in 60–80% of patients, suggesting a genetic predisposition

Risk Factors

  • New or high-risk sexual contacts 1–4 weeks before the onset of clinical presentation; the primary infection may be subclinical and undiagnosed.
  • Food poisoning or bacterial dysentery

General Prevention

  • 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

  • Enteric disease
    • Shigellosis; Salmonellosis; Campylobacteriosis
    • Enteric infection with Yersinia spp.
  • Urogenital infection
    • Chlamydia urethritis/cervicitis (3)[C]
    • Mycoplasma or Ureaplasma spp.
  • HIV/AIDS

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Basics

Reiter syndrome is a seronegative, multisystem, inflammatory disorder classically involving joints, the eye, and the lower genitourinary (GU) tract. It is a postinfectious autoimmune process. Axial joint (e.g., spine, sacroiliac joints) and dermatologic manifestations are common (1)[C],(2)[C].

Description

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

Pediatric Considerations
Juvenile rheumatoid arthritis (RA) has many of the same clinical features as Reiter syndrome.

Pregnancy Considerations
No special considerations; usual drug precautions

Epidemiology

Incidence
  • 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
  • ~3–5 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.

Genetics
HLA-B27 tissue antigen present in 60–80% of patients, suggesting a genetic predisposition

Risk Factors

  • New or high-risk sexual contacts 1–4 weeks before the onset of clinical presentation; the primary infection may be subclinical and undiagnosed.
  • Food poisoning or bacterial dysentery

General Prevention

  • 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

  • Enteric disease
    • Shigellosis; Salmonellosis; Campylobacteriosis
    • Enteric infection with Yersinia spp.
  • Urogenital infection
    • Chlamydia urethritis/cervicitis (3)[C]
    • Mycoplasma or Ureaplasma spp.
  • HIV/AIDS

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