Rheumatology Book

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Reiter's Syndrome

Aka: Reiter's Syndrome, Reiter's Disease, Reactive Arthritis, Circinate Balanitis
  1. Definition
    1. Spondyloarthropathy
    2. Aseptic inflammatory Polyarthritis
  2. Epidemiology
    1. Most common inflammatory Polyarthritis in young men
      1. Incidence: as high as 33 in 100,000 males
    2. More commonly affects men by ratio of 9:1 to 5:1
    3. Age of onset as early as 13 years
  3. Pathophysiology
    1. Associated with HLA-B27 Genotype in >66% of patients
    2. Reactive Arthritis may be initial presentation of HIV
    3. First described by Hans Reiter in 1916
      1. Reference case was Prussian Soldier with Diarrhea
  4. Infectious Agents in Reiter's Syndrome
    1. Diarrheal Illness
      1. Shigella flexneri
      2. Shigella dysenteriae
      3. Clostridium difficile
      4. Salmonella typhimurium
      5. Salmonella enteritidis
      6. Yersinia enterocolitica
      7. Campylobacter jejuni
    2. Nonspecific Urethritis
      1. Chlamydia trachomatis
      2. Ureaplasma urealyticum
    3. Immunodeficiency
      1. Human Immunodeficiency Virus (HIV)
  5. Differential Diagnosis
    1. Ankylosing Spondylitis
    2. Colitic Arthritis (associated with Ulcerative Colitis)
    3. Gonococcal Arthritis (NeisseriaGonorrhea)
    4. Systemic Lupus Erythematosus
    5. Lyme Disease
    6. Psoriatic Arthritis (Associated with Psoriasis)
    7. Rheumatic Fever
    8. Rheumatoid Arthritis
    9. Juvenile Rheumatoid Arthritis (Still's Disease)
    10. Gouty Arthritis
  6. Signs
    1. Arthritis onset 1-4 weeks after GI or GU infection
    2. Classic Clinical Triad (infrequently present)
      1. Arthritis
      2. Conjunctivitis
      3. Non-Gonococcal Urethritis
    3. Asymmetric Oligoarticular Arthritis (2-4 joints)
      1. Affects lower extremities most commonly
      2. Large Knee Effusion
      3. Sausage-shaped fingers and toes
        1. Also seen in Psoriatic Arthritis
      4. Enthesitis (ligament, tendon insertion inflammation)
        1. Achilles Tendonitis
        2. Plantar Fasciitis
        3. Patellofemoral Syndrome
      5. Low Back Pain from inflammatory Sacroiliitis
      6. Other musculoskeletal involvement
        1. Anterolateral ribs
        2. Pubic symphysis
        3. Iliac crest
    4. Constitutional symptoms
      1. Weight loss
      2. Fever up to 102 F
    5. Gastrointestinal (precedes Arthritis by 1-4 weeks)
      1. Acute Diarrhea
    6. Genitourinary (precedes Arthritis by 1-4 weeks)
      1. Urethritis
      2. Cervicitis
      3. Cystitis
      4. Hematuria
      5. Hydronephrosis
      6. Circinate Balanitis (10-20% of cases)
        1. Shallow, painless gray-border ulcer of glans penis
    7. Skin changes
      1. Keratoderma blenorrhagica
        1. Hyperkeratotic Papules on plantar foot surface
        2. Similar to lesions in Pustular Psoriasis
      2. Painless, shallow Oral Ulcers
        1. Tongue ulceration
        2. Lip Ulceration
        3. Pharyngeal ulceration
        4. Palate and Buccal mucosa ulcerations
    8. Eye changes
      1. Conjunctivitis
      2. Acute Anterior Uveitis (in up to 37% of cases)
    9. Cardiovascular changes (rare)
      1. Aortitis
      2. Aortic Insufficiency
      3. Conduction abnormality with potential Heart Block
  7. Labs
    1. Complete Blood Count
      1. Anemia
    2. Erythrocyte Sedimentation Rate (ESR) increased
    3. C-Reactive Protein (CRP) increased
    4. Joint Fluid exam
      1. Synovial Fluid WBC: 15,000 to 30,000 per mm3
      2. Neutrophils predominate on differential (>66%)
      3. Normal Joint FluidGlucose
      4. No Synovial Fluid Crystals on Polarized Microscopy
    5. HIV Test
  8. Precautions
    1. Rule-out Septic Arthritis as cause!
      1. Obtain Synovial Fluid as above
      2. Consider Antistreptolysin-O Antibody Test
  9. Management: Similar to Ankylosing Spondylitis
    1. First Line Medications
      1. NSAIDs: Indomethacin SR 75 mg PO bid to tid
      2. Doxycycline 100 mg PO bid for three months
        1. Indicated for suspected Chlamydia etiology
      3. Intra-articular Corticosteroid Injection
        1. Indicated for large Knee Effusions
    2. Second line agents for persistent disease
      1. Sulfasalazine 1 gram PO bid to tid
    3. Third line agents for chronic Disability (avoid in HIV)
      1. Methotrexate 7.5 to 25 mg per week
      2. Azathioprine (Imuran) 100 to 150 mg PO qd
  10. Course
    1. Self-limited: Resolves over 3-12 months
    2. Chronic Arthritis may develop in up to 30% of cases
  11. References
    1. Tak Yan Yu in Ruddy (2001) Kelley's Rheum, p. 1055-67
    2. Arnett in Klippel (1997) Primer Rheumatic, p. 184-88
    3. Barth (1999) Am Fam Physician 60:499-507 [PubMed]
    4. Kataria (2004) Am Fam Physician 69:2853-60 [PubMed]
    5. Kirchner (1995) Postgrad Med 97(3): 111-22 [PubMed]

Reiter Syndrome (C0035012)

Definition (MSHCZE) Chorobný stav řazený k reaktivním artritidám (spondylartritidám) charakterizovaný nehnisavým zánětem kloubů při současném zánětlivém postižení močové trubice (uretritida), oční spojivky (konjunktivitida), následující obv. po střevním zánětu, klasicky po dysenterii. Může být při venericky získané chlamydiové infekci močových cest. Často je přítomen histokompatibilní antigen HLA-B27. Klasická triáda je spíše vzácná. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) A rare, reactive inflammatory disorder seen following bacterial infection. It predominantly affects males aged 20-40. Individuals with HLA-B27 antigen are estimated to have a 50 % increased risk. The disorder is characterized by arthritis, conjunctivitis, uveitis, iritis and ulceration of the oral cavity, genitals and volar surfaces of the hands and feet. The clinical course is self-limited with resolution of clinical disease usually within six months of onset.
Definition (CSP) triad of nongonococcal urethritis followed by conjunctivitis and arthritis.
Definition (MSH) Historically characterized by a triad of inflammation involving the eye (CONJUNCTIVITIS), the bone (POST-INFECTIOUS ARTHRITIS), and the urethra (URETHRITIS), it is now thought to be nearly synonymous with reactive arthritis.
Concepts Disease or Syndrome (T047)
MSH D016918
ICD9 099.3
ICD10 M02.3, M02.30, M02.39
SnomedCT 67224007, 154390002, 266212009, 154389006
English Fiessinger-Leroy-Reiter syndrome, REITER'S SYNDROME, REITERS DISEASE, Reiters Disease, REITER DIS, Disease, Reiter's, Reiter Disease, Syndrome, Reiter, Disease, Reiter, REITERS DIS, Reiter's Disease, Fiessinger Leroy Reiter syndrome, Reiter's syndrome with arthropathy, Reiter's syndrome with arthropathy (diagnosis), Reiter's syndrome (diagnosis), Reiter's Syndrome, Reiters disease, Reiter syndrome, Reiter disease, Reiter Syndrome, Reiter's disease, unspecified site, Reiter's disease, site unspecified, reiters disease, reiter syndrome, reiters syndrome, syndrome reiter, syndrome reiter's, reiter's disease, disease reiters, reiter disease, reiter's syndrome, Urethrooculoarticular syndrome, Reiter's syndrome, Reiter's disease, Reiter's disease (disorder), arthritis; urethritica, Reiter; triad, Reiter, syndrome; urethro-oculo-articular, triad; Reiter, urethritica; arthritis, urethro-oculo-articular; syndrome, uroarthritis; infectious, Reiters syndrome
Dutch ziekte van Reiter, Reiter-syndroom, syndroom van Fiessinger-Leroy-Reiter, Reiter; trias, artritis; urethritica, syndroom; urethro-oculo-articulair, trias; Reiter, urethritica; artritis, urethro-oculo-articulair; syndroom, uroartritis; infectieus, Ziekte van Reiter, syndroom van Reiter
German Reiter-Syndrom, Fiessinger-Leroy-Reiter-Syndrom, Reiter-Krankheit, Morbus Reiter, Urethro-okulo-synoviales Syndrom, MORBUS REITER
Italian Sindrome di Fiessinger-Leroy-Reiter, Malattia di Reiter, Sindrome di Reiter
Portuguese Síndrome de Fiessinger-Leroy-Reiter, Doença de Reiter, SINDROME DE REITER, Síndrome de Reiter
Spanish Enfermedad de Reiter, Síndrome de Fiessinger-Leroy-Reiter, SINDROME DE REITER, enfermedad de Reiter (trastorno), enfermedad de Reiter, síndrome de Reiter, síndrome uretrooculoarticular, Síndrome de Reiter
Japanese ライター病, ライター症候群, ライターショウコウグン, ライタービョウ
French Syndrome conjonctivo-urétro-synovial de Fiessinger-Leroy-Reiter, Syndrome conjonctivo-uréthro-synovial de Fiessinger-Leroy-Reiter, Syndrome de Fiessinger-Leroy-Reiter, Syndrome de Reiter, Maladie de Reiter, Syndrome oculo-urétro-synovial, SYNDROME DE REITER
Czech Reiterova choroba, Fiessinger-Leroy-Reiterův syndrom, Reiterova nemoc, Reiterův syndrom
Korean 라이터병
Hungarian Reiter-syndroma, Fiessinger-Leroy-Reiter syndroma, Reiter-betegség, Reiter syndroma, Reiter betegség
Norwegian Reiters syndrom, Reiters sykdom
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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