Reiter's disease is named after the German physician Hans Reiter, who in 1916 described the clinical picture of a strange illness that included 3 symptoms: urethritis, arthritis and conjunctivitis.
disease or syndrome is a fairly rare disease that has become widespread due to the intensification of international tourism and, as a consequence, an increase in the risk of infectious diseases, including sexually transmitted diseases. This is a complex disease in which the organs of the genitourinary system, joints and eyes are simultaneously or sequentially affected. This disease is primarily the responsibility of a rheumatologist, but also of related specialists - urologists, gynecologists and ophthalmologists.
1
Consultation with a urologist for Reiter's disease
2 Consultation with a gynecologist for Reiter’s disease
3 Consultation with an ophthalmologist for Reiter’s disease
Causes of the disease
According to statistics, this syndrome most often affects representatives of the stronger sex; Reiter's disease in men (mostly aged 20-40 years) occurs in 80% of cases. Reiter's disease develops much less frequently in women; in isolated cases, children become infected.
It is assumed that one of the main factors of the disease is sexually transmitted infections. Most often, the causative agent is chlamydia, a microorganism 250-300 nm in size that can exist in the human body for a long time. In a life-threatening situation for the microorganism, chlamydia can transform into the L-form, which is more resistant to external influences and has the ability to be parasitized for a long time. All this contributes to the chronic course of the disease.
Reiter's disease can also be preceded by an acute intestinal infection, such as salmonellosis or dysentery. There are known cases of Reiter's disease caused by pathogenic flora that enters the human body through food intake or the respiratory route.
Hereditary predisposition plays a major role in the development of Reiter's syndrome. Improper immune activity is inherited from parents. Under appropriate, unfavorable conditions, the immune system begins to direct its forces to the cells of its own body.
In this regard, cases of the development of the disease due to sexually transmitted infection and after the patient has suffered infectious enterocolitis are usually separated.
General aspects and historical aspects of the disease
Important! Reiter's syndrome is an outdated name for this pathology today. All developed countries have come to the conclusion to change the term to “reactive arthritis”. The reason for this is Dr. Reuter's direct connection with the brutal actions of the Nazi government in Germany during World War II. More details about the historical aspects of this pathology in the video in this article.
Patients with symptoms of genitourinary infection, inflammation of the conjunctival membranes of the eyeball and the involvement of joints in the inflammatory process combined with this picture have always aroused interest from doctors even before the discovery of this syndrome. The presence of a single pathogenetic mechanism between the above-described manifestations has always been suspected.
Uveitis or conjunctivitis is a sign from the characteristic Reiter triad.
And it was precisely the large number of clinical cases with this triad, which arose during the First and Second World Wars, that made it possible to determine the unity of pathogenesis between them, and to identify the etiology that is responsible for the development of this syndrome.
Identification of the bacterial agents responsible for the development of this syndrome and the presence of the HLA-B27 antigen (which characterizes the patient as susceptible to the development of the disease) made it possible to examine this syndrome in more detail.
Symptoms of Reiter's syndrome with chlamydia develop in 4-8% of those infected, which is very different from the incidence of reactive arthritis after an intestinal infection (1-30%, respectively). Moreover, among all patients, the average age ranges from 18 to 40 years.
What happens during Reiter's disease?
As a result of sexual infection in the genitourinary organs (urethra, prostate, cervical canal of the uterus), a focus of chronic inflammation is formed, which acts as a trigger for further inflammation in the joint tissues or organ of vision.
After some time, a cross-immune reaction appears, the severity of which determines the nature of the course of the disease.
There are 2 stages of the disease: the first is infectious, characterized by corresponding signs of damage to the genitourinary or gastrointestinal tract. The second is immunopathological, accompanied by the development of immune-mediated pathology with damage to the joints and conjunctiva of the eye.
Symptoms of Reiter's disease
Symptoms of Reiter's disease have a number of features:
- The period from the moment of infection to the moment of manifestation of the disease (incubation period) is 1-2 weeks;
- The onset of the disease is characterized by the appearance of signs of urethritis (pain when urinating, changes in urine, which are confirmed by laboratory tests).
- After a few days, conjunctivitis may begin (the patient experiences eye irritation, a feeling of sand, and the eyes become red).
- After some time (from 2 weeks to several months), large joints, usually knees or ankles, begin to hurt. Then the inflammation rises, and later the joints of the hands begin to ache. In this case, the joint enlarges, swells, and the skin around it becomes swollen.
- During the illness, periods of exacerbation and remission may alternate.
Cases of asymptomatic development of urethritis, when the appearance of conjunctivitis and arthritis seem unrelated, require special competence of doctors.
Only experienced and qualified specialists, such as rheumatologists at MedicCity, can recognize a hidden threat to the body and prescribe adequate treatment.
1 General blood test
2 X-ray of joints
3 Diagnosis of Reiter's disease
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How dangerous is the disease?
The picture of the advanced stage of Reiter's disease looks very sad: pain and itching in the urethra, discharge from the urethra, pain in the knee, ankle, interphalangeal joints, inflammation of the mucous membrane of the eyes.
Inflammation of the Achilles tendon and severe pain in the heels often occur.
The development of balanoposthitis is possible.
In the acute period of the disease, keratoderma (mainly on the feet and palms) and psoriasis-like manifestations on the skin and nails often occur.
Lymphadenitis (usually inguinal glands), cardiac arrhythmias and conduction disturbances due to myocardial damage, and pericarditis may occur.
Kidney damage (glomerulonephritis, pyelonephritis, etc.) is common.
Severe forms of pustular dermatoses, which include various forms of pustular psoriasis, subcorneal pustular dermatosis of Sneddon-Wilkinson, deep forms of pyoderma, as well as blenorrheic keratoderma in Reiter's disease, present certain difficulties for differential diagnosis, as well as treatment of patients. In persons infected with the human immunodeficiency virus (HIV), these diseases acquire a number of characteristics: they occur in unusual age and gender groups, have a severe course, manifest themselves atypically, and are difficult to treat. The occurrence of sexually transmitted infections (STIs) in HIV-infected people also causes a more malignant course of the disease [1].
Reiter's disease (RD) is diagnosed in a timely manner in 20% of patients [2, 3]. BR is a combination of urethritis (in women - cervicitis), arthritis, in the absence of rheumatoid factor, and inflammatory changes in the skin and mucous membranes in the form of conjunctivitis, dermatitis, erosions of the oral mucosa [4]. The disease was known long before its description by G. Reiter [5], who in 1916 published the case history of a young officer who suffered from diarrhea, who developed urethritis and conjunctivitis after 1 week, and subsequently developed polyarthritis. In 1962, A. Siboulet and P. Galistin first established a connection between the disease and the presence of chlamydia in the urethra [6]. Almost 90% of patients with BD have the HLA-B27 allele, while the frequency of this allele in the population is less than 10% [4]. Outbreaks of BD most often occur in countries with a high prevalence of HLA-B27, such as the Scandinavian countries. The ratio of men to women, according to various sources, varies from 2:1 [4] to 100:1 [7]. The etiology of the disease is associated with Chlamydia trachomatis
, without excluding the possibility of its development during infection with other pathogens - ureaplasmas, mycoplasmas, Trichomonas, gonococci, etc. [7, 8]. BD is the most common cause of arthritis in young people. In HIV-infected people with HLA-B27, the risk of Reiter's syndrome is even higher [4].
The incubation period is usually 1-4 weeks after infection. Patients are usually concerned about pain, swelling and limited joint mobility. During the first episode of the disease, 1-3 joints are usually affected. Diffuse synovitis of one or more fingers or toes, the so-called sausage finger, is uncommon, but is a classic symptom of the disease [4]. A typical skin lesion in BD is keratoderma blenorrheica. Differential diagnosis of skin manifestations and joint lesions includes pustular psoriasis, psoriatic arthropathy, rupees and ecthymas in secondary syphilis, cutaneous pyoderma. As many authors point out, clinically and histologically keratodermic and psoriasiform lesions in BD are similar to elements of rupoid psoriasis [2, 3]. Late diagnosis of the disease, lack of a full examination, irrational treatment at the initial stages, underestimation of concomitant pathology can lead to a severe course of this pathology. We present the results of our observations.
Patient B.
, 23 years old, on November 10, 2012, was transported by an ambulance team to a multidisciplinary city hospital. She was hospitalized in the therapeutic department with a diagnosis of “common pyoderma, acute, moderate severity, candidal onychomycosis of the hands and feet.” She was hospitalized on an emergency basis with complaints of rashes and itching of the skin of the upper and lower extremities, chest, abdomen, and increased body temperature to febrile levels. On admission the condition was of moderate severity. Respiratory rate - 16 per minute, heart rate (HR) - 76 per minute, blood pressure - 110/70 mm Hg.
Laboratory data.
General blood test
dated November 10, 2012: erythrocytes - 3.55·1012/l, hemoglobin - 130 g/l, platelets - 542·109/l, leukocytes - 12.8·109/l, gr.
- 79.5%, lymphocytes - 13.4%, monocytes - 7.1%, erythrocyte sedimentation rate (ESR) - 40 mm/h. The microreaction to syphilis is negative. Biochemical blood test
: creatinine - 128 µmol/l, total bilirubin - 6.8 mmol/l, aspartate aminotransferase (AST) - 13 U/l, alanine aminotransferase (ALT) - 19 U/l, sodium - 133, potassium - 4.1 , chlorine - 97, urea 5.7 mmol/l, sugar - 5.3 mmol/l.
X-ray of the chest organs
: lungs without focal and infiltrative shadows, sinuses are free, heart is normal.
Electrocardiogram
: sinus tachycardia, heart rate - 103 per minute, signs of load on the right atrium. Blood was taken for HIV on 11/12/12.
The patient received treatment: prednisolone 60 mg intravenous drip No. 1; suprastin 1.0 intramuscularly; Ringer's solution intravenously No. 1; ceftriaxone 2 g/day; sodium thiosulfate 30% 10.0 intravenously; calcium gluconate 10% 10.0 intravenously; pancreatin tablets, activated carbon, omeprazole, fluconazole 150 mg. Consulted with an infectious disease specialist, a surgeon, and the head of the inpatient department of the OKVD. Transferred to Tyumen OKVD on 11/14/12.
Upon admission to the inpatient department of the OKVD, complaints of skin rashes, crusts, damage to the nails, pain in the joints, and an increase in body temperature within 1.5 months to 37.5-38 ° C.
From the medical history
: sick for about 1.5 months. He attributes his illness to consuming large quantities of plums. The first rashes appeared on the lower extremities. After intensive combing, the elements began to become covered with crusts. She did not treat herself.
An. vitae
.
Born and lives in the Kurgan region. In 2009, hepatitis B was diagnosed. Multiple fractures of the pelvis, hips, and legs as a result of a fall from a height in 2009. No history of allergies. Gynecological history
: regular menstruation, no pregnancies. Single. Has a permanent sexual partner, born in 1979, sexual relations for 2 years. Last sexual intercourse 1.5 months ago. Does not indicate other sexual contacts. The sexual partner is called to the venereologist at the OKVD. Heredity is not burdened.
Status praesens
. The general condition is satisfactory, the position is passive. Body temperature 37.6 °C. The physique is irregular, the constitution is hyposthenic. Reduced nutrition. The skin is pale and moist. Minor swelling of the knees, ankles, lower third of the legs. The inguinal lymph nodes are enlarged to the size of a bean, heavy, painful on palpation.
Status localis
. The pathological process is widespread. Localized on the skin of the red border of the lips, forearms, elbow joints, abdomen, thighs, legs, feet. The red border of the lips is brightly hyperemic, in the corners of the mouth there are linear ulcers with serous-hemorrhagic crusts. On the mucous membrane of the tongue there is a “geographical pattern”, folding. On the skin of the forearms and shins there are multiple rashes, rounded lesions against the background of hyperemic, edematous, infiltrated skin, 1-5 cm in diameter. On the surface of the elements there is a layering of thick brown scaly crusts in the form of rupees. On the skin of the thighs, pubic area, perineum - confluent erythema, swelling, layered scaly crusts. On the skin of the periungual ridges there is swelling, bright hyperemia, with a layer of grayish-yellow scales. The nail plates on the hands and feet are thickened, peel off from the nail bed, and have a yellow-gray color.
The interphalangeal joints of the first finger of the right hand are swollen like a “sausage-shaped” finger, the interphalangeal joints of the feet are also swollen, stiff and painful when moving. On the skin in the joint area there is hyperemia, stagnant red color, layering of crusts (Fig. 1-5)
.
Figure 1. Patient B. BR. Blenorrheic keratoderma.
Figure 2. Patient B. BR. Joint damage. Sausage finger.
Figure 3. Patient B. BR. Keratoderma. Joint damage. Onychia. Figure 4. Patient B. BR. Keratoderma of the feet.
Figure 5. Patient B. BR.
Arthritis of the first finger. Keratoderma. Candidal onychia and paronychia. The external genitalia are formed correctly. The labia majora and minora are sharply swollen, the mucous membrane is clearly hyperemic and has a granular texture. The urethral sponges are swollen and hyperemic. The posterior commissure is torn and bleeding. Vaginal discharge is profuse, purulent-hemorrhagic. Examination in mirrors is difficult due to severe pain and the patient’s refusal to be examined in mirrors.
Examination.
Complete blood count
(from 11/14/12): leukocytes - 4.7 l09/l, erythrocytes - 3.07 l012/l, hemoglobin - 93 g/l, hematocrit - 17.9%;
platelets - 200·109/l, eosinophils - 0, band cells - 2, segmented cells - 79, lymphocytes - 12, m-6, ESR - 69 mm/h; anisocytosis, poikilocytosis. General urine analysis
(from 11/14/12): pH 6.5, transparent, specific gravity - 1030, protein - 0.3 g/l, negative sugar, urobilinogen - 17 µmol/l, leukocytes - 25/µl, ketone - 0 .5 mmol/l, nitrates are positive.
RMP, ELISA for syphilis total - negative (from 11/13/12).
RIF for chlamydia is positive (from 11/13/12).
PCR for chlamydia is positive (dated 11/13/12).
Bacteriological culture
for ureaplasma urealiticum, mycoplasma hominis in the sample dated 11/15/12 - negative.
Microflora smear
(11/13/12). Urethra: leukocytes - 6-8 in the field of view (n/z), epithelium - 2-4 in n/v. Cervix of the uterus: leukocytes - 40-60 in the field of vision, epithelium - 6-8 in the field of view. Posterior vaginal fornix: leukocytes - 20-24 in the field of view, epithelium - 2-4 in the field of view, trichomonas were detected, microflora (G+) was moderate.
Bacteriological culture
skin scales and nail plates from 11/15/12: growth of fungi of the genus
Candida albicans
.
Feces for worm eggs (11/14/12) - not found.
RIF for herpes type 1 and 2 (dated 11/26/12) were detected.
Blood chemistry
(from 11/16/12): total bilirubin - 9 µmol/l, direct - 1 µmol/l, AST - 29 U/l, ALT - 33 U/l, alkaline phosphatase - 124 U, seromucoid - 0.67, C- reactive protein - 4 units.
ELISA for Chl. trachomatis
(from 11/16/12): IgA not detected, IgG - 1:5 OD, 0.367/0.290.
HIV RNA by PCR method dated November 21, 2012: detected at a concentration of 2.14·105 copies/ml.
Immunogram dated November 19, 2012: CD4 - 252, CD8 - 488, CD4/CD 8: 0.52.
Consulted by the Deputy Chief Physician of the Center for AIDS Control (CPBC) and IH, preliminary diagnosis: HIV infection, stage IVa, progression phase. After discharge, further observation and treatment at the Center for Antiretroviral Therapy is recommended.
An analysis of the patient’s medical history and the results of clinical and laboratory studies allowed us to establish the following diagnosis: “BD, acute, moderate severity (arthritis, urethritis, vulvitis, widespread keratoderma blenorrhea). Chlamydial infection of the lower genitourinary tract. Urogenital trichomoniasis. Urogenital herpes, exacerbation. HIV infection, stage IVa, progression phase. Candidal onychomycosis, paronychia. Hypochromic anemia, mild severity.”
Treatment.
Sodium thiosulfate solution 30% - 10.0 intravenously No. 10; sodium chloride solution 0.9% - 400.0 + dexazone 8 mg intravenously drip No. 5 daily; sodium chloride solution 0.9% - 200.0 + ascorbic acid solution 5% - 4.0 intravenous drip No. 5 daily; doxycycline 0.1 1 capsule 2 times a day for 21 days; metronidazole solution (metrogyl) 100.0 2 times a day intravenously drip No. 6; diclofenac retard capsules 0.1 once a day for 10 days; itraconazole 0.1 2 times a day for 21 days. From 11/17/12 - metronidazole 0.25, 2 tablets 2 times a day for 5 days. From November 26, 2012 - acyclovir 200 mg 3 times a day for 7 days. Fluconazole - 150.0 mg 1 time per day after 3 days No. 3.
Local:
bath for the external genitalia with potassium permanganate No. 1. On the legs, thighs - tetracycline ointment + 2% salicylic ointment under a bandage once a day. On the pubic area and external genitalia - tetracycline ointment under a bandage. On the nail plates - 5% iodine solution. For periungual ridges - 5% iodine solution, clotrimazole cream. For snacks - fucorcin solution 2 times a day. From 11/28/12 on the external genitalia - lotions with a tannin solution for 1.5 hours, 2 times a day.
Examined in mirrors to take a control smear and after resolution of the process on the external genitalia (11/26/12). On the commissures of the labia majora, the mucous membrane of the right labia, and the vestibule of the vagina up to 0.5 cm, there are several round-shaped erosions with a coating of fibrin. Urethral sponges without swelling or hyperemia. The cervix is smooth, there is no discharge from the cervical canal. In the posterior vaginal fornix there is mucous discharge. Control smear for microflora dated November 26, 2012: leukocytes - 3-10 in the field of vision, epithelium - 2-9 in the field of view.
General blood analysis
from 11/23/12: leukocytes - 9.7 109/l, erythrocytes - 3.68 1012/l, hemoglobin - 105 g/l, hematocrit - 22.1%, platelets - 350 109/l, eosinophils - 1, rod-nuclear - 0, segmented - 85, l.
- 7, m. - 7, ESR - 68 mm/h, anisocytosis, poikilocytosis. General urine test
dated 11/23/12: pH 8, transparent, specific gravity - 1005, protein negative, sugar negative, urobilinogen negative, leukocytes - 25 µl, ketone negative, nitrates negative
She was discharged with improvement: on the skin of the face and forearms the crusts were rejected, on the skin of the torso and limbs there were secondary brownish spots at the site of former lesions. Erythema of the periungual ridges persists. The nail beds of the hands and feet are bare. Nail plates are yellow. The area of the external genitalia with complete epithelization of erosions, with persistent secondary erythema.
Recommendations were given: continue clinical and laboratory monitoring at the OKVD clinic, consultation with a mycologist. Taking itraconazole in courses (1 capsule 2 times a day for 7 days with 3-week breaks, 3 courses). Take medications that normalize intestinal flora (“Bifidumbacterin”, “Normoflorin”). Barrier contraception! Examination and treatment of the sexual partner. Consultation and further observation of specialists at the Central Children's Hospital.
Discussion
Patients with severe pustular dermatosis should be carefully screened, including for STIs. To make an etiopathogenetically based diagnosis, it is necessary to take into account the totality of symptoms. Particularly severe forms of pustular dermatoses raise concerns about possible HIV infection. Delayed diagnosis and incorrect patient management tactics can aggravate the patient’s condition and lead to an unfavorable outcome.
Diagnosis of Reiter's disease
The clinical diagnosis is not difficult to predict if the characteristic symptoms of Reiter's disease are present. However, laboratory diagnostics are used to confirm the diagnosis:
- an increase in ESR indicates inflammation in the body;
- an increase in white blood cells indicates a bacterial infection;
- a clinical urine test can reveal urethritis, with the appearance of leukocytes;
- the presence of chlamydia is confirmed using polymerase chain reaction (PCR);
- Thanks to radiography and ultrasound examination of joints, it is possible to determine the degree of structural changes in the joints.
Diagnosis of reactive arthritis
The problem with diagnosing reactive arthritis is the lack of clinical criteria, as for other pathologies. Therefore, the patient’s collected medical history, data obtained during the examination and the results of laboratory and instrumental studies play a large role. At the same time, a number of diagnostic methods are required, since there is no single test whose positive result will confirm Reiter's syndrome in a patient.
Laboratory research
- ESR and other acute phase indicators are increased;
- mild anemia;
- analysis of synovial fluid shows nonspecific inflammation;
- HLA-B27 is positive in 30-50% of cases;
- isolating a culture of the trigger microorganism is possible (but not necessary) at the site of its primary infection;
- PCR for chlamydial DNA can be positive in the acute phase of the disease.
Instrumental diagnostics
Radiological signs are absent in the early stage of the disease or its mild form.
However, with chronicity of the process and long-term inflammation, the following symptoms may be observed:
- narrowing of the joint space;
- marginal erosion;
- inflammation of the periosteum;
- formation of spurs at the site of attachment of the plantar fascia.
The extent of eye damage in reactive arthritis varies widely.
Attention! In reactive arthritis, sacroiliitis is unilateral, unlike ankylosing spondylitis.
Treatment of Reiter's disease
Treatment of the disease is complex, the following drugs are used:
- broad-spectrum antibiotics;
- anti-inflammatory drugs (diclofenac, ortofen, etc.); if there is no effect, the doctor may prescribe hormonal anti-inflammatory drugs.
- painkillers to reduce joint pain;
- eye drops;
Therapeutic gymnastics can also be used to restore joint mobility.
A patient with Reiter's disease may require complex treatment from various specialists, using modern drugs, the latest diagnostic and therapeutic medical equipment. The MedikCity Clinic is a multidisciplinary clinic that provides medical services in 30 areas and has its own diagnostic center. We know how to treat Reiter's disease and other rheumatological diseases.
Therapeutic tactics
The presence of all signs of reactive arthritis in a patient allows him to be prescribed high doses of NSAIDs (non-steroidal anti-inflammatory drugs), which help the vast majority of patients with acute symptoms of the disease. However, severe Reiter's syndrome may not respond to this drug treatment.
Indomethacin is usually the first-line drug in the treatment of reactive arthritis.
Important! Patients with renal failure should not only pay attention to the warnings in the instructions for this drug, but also consult with a doctor about the specifics of taking NSAIDs with reduced renal function.
Antibacterial therapy does not have a positive effect on the course of reactive arthritis in the patient. However, specific treatment of chlamydial infection in its acute period even before the development of Reiter's syndrome can increase the chances of preventing the development of the latter.
Heel spur with plantar fasciitis and Achilles tendinitis in a patient with reactive arthritis.
Dermatological manifestations may require topical glucocorticoid therapy, and for tendinitis, administration of GCS directly to the site of inflammation can be used.
An aggressive treatment option may be needed in case of protracted reactive arthritis, or in the presence of its severe manifestations - a systemic process, severe uveitis, threatening the patient with blindness. In this case, drugs such as Sulfasalazine, Methotrexate and others can be used.
Attention! The treatment described above is not routinely used, and there are no studies conducted to determine its effectiveness in severe reactive arthritis.
Inflammation of the joint of the first finger can accompany the course of not only gout, but also reactive arthritis.
Systemic glucocorticosteroids are not used for Reiter's syndrome, unlike other rheumatological pathologies.
In conclusion, it is important to note that the price of your own health should be above all else. In order to achieve it, it is necessary to make every effort not only when various diseases appear, in order to recover as quickly as possible. The way of life should be aimed at preventing diseases and maintaining health at a high level.