Section 5. Bone, Joint, and Muscle Disorders

Chapter 67. Rheumatoid Arthritis and Other Types of Inflammatory Arthritis

Topics: Introduction | Rheumatoid Arthritis | Psoriatic Arthritis | Reiter's Syndrome | Ankylosing Spondylitis

Reiter's Syndrome

Reiter's syndrome (reactive arthritis) is inflammation of the joints and tendon attachments at the joints, often accompanied by inflammation of the eye's conjunctiva (see Section 20, Chapter 229) and the mucous membranes, such as those of the mouth and genitourinary tract, and by a distinctive rash.

Reiter's syndrome is also called reactive arthritis because the joint inflammation appears to be a reaction to an infection originating in the intestine or genital tract. This syndrome is most common in men aged 20 to 40.

There are two forms of Reiter's syndrome. One occurs with sexually transmitted diseases such as a chlamydial infection and occurs most often in young men; the other usually follows an intestinal infection such as shigellosis or salmonellosis. Most people who have these infections do not develop Reiter's syndrome. People who develop Reiter's syndrome after exposure to these infections appear to have a genetic predisposition to this type of reaction, related in part to the same gene found in people who have ankylosing spondylitis. There is some evidence that the chlamydia and possibly other bacteria actually spread to the joints, but the roles of the infection and the immune reaction to it are not clear.

Symptoms

Typically, symptoms begin 7 to 14 days after the infection. Inflammation of the urethra (the channel that carries urine from the bladder to the outside of the body) can result either directly from infection of the urethra or even from a reaction to the intestinal infection. In men, inflammation of the urethra causes moderate pain and a discharge from the penis or a rash on the glans of the penis (balanitis circinata). The prostate gland may be inflamed and painful. The genital and urinary symptoms in women, if any occur, are usually mild, consisting of a slight vaginal discharge or uncomfortable urination.

The conjunctiva (the membrane that lines the eyelid and covers the eyeball) can become red and inflamed, causing itching or burning and excessive tearing. Joint pain and inflammation may be mild or severe. Several joints are usually affected at once--especially the knees, toe joints, and areas where tendons are attached to bones, such as at the heels.

Small, painless or tender sores can develop in the mouth. Occasionally, a distinctive rash of hard, thickened spots may develop on the skin, especially of the palms and soles (keratoderma blennorrhagicum). Yellow deposits may develop under the fingernails and toenails.

In most people, the initial symptoms disappear in 3 or 4 months. In half of the people, however, joint inflammation or other symptoms recur over several years. Joint and spinal deformities may develop if the symptoms persist or recur frequently. Very few people who have Reiter's syndrome become permanently disabled.

Diagnosis and Treatment

The combination of joint, genital, urinary, skin, and eye symptoms leads a doctor to suspect Reiter's syndrome. Because these symptoms may not appear simultaneously, the disease may not be diagnosed for several months. No simple laboratory tests are available to confirm the diagnosis, but x-rays are often performed to assess the status of joints. A sample taken from the urethra with a swab or a sample of joint fluid may be tested, or a biopsy (removal of tissue for examination under a microscope) of the joint may be performed to try to identify the infectious organism that triggered the syndrome.

When the disease affects the genitals and urinary tract, antibiotics are given to treat the infection, but treatment is not always successful and its optimal duration is not known.

Joint inflammation is usually treated with a nonsteroidal anti-inflammatory drug (NSAID) (see Section 6, Chapter 78). Sulfasalazine or methotrexate, an immunosuppressive drug, may be used, as in rheumatoid arthritis. Corticosteroids are generally not given by mouth but by direct injection into an inflamed joint, which sometimes helps.

Conjunctivitis and skin sores do not usually need treatment, although severe eye inflammation may require a corticosteroid ointment or eyedrops.