| Reiter's syndrome is an inflammatory complication arising from immune response to a previous infection elsewhere in the body. It is considered a rheumatic disease in the category of seronegative spondyloarthropathies, including ankylosing spondylitis, psoriatic arthritis, arthropathy associated with inflammatory bowel disease, or juvenile chronic arthritis. The syndrome is a group of symptoms that includes inflammation of the urethra (urethritis), inflammation of the eye (conjunctivitis), skin lesions, and reactive arthritis. Arthritis is typically asymmetric and can affect the weight-bearing joints of the lower extremity, most frequently at the knee and ankle. Less commonly, arthritis due to Reiter's syndrome also may affect the metatarsophalangeal joints, heel, shoulder, wrist, hip, or lumbar spine.
Reactive arthritis is most often triggered by intestinal (enteric) or urogenital infections, and the infective organisms are typically either enteric or venereal. Most cases of Reiter's occur within 2 to 4 weeks of a sexually transmitted chlamydia (Chlamydia trachomatis) infection (Smith; Lozada). However, dysenteric infections caused by Salmonella enteritidis, Streptococcus viridans, Mycoplasma pneumonia, Shigella flexneri, Yersinia enterocolitica, and Yersinia pseudotuberculosis, or Campylobacter also can lead to Reiter's syndrome. Reiter's syndrome itself is not an infection, and it is not contagious. Ten percent of individuals are not actually diagnosed with a preceding symptomatic infection (Lozada). If infection has been recent, the causative organisms can sometimes be identified in joint fluid (synovial fluid) or synovial biopsy specimens.
It is thought that susceptibility to Reiter's syndrome may be an inherited genetic trait, as 50% to 95% of individuals with the syndrome are seropositive for human leukocyte antigen-B27 (HLA-B27) (De La Torre; Lozada; Scoggins). However, HLA-B27 may be absent in HIV positive individuals with Reiter’s syndrome (Scoggins).Risk: White men between the ages of 20 and 40 are most likely to develop Reiter's syndrome based primarily on a postvenereal male-to-female ratio of 5-10:1 (Scoggins). The postenteric male-to-female ratio, however, is 1:1, indicating equal risk (Scoggins; Lozada). Risk is greater among individuals who have HIV/AIDS and are HLA-B27 seropositive; of these 75% will develop Reiter's syndrome (Schwartz). Risk is also increased in individuals with nonspecific urethritis; 1% to 3% of these individuals develop reactive arthritis (Scoggins). Incidence and Prevalence: Reiter's syndrome is a rare disease estimated to occur in 3.5 individuals per 100,000 in the US (Scoggins). Occurrence correlates with HLA-B27 prevalence and the incidence rate of urethritis/cervicitis and infectious diarrhea (dysentery) (Scoggins). In Finland, incidence is 30 to 40 per 100,000 (Lozada). In the United Kingdom, incidence is 0.8% following urethritis (Schwartz). A high prevalence of chlamydial infection in a given population can increase incidence of Reiter’s syndrome. |
Source: Medical Disability Advisor
| History: Individuals may report initial symptoms of burning or stinging with urination, a constant urge to urinate, and discharge may be seen from the urethra. This may be followed by fever, redness, pain, and discharge from the eye. Pain in the joints then occurs over the next several weeks, typically in the hip, knee, ankle, feet, and lower back, sometimes radiating to thighs and buttocks. Painless ulcers can occur in the mouth and a skin rash may develop that resembles psoriasis. Individuals may report a recent history of dysentery (diarrheic disease) or sexually transmitted disease. Physical exam: The exam may reveal inflammation of the eye, skin lesions, inflammation of the urethra, a tender prostate in men, or an inflamed cervix in women. Joints may be swollen and tender, with stiffness interfering with range of motion. Tests: Tests are not typically used to make a diagnosis, but joint x-rays and a blood test for the genetic marker HLA-B27 may be performed. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may be done to evaluate extent of the inflammatory process. Other blood tests such as a complete blood count (CBC) and a routine blood chemistry panel may be performed to evaluate general health status and to rule out diseases or conditions other than Reiter’s syndrome. The individual may be tested for rheumatoid factor (RF) to rule out rheumatoid arthritis or other rheumatic disease, and the individual will be tested for HIV. Cultures may be done on cervical or urethral discharge or joint fluid to identify any infectious agent. A special culture may be performed for chlamydia since this organism is often difficult to grow and diagnose and is associated with Reiter's. Stool cultures also may be done even though no bowel symptoms are present. |
Source: Medical Disability Advisor
| The syndrome is self-limiting and is not treatable; however, specific symptoms can be treated. Conjunctivitis and skin sores typically resolve without treatment. Active infection such as cervicitis or urethritis can be treated with antibiotics.
Nonsteroidal anti-inflammatories (NSAIDs) as well as corticosteroids are used to treat arthritis associated with Reiter's syndrome. Sometimes simple bed rest can reduce pain and inflammation caused by arthritis associated with Reiter's syndrome. Severe symptoms of Reiter's may be treated with immunosuppressive drugs that reduce the exaggerated immune response and resultant inflammatory process.
Prevention and appropriate treatment of sexually transmitted disease and dysentery may prevent Reiter's syndrome. |
Source: Medical Disability Advisor
| For most individuals, symptoms of Reiter's syndrome are severe for the first few weeks and resolve fully in 3 to 12 months without treatment, although there is a high tendency of recurrence (Lozada). Rate of symptom recurrence is 15% to 50%, and individuals will typically have symptoms that include back pain and arthritis. Rarely will individuals experience severe, deforming, long-term arthritis (Scoggins).
About 15% to 30% of individuals will experience chronic but mild arthritis that continues beyond 6 months (Lozada; Scoggins). Underlying infections resolve with antibiotic treatment. |
Source: Medical Disability Advisor
| Individuals with arthritis associated with Reiter's syndrome may benefit from physical or occupational therapy. Therapists instruct individuals in the use of heating pads as needed for pain control and to decrease joint stiffness. Therapists instruct in gentle stretching and strengthening exercises for the affected joints. Individuals learn to perform these exercises independently to help reduce impairment due to progressive arthritis. Individuals also perform low-impact aerobic exercise such as walking, stationary bicycling, or swimming in order to increase strength and endurance and decrease fatigue. Physical therapists can order assistive devices for walking, such as a cane or walker, that decrease stress through the legs. For those individuals with arthritis in the fingers, wrist, and hand, occupational therapists can order adaptive equipment to reduce the stress these joints experience in daily activities. Therapists address any fatigue or shortness of breath that may occur during activities of daily living (ADLs), and may teach energy conservation techniques where ADLs are broken up into smaller components to make tasks more manageable.
Individuals with heart rhythm or heart valve disturbances associated with Reiter's disease should attend outpatient physical and occupational therapy at a clinic specializing in cardiac rehabilitation. Cardiac rehabilitation centers offer electrocardiogram (ECG) monitoring of all participants during the exercise sessions. Additionally, individuals learn to self-monitor their pulse and perceived exertion so they can perform exercise within safe parameters. |
Source: Medical Disability Advisor
Source: Medical Disability Advisor
| If arthritic joint pain is severe, modifications may be necessary during weight-bearing activities. When hips or lower extremities are involved, limited stair climbing, squatting, and kneeling are advised. Additional rest periods may be needed. Accommodations must be made for supportive devices such as canes, braces, stools, or wheelchairs. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did individual present with symptoms of irritation to the eyes, and skin? Did associated joint pain, swelling, and stiffness occur?
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Were constitutional symptoms such as fever and malaise present?
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Was cervicitis or urethritis present? Did individual present with current or recent diarrheal condition?
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Have diagnostic tests been done to identify underlying infection or to rule out other conditions with similar symptoms such as gonorrhea, rheumatoid arthritis, inflammatory bowel disease, rheumatic fever, ankylosing spondylitis, and psoriasis or psoriatic arthritis?
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Has diagnosis of Reiter's syndrome been confirmed based on the physical exam and history?
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Did individual test positive for HLA-B27?
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Was individual tested for HIV?
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Was individual tested for rheumatoid factor (RF) to rule out rheumatoid arthritis?
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Was synovial fluid tested for the presence of specific bacteria?
Regarding treatment:
- Were specific symptoms of arthropathy treated with bed rest and anti-inflammatory agents? Corticosteroids?
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Were anti-inflammatory and/or immunosuppressive medications effective in resolving pain and inflammation?
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Was an active infection present?
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Were culture and sensitivity testing done to identify causative organism and determine the most effective antibiotic to use?
Regarding prognosis:
- Has a 6-month period passed without resolution of symptoms?
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Are symptoms persisting or is this a recurrence of Reiter's syndrome? If symptoms persist, should diagnosis be revisited?
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Would individual benefit from consultation with specialist such as an infectious disease specialist, rheumatologist, orthopedic surgeon, cardiologist, or dermatologist?
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Have any complications developed as a result of Reiter's syndrome (joint and bone damage or cardiac abnormalities)? If so, are these conditions being addressed in the treatment plan?
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Source: Medical Disability Advisor
| De La Torre, Garcia. "Advances in the Management of Septic Arthritis." Rheumatic Diseases Clinics of North America 29 1 (2003): 61-75. MD Consult. 1 Feb. 2003. Elsevier, Inc. 3 Dec. 2008 <http://home.mdconsult.com/das/journal/view/41631337-2/N/13047894?sid=292570839&source=MI>.Lozada, Carlos J., and Carlos Alonso. "Reactive Arthritis and Reiter Syndrome." eMedicine. Eds. John Varga, et al. 1 Oct. 2008. Medscape. 24 Mar. 2009 <http://emedicine.medscape.com/article/331347-overview>. Schwartz, Robert A. "Reiter Syndrome." eMedicine. Eds. Robin Travers, et al. 21 Apr. 2008. Medscape. 24 Mar. 2009 <http://emedicine.medscape.com/article/1107206-overview>. Scoggins, Thomas, and Igor Boyarsky. "Reiter Syndrome." eMedicine. Eds. Dana A. Stearns, et al. 15 Feb. 2007. Medscape. 24 Mar. 2009 <http://emedicine.medscape.com/article/808833-overview>. Smith, J. R. "HLA-B27--Associated Uveitis." Ophthalmology Clinics of North America 15 3 (2003): 297-307. MD Consult. 1 Sep. 2002. Elsevier, Inc. 3 Dec. 2008 <http://home.mdconsult.com/das/journal/view/41631337-2/N/12596843?sid=292570839&source=MI>. |
Source: Medical Disability Advisor
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