Reiters disease is a reactive form of arthritis characterized by a triad of seronegative arthritis, urethritis and conjunctivitis.
Young adult males are commonly affected and the disease is rare in females. Its incidence is highest in 3rd and fourth decades. Most of the patient of the diseases are HLA-B27 positive.
Two types of the Reiters disease are recognized.
1. Those which follow dyseneteric infection like Shigella flexneri, Salmonella, Yersinia enterocolitica and Campylobacter jejuni.
2. Following genitourinary infection with pathogens like Chlamydia trachomatis, N. gonorrhoea, Streptococcus pyogenes and Ureaplasma urealyticum.
In majority of cases an antecedent history of infection shall be available in the preceding 2-4 weeks. The diseases starts with low grade fever, fatigue, malaise and weight loss.
There is asymmetric involvement of joints predominantly of lower limbs like knee, ankle, metatarsophalangeal and sacroiliac joints. The wrists and other joints of upper limbs are also involved occasionally.
The joints are involved in varying degrees though most commonly they are very painful with joint effusion and erythema. Tendinitis and fascitis are important lesions. There is specific inflammation at insertion of tendons especially of tendoachilles and plantar fascia. A typical feature is ‘Sausage Digit’ where there is diffuse swelling of a solitary finger or toe.
The arthritis may be very acute but resolves over a period of time. Urethritis may be associated with a sterile urethral dischaige or in the venereal from there is mucoid to mucopurulent discharge.
There is prostatitis in men while in women there is cervicitis or salpingitis. Urethritis may serve as triggering mechanism. Mild conjunctival congestion usually bilateral is present in 30-50% of cases. It resolves spontaneously in 4-6 weeks. Other eye complications include anterior uveitis, iritis, comeal ulcers, keratitis which occur in severe form of disease.
Skin lesions develop in large number of Reiters disease cases. These include keratodenna blenorrhagica which is a form of thick crusted scales appearing on the palms and soles. Such lesions may appear elsewhere in the body on scalp, trunk and extremities.
Nail changes in the form of yellowish discoloration and hyperkeratosis also are seen. Transient, painless, superficial ulcers may be present in the oral cavity. These are quite frequent but asymptomatic lesions in the form of vesicles rupturing to form serpiginous erosions appear on the glans penis.
Uncommon manifestations include pericarditis, conduction defects. Aortic regurgitation, pleurisy, pulmonary fibrosis, meningoencephalitis peripheral neuropathy etc.
Late complication include ankylosing spondylitis and persistent joint pains.
Laboratory investigation of Reiters disease
There is mild anemia with raised sedimentation rate. Rheumatoid factor and auto antibodies are negative. Serologic evidence of a recent infection (Shigella / chlamydia! yersinia) may be present. X-ray changes in early stage are minimal.
In long standing cases there is marginal erosions and loss of joint space in the affected joints. Signs of sacroilitis and spondylitis similar to that of ankylosing spondylitis may be seen. Synovial fluid on aspiration shows to be non-specifically inflammatory with a high neutrophiic count. It is sterile.
Diagnosis of Reiters disease is mainly clinical. In a case of asymmetric, inflammatory arthritis typing for HLA-B27 antigen is an important pointer to the diagnosis. Other tests are non-specific.
It is mainly by NSAIDs. Indomethacin in the dose of 75-150 mg per day in divided doses is given. Results are good. Steroids are not of much use except in cases of uveitis.
Patients who fail to respond to NSAIDs may be administered cytotoxic agents (Azathioprine 1-2mg! kg per day or methotrexate 7.5-15 mg per week). Sulfasalazine upto 3 g!day in divided doses may benefit patients with prolonged and persistent arthritis.
Patients should be watched for systemic complications in Reiters disease. Physical therapy is advised for prevention of disability due to arthritis/ankylosing spondylitis.