Review
Reiter's syndrome: The classic triad and more

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Reiter's syndrome, also known as reactive arthritis, is the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection, particularly those in the urogenital or gastrointestinal tract. Dermatologic manifestations are common, including keratoderma blennorrhagicum, circinate balanitis, ulcerative vulvitis, nail changes, and oral lesions. Epidemiologically, the disease is more common in men, although cases have also been reported in children and women. The pathophysiology has yet to be elucidated, although infectious and immune factors are likely involved. Clinical presentation, severity, and prognosis vary widely. Treatment is difficult, especially in HIV-positive patients. Prognosis is variable; 15% to 20% of patients may develop severe chronic sequelae.

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Historical aspect

Hippocrates was perhaps the earliest to allude to the association between joint symptoms and venereal infections when he wrote: “Youth does not suffer from gout until after sexual intercourse.”1 Although the disease is named after Hans Reiter, who published a case in 1916,2 Reiter's symptoms were actually mentioned as early as the 1500s in Mexican texts.3 Stoll4 published a case in 1869, and Brodie5 followed in 1818 with patients who developed Reiter's symptoms after venereal infections. In

Epidemiology

There are generally considered to be two types of reactive arthritis: epidemic or postdysenteric, and endemic or venereal. Children are more likely to develop postdysenteric reactive arthritis, whereas adults tend to manifest reactive arthritis after venereal infection.8 Reiter's syndrome has also been reported after respiratory infections, urinary tract infections, and after bacillus Calmette-Guérin treatment for bladder carcinoma.9, 10, 11, 12, 13, 14, 15

Epidemiologic studies have been

Pathophysiology/origin

The pathophysiology of Reiter's syndrome is generally thought to have infectious and immune components.

It can occur weeks after an infection in the gastrointestinal or urogenital tracts. Organisms associated with Reiter's include Chlamydia trachomatis,27Shigella flexneri,44Salmonella enteritidis,45Salmonella typhimurium,46Salmonella muenchen,47Yersinia enterocolitica,48Y pseudotuberculosis,49Campylobacter jejuni and Campylobacter fetus,50Ureaplasma urealyticum,51 and Clostridium difficile.52, 53

Clinical manifestations

There is great variation in the severity, number, and timing of clinical features in Reiter's syndrome. Symptoms generally appear within 4 weeks after infection. In children, diarrhea is seen before disease onset in 65% to 69% of cases.8, 21 The predominant symptom may be different in each patient. A woman exhibited mucocutaneous symptoms 4 years before arthritic symptoms.26 In some patients, certain symptoms may not manifest until years later; one patient exhibited skin manifestations 12 years

Diagnosis

Diagnosis is made by medical history and clinical findings.89 Diagnosing Reiter's syndrome can be difficult because only about one third of patients show the complete classic triad90 and some of the clinical features may not develop until years after initial presentation. Symptoms taken individually cannot diagnose reactive arthritis, but the disease becomes more evident with a constellation of symptoms.91 No laboratory tests can single-handedly confirm a diagnosis of Reiter's syndrome, and

Differential diagnosis

Differential diagnosis of reactive arthritis includes the other seronegative spondyloarthropathies, and various diseases affecting the joints such as gout, gonococcal arthritis, septic arthritis, rheumatoid arthritis, and psoriatic arthritis. Skin manifestations can resemble pustular psoriasis, atopic dermatitis, Behçet's disease, and contact dermatitis.8 Keratoderma, uveitis, and balanitis may be syphilis mimicking Reiter's syndrome.92

Psoriasis and Reiter's syndrome share similarities in

Antibiotics

There is no consensus about the use of antibiotics in reactive arthritis. Some suggest that treatment with antibiotics should be prescribed pending culture results20, 39; however, its effect on the severity and duration of Reiter's syndrome is not clear.

Many studies have been done regarding use of antibiotics. One showed that short-term antibiotic treatment has no beneficial effect on the clinical outcome of reactive arthritis associated with enteric infection.96 Another study reported that

Prognosis

Reactive arthritis has a variable course.91 It usually has a duration of 3 to 12 months, and may resolve spontaneously or progress to chronic illness. In adults, exacerbations and remissions are the typical long-term events. One study found that 75% of the patients are in complete remission from all symptoms at the end of the second year after onset.70 Another work, however, found that only 22% of patients were asymptomatic after 6 years.24 Recurrent exacerbations can involve chronic arthritis

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    Funding sources: None.

    Conflicts of interest: None declared.

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