Reiter’s Disease

Reiter’s Disease:

Reiter’s disease is characterised by a symptom complex of urethritis, arthritis and conjunctivitis.

Adult males are most commonly affected, though there may be under-diagnosis in females. The peak incidence is in the 3rd and 4th decades. AIDS-related Reiter’s disease is on the increase.

Aetiology:

There are two forms of Reiter’s disease: post venereal (post urethretic) and post dysenteric. The post venereal form appears after variable intervals of infection with N. gonorrhoea, C. trachomatis and Ureaplasma urealyticum. The post dysenteric form is reported after enteric infection due to salmonella and shigella species as well as Yersinia enterocolitica and C. jejuni. The post dysenteric form is common in India.

HLA-B27 is reported in 70-80% of cases and the rest have HLA-BW22 and BW42 which cross-react with HLA-B27.

Clinical features

Urethritis:

Urethral discharge develops in the venereal form of the disease 1-4 weeks after sexual exposure. It is mucoid or mucopurulent, similar to non-gonococcal infection, and is associated with mild to moderate symptoms. In the dysenteric form too, urethral discharge is known to occur, suggesting an immune mechanism.

Conjunctivitis:

60% of cases develop mild conjunctival congestion which subsides within a month. Episcleritis, superficial punctuate keratitis, corneal ulcers and iritis are the complicating features which may appear in severe cases.

Arthritis:

Sequential asymmetrical polyarthritis involving the knee, ankle, feet and sacro-iliac joints is the most common pattern of joint involvement. The symptoms vary from mild arthralgia to marked erythema, oedema and redness of joints with severe morbidity. The symptoms are more marked within 3 weeks of onset. 20% of cases also develop fasciitis (lover’s heel). Entheseopathy is another feature with marked inflammation at the tendon insertion sites, especially of the tendoachilles (see rheumatology section for details).

Cutaneous manifestations:

Keratoderma blenorrhagica are the skin lesions of Reiter’s disease developing in about 10% of cases. They are thick, crusted scales appearing on the palms and soles with diffuse involvement. Similarly, conical limpet-scales appear on the trunk and extremities on a background of dusky erythema. Some of the crusted plaques resemble psoriasis clinically and histopathologically. The initial lesion may be macular and later turns into vesicle or pustule. Scalp, trunk, extremities, palms, soles and nails are known to be affected severely.

Mucous membranes:

Painless erosions and macules appear in the oral cavity especially on the palate, buccal mucosa, gums and tongue. Circinate balanitis occurs in most cases in the form of geographical serpiginous lesions on the glans penis.

The systemic manifestations are as follows

Systemic manifestations of Reiter’s disease

1. Cardiovascular system Conduction defects
Pericarditis
Myocarditis
Aortic regurgitation
2. Respiratory system Pleurisy
Pulmonary fibrosis
3. Nervous system Organic brain syndrome
Peripheral neuropathy
Meningoencephalitis
4. Miscellaneous Lymphadenopathy
Splenomegaly

The fully manifested disease can be easily diagnosed. The incomplete forms may have to be differentiated from other arthritic disorders.