A 29-year-old man sought treatment at our clinic for an extensive rash he'd developed the month until that time. The rash be on his scalp, umbilicus, glans penis, palms, and soles of his feet. He reported swelling in his departed knee and his fourth toes bilaterally that be exacerbated by weight position. During the 2 days prior to his visit to the clinic, the tolerant said he'd had a confusion and night sweats; he denied optical symptoms, GI complaints, dysuria, or penile discharge.
When asked about his sexual history, the tolerant noted that he'd had unprotected intercourse beside a woman a year earlier that resulted within pain on urination and resolved on its own. Other than a resolved defence of oral thrush, the patient have a noncontributory past medical history, took no medication, and had no loved ones history of psoriasis.
A physical exam revealed circinate, scaly, and erythematous plaques covering his entire scalp (FIGURE 1). The tolerant's conjunctiva and oropharynx were clear. His fingernails showed hyperkeratosis, subungual jetsam, and nail fold erythema, in need pitting. He also had bilateral swelling of the distal interphalangeal joint of his index fingers.
[FIGURE 1 OMITTED]
The patient's umbilicus have a scaly erythematous plaque, while in attendance were confluent erythematous plaques within the groin area, and on the glans penis. There be also similar erythematous plaques in the axilla and inguinal folds; plaques on the lower extremities have a thicker layer of ascend. The patient's foot had crusted plaques on the plantar surface, hyperkeratotic nail with gelatinous subungual debris, and swelling and pain of the fourth toes bilaterally (FIGURE 2).
* What is your diagnosis?
[FIGURE 2 OMITTED]
* Diagnosis: Reiter's syndrome
This young man have Reiter's syndrome (RS), a form of reactive arthritis that comprises a small subset of cases within the larger nearest and dearest of rheumatoid factor-seronegative spondyloarthritides--conditions noted primarily for inflammation of the axial skeleton. (1)
Of historical interest is the fact that this diagnosis shares its name next to the man who first described it, Hans Reiter, a Nazi physician who tested unapproved vaccines and performed experimental procedures on victims surrounded by concentration camps. The infamous birthright of Reiter's name have led to the proposal that the syndrome be referred to by another, more descriptive moniker. (2) For the sake of simplicity, we'll refer to the syndrome by the abbreviation RS.
* Look for elements of the classic triad
RS is disreputably inconsistent in its presentation. Only a third of patients will develop the "classic triad"--that is: peripheral arthritis permanent at least 1 month, urethritis (or cervicitis), and conjunctivitis. Nearly partly of patients will have single a single element of the triad. (3)
Patients beside RS will complain of generalized malaise and fever and will normally describe dysuria with concomitant urethral discharge. If conjunctivitis is present, the merciful will report reddened, sensitive eyes. Pain will recurrently originate from axial bones, lower extremities (in an oligoarticular asymmetrical pattern), swollen digits, and the heels (from enthesopathy).
Skin manifestation are often particularly noticeable and include psoriasiform lesion (FIGURE 3) on the palms, soles, and glans penis. Specifically, you'll see keratoderma blenorrhagicum (FIGURE 4), brown and red macules/papules with pustular or hyperkeratotic features, on the palmar and plantar surfaces. Erythematous and crusty lesions resembling psoriatic plaques repeatedly appear elsewhere on the body. On the uncircumcised penis, these shallow ulcerations have a micropustular, serpiginous border and are referred to as balanitis circinata. However, they may also appear psoriasiform organically on circumcised men, as was the luggage with our merciful.
Coincident findings include onycholysis and subungual hyperkeratosis, lesions mimicking migratory glossitis, and anterior uveitis.
* The typical tolerant? A young, white man
Patients next to RS are almost always Caucasian males contained by their early twenties and are typically HLA-B27 positive. Seronegativity for this HLA factor may portend a smaller quantity severe version of the syndrome. Individuals infected near HIV show increased incidence of developing RS. (3)
A microbial antigen is likely responsible for the initial activation of RS. This is followed by an immune impulse involving the joints, skin, and eyes. This premise is supported by the absence of autoantibodies, the frequent association near HLA-B27, and the fact that patients near advanced AIDS experience the same severity of RS symptoms, despite depressed CD4+ T cell function. (1)
* Bacteria trigger syndrome via 1 of 2 pathways
The germs that trigger RS typically enter the body through one of 2 pathways: the genitourinary tract or the gastrointestinal tract.
** The sexual nouns pathway involves infection with Chlamydia trachomatis or Ureaplasma urealyticum 1 to 4 weeks prior to nouns of urethritis and possibly conjunctivitis. The arthritic component follows later.
(In our long-suffering's case, his report of a sexually transmitted infection a year more rapidly did not appear to be the trigger for his RS. We believe that another, subsequent, infection was to blame.)
** The gastrointestinal pathway involves an enteric pathogen, such as Salmonella enteritidis, Yersinia enterocolitica, Campylobacter fetus, or Shigella flexneri that infects the host and follows like peas in a pod time frame as noted earlier, though diarrhea fairly than urethritis emerges as a chief complaint. (4)
The post-venereal type of RS comprises most cases in adults. Children who develop RS, however, are more credible to present with diarrhea fairly than urethritis, leading the clinician to suspect a gastrointestinal infection as the etiology of the condition. (5)
* Various forms of arthritis comprise the differential
A number of conditions must be ruled out until that time the RS diagnosis is considered definitive. The most likely imposters include:
** Gonococcal arthritis
** Rheumatoid arthritis
** Ankylosing spondylitis
** Psoriatic arthritis.
In appendage, an attack of gouty arthritis, systemic lupus erythematosus, serum sickness, Behcet's syndrome, rheumatic fever, Still's disease, and HIV could also present contained by a similar fashion.
The lab work, detailed below, separates RS from the imposters.
* Test blood and urine; check the ankles
Although nearby is no specific test for RS, several laboratory procedures are essential to honing in on the diagnosis. Hematological inquiry will confirm anemia, leukocytosis, thrombocytosis, and an elevated erythrocyte sedimentation rate (ESR). Though the urethral try-out may not be positive for a suspected organism, this procedure must be done to rule out gonococcal or chlamydial infection. This can now be done on a urine specimen to some extent than inserting a swab into the urethra. The urine is sent for a polymerase chain spontaneous effect (PCR) test to some extent than a culture. If enteritis was the preceding infection, a stool culture to simplify potential pathogens is warranted.
[FIGURE 3 OMITTED]
You'll also inevitability to order serological test for antinuclear antibodies (ANAs), rheumatoid factor (RF), and HIV. As you would expect, these tests will be uncharacteristic for systemic lupus erythematosus, rheumatoid arthritis, and HIV respectively. Though these tests are recurrently negative contained by RS patients, a strong association with HIV infection does exist.
Keep in mind, too, that you can differentiate gonococcal arthritis from RS base on historical features, as well as clinical features, including migratory polyarthritis near necrotic and pustular skin lesions. Patients near gonococcal arthritis will also have a positive gonococcal culture and speedy improvement near antibiotics.
If you order a biopsy, pathology is promising to find a variety of features surrounded by an RS patient, such as spongiform pustules, neutrophilic infiltrate in a perivascular model, and an epidermal hyperplasia that resembles psoriasis. (3)
Radiographic imaging for a suspected case of RS may reveal a few signs that resemble psoriatic arthritis (pencilin-cup deformity, syndesmophytes, sacroiliitis), but enthesitis, chiefly in the ankle collective region, should raise your index of suspicion for RS. (6)
[FIGURE 4 OMITTED]
* Tx: Antibiotics, NSAIDs, and steroids
Antibiotic analysis for 3 months is indicated if a patient's defence of RS can be traced back to an infection. If a Chlamydia species is the offending organism, later doxycycline or tetracycline can be used (7) (strength of recommendation [SOR]: B). If the infectious agent is unknown, next ciprofloxacin can offer broad-spectrum coverage (8) (SOR: B).
Though few studies enjoy evaluated the long-term effects of NSAID treatment on RS, a regular schedule of dignified doses for several weeks is appropriate for inflammation and pain paperwork. It's most effective when given impulsive in the disease course (5) (SOR: B).
Topical corticosteroids can be used on mucosal and skin lesion. For refractory disease, immunosuppressive agents such as sulfasalazine at 2000 mg/day (9) (SOR: B) or a subcutaneous injection of etanercept at 25 mg twice weekly (10) (SOR: B) offer nouns.
Our patient's treatment included an NSAID and corticosteroids
Because our lenient's syndrome involved a variety of systemic manifestation, we used several medications to cover adjectives of his symptoms. We prescribed piroxicam 20 mg daily, clobetasol 0.05% emulsion applied daily to legs and foot, triamcinolone 0.1% cream applied to scalp twice daily and genitals and armpits once day after day, and acitretin 25 mg daily. We consulted Rheumatology to assess and treat his shared disease. We also consulted Ophthalmology to assess for potential ocular manifestation.
Though the patient did report a history of a sexually transmitted infection, it occur long before his call in, and we were inept to identify an infectious agent. As a result, we did not start him on any antibiotics.
We instructed the patient to return contained by 2 weeks. Unfortunately, he was lost to follow-up. Patients near RS, though, typically make a full reclamation from their symptoms. Some patients, however--10% to 20%--may go on to enjoy a chronic, deforming arthritis. (3)
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