Reiter's disease: a review with special attention to cardiovascular and neurologic sequellae

Reactive arthritis: the convoluted history of Reiter's disease

Reactive arthritis, previously known as Reiter's Syndrome or Disease was a post-dysenteric, asymmetrical acute large joint polyarthritis, with fever, conjunctivitis, iritis, purulent urethral discharge, rash and penile soft tissue swelling. Although the eponym was given to Hans Reiter, various forms of the condition have been recorded in history a few hundred years before Reiter. Two French doctors, Noel Fiessinger (1881-1946) and Edgar Leroy (d. 1965), presented a paper at la Societe des Hopitaux-in Paris on the 8th December 1916 on dysentery in 80 soldiers on the Somme, and four of whom developed a "syndrome conjunctivo-uretro-synovial". Their paper was given 4 days before Reiter's presentation on 12th December 1916 at the Society of Medicine in Berlin, on a German army officer with an illness similar to those described by Fiessinger and Edgar Leroy. It is documented that Hans Reiter was one of a number of University professors who signed an oath of allegiance to Adolf Hitler in 1932. For socio-ethical reasons and for clinical utility, Reiter's syndrome is now known as reactive arthritis.

Aortic insufficiency in a patient with reactive arthritis: case report and review of the literature

BACKGROUND

Reactive arthritis (ReA) consists of the classic clinical triad of arthritis, urethritis, and conjunctivitis generally occurring within 6 weeks of an infection, typically of the gastrointestinal or genitourinary systems. Cardiovascular manifestations of ReA and other members of the spondyloarthritis family have long been recognized.

CASE REPORT

A 43-year-old male who was human leukocyte antigen-27 (HLA-B27)-positive and who had ReA for 19 years developed severe aortic insufficiency requiring aortic valve replacement. Typically, the onset of musculoskeletal symptoms precedes development of aortic insufficiency by many years. The average calculated from reported cases was 13 years, with a range from 4 days to 61 years. The mechanism by which the aortic valve leaflets become targets in HLA-B27-associated disease is unclear. At one point, interest developed as to whether the HLA-B27 allele was independently associated with lone aortic insufficiency, in the absence of clinical spondylitis. The preponderance of cardiac abnormalities in patients with HLA-B27-positive ReA has led to the suggestion that a genetic syndrome of the heart consisting of aortic insufficiency and conduction-system abnormalities exists, and has been dubbed the "HLA-B27-associated cardiac syndrome". This case highlights the importance of recognizing the association between HLA-B27-associated spondyloarthritis and serious aortic valvular complications.

CONCLUSION

Clinicians should maintain a high suspicion for aortic insufficiency in patients with ReA, including a low threshold for echocardiographic evaluation. A heightened awareness can lead to earlier identification and potential avoidance of fatal events in these patients.

Atrial arrhythmias--the dominating cardiac problem in three patients with HLA B27 associated rheumatic disorders

Three young patients with atrial arrhythmias as the probable consequence of an HLA B27 associated inflammatory disease process are described. They are presented as an expansion of the spectrum of cardiac manifestations that can be seen in patients with HLA B27 associated rheumatic disorders, and as possible evidence of myocardial involvement of this disease process.

Reiter's syndrome: the classic triad and more

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.

Cardiovascular disease in patients with spondyloarthropathies

Spondyloarthropathies are associated with a greater cardiovascular risk than expected based on the cardiac lesions known to occur in these diseases. The prevalence of several conventional risk factors is high in spondyloarthropathy patients, and chronic inflammation also contributes to premature plaque formation. In addition, susceptibility genes for spondyloarthropathies may be associated with an increased risk of cardiovascular disease. Finally, several drugs used to treat spondyloarthropathies may contribute to the occurrence of cardiovascular events. A careful evaluation of the cardiovascular risk profile is a key component of the management of patients with spondyloarthropathies.

Spondyloarthropathy-Associated Aortitis and Massive Thickening of the Aortic-Mitral Curtain: Diagnosis by Echocardiography

Cardiac involvement in reactive arthritis is well-recognized, and usually results in aortic regurgitation, proximal aortitis, and conduction system abnormalities. Aortitis is usually recognized in conjunction with aortic regurgitation, but can be diagnosed in isolation as aortic root thickening and subaortic fibrous ridging. We report a case of spondyloarthropathy-associated aortitis diagnosed by transesophageal echocardiography. The case illustrates the aortic root pathology and highlights the unique morphologic echocardiographic feature of this condition, prominent thickening of the aortic-mitral curtain.

Nonneoplastic diseases of aorta and pulmonary trunk--Part III

The five-part review focuses on selected nonneoplastic diseases of the aorta and pulmonary trunk. Because many more disease affect the aorta compared with the pulmonary trunk and right and left main pulmonary arteries, most of this review will be devoted to disorders of the aorta. Part III of this five-part series discusses the etiology of aortic aneurysms and aortitis.

Facial palsy and partial accommodative insufficiency associated with sulphasalazine treatment in a patient with ankylosing spondylitis

We report on a patient with peripheral facial nerve palsy and blurred near vision in association with sulphasalazine treatment. The possibility of this being an adverse reaction to sulphasalazine is discussed.

Acute aortic insufficiency in a patient with presumed Reiter's syndrome

Cardiac disease is rare in patients with Reiter's syndrome. There have been 15 reported cases of aortic insufficiency in patients with Reiter's syndrome, with the aortic insufficiency developing over several years. This paper reports the case of a black HLA-B27 negative woman who presented with Reiter's syndrome and acute aortic insufficiency. An antecedent streptococcal infection is suggested as the inciting factor. To our knowledge, this is the first report of Reiter's syndrome in a black woman with acute aortic insufficiency.

Spontaneous inflammatory disease in transgenic rats expressing HLA-B27 and human beta 2m: an animal model of HLA-B27-associated human disorders

Humans who have inherited the human class I major histocompatibility allele HLA-B27 have a markedly increased risk of developing the multi-organ system diseases termed spondyloarthropathies. To investigate the role of B27 in these disorders, we introduced the B27 and human beta 2-microglobulin genes into rats, a species known to be quite susceptible to experimentally induced inflammatory disease. Rats from one transgenic line spontaneously developed inflammatory disease involving the gastrointestinal tract, peripheral and vertebral joints, male genital tract, skin, nails, and heart. This pattern of organ system involvement showed a striking resemblance to the B27-associated human disorders. These results establish that B27 plays a central role in the pathogenesis of the multi-organ system processes of the spondyloarthropathies. Elucidation of the role of B27 should be facilitated by this transgenic model.

Amyloidosis and Reiter's syndrome: report of a case and review of the literature

Reiter's syndrome is classically described as the triad of urethritis, conjunctivitis, and arthritis, It has many manifestations and has rarely been reported to occur in association with amyloidosis. Four cases of systemic amyloidosis have previously been reported. This case describes a patient who developed progressive renal amyloidosis after a 17-year history of severe Reiter's syndrome. Immunofluorescent staining of the renal biopsy was strongly positive for AA protein, the type of protein found in secondary amyloidosis. This is the first case in which amyloidosis has been proven to be secondary to Reiter's syndrome and not merely the coincidental occurrence of two rare diseases.

Atrioventricular conduction disturbance as an early feature of Reiter's syndrome

Atrioventricular (A-V) conduction disturbances in Reiter's syndrome are usually described in longstanding disease. This report deals with two male patients with Reiter's syndrome who developed an A-V block early in the course of the disease. One of these patients developed a second degree A-V block, Wenckebach type, which has not been described before at an early stage of this syndrome.

The clinical diagnosis of Reiter's syndrome. Ophthalmic and nonophthalmic aspects

The histories of 113 patients with Reiter's syndrome were reviewed to obtain information regarding the sequence of the clinical signs and symptoms, laboratory findings, and progression of disease. Rheumatologic manifestations occurred in 98% of the patients, genitourinary manifestations in 74%, ophthalmic manifestations in 58%, and mucocutaneous manifestations in 42%. Four major criteria and six categories of minor criteria for the diagnosis of Reiter's syndrome, based on the frequency and specificity of the various manifestations of the disease, are proposed. The ophthalmic and nonophthalmic features are important to appreciate because the ophthalmologist is frequently at the pivotal point in suggesting or supporting the diagnosis.

Two-dimensional echocardiographic detection of preclinical aortic root abnormalities in rheumatoid variant diseases

Two-dimensional echocardiographic findings of subaortic fibrous ridging, aortic leaflet thickening, and aortic root dilatation and thickening are described in a group of 36 patients with rheumatoid variant diseases. The group consisted of 25 patients with ankylosing spondylitis, nine patients with Reiter's syndrome, and two patients with inflammatory bowel disease and spondylitis. No patient had clinical or laboratory evidence of aortic regurgitation or heart block. Subaortic fibrous ridging or marked leaflet thickening was noted in 11 of 36 patients; in contrast, no such changes were found in an age-matched control group of 29 men. The subgroup of patients with subaortic fibrous ridging or leaflet thickening (11 patients) had significantly longer disease duration (28.1 versus 17.7 years) and higher incidence of aortic root echo-density (82 versus 36 percent) than the remaining patients. It is concluded that a significant portion of patients with ankylosing spondylitis or Reiter's syndrome have echocardiographic evidence of aortic root involvement prior to the clinical onset of aortic regurgitation.

Cardiovascular lesions in collagen-vascular diseases

In this review, the cardiac lesions which develop in association with the various collagen-vascular diseases are described. In rheumatoid arthritis, the most frequent lesions are: fibrous obliterative pericarditis, with pericardial deposits of calcium, fibrin, cholesterol, and rheumatoid granulomas; granulomatous or nonspecific myocarditis; valvulitis, vasculitis, and amyloid deposits. In ankylosing spondylitis, the lesions involve mainly the valves (aortic and mitral valves) and the aorta. In systemic lupus erythematosus, the predominant cardiovascular lesions are: pericarditis, Libman-Sacks endocarditis, nonspecific myocarditis, vasculitis with fibrinoid necrosis, and acceleration of atherosclerosis. In scleroderma, the main cardiac lesion is fibrosis with only scanty inflammatory cells; pericarditis and nonbacterial thrombotic endocarditis also occur. In dermatomyositis/polymyositis, fibrous or fibrinous pericarditis can occur, as well as myocarditis with infiltrates of lymphocytes and plasma cells and with degeneration and necrosis of myocytes; valvulitis is uncommon except when the disease is related to mucinous adenocarcinoma. In polyarteritis nodosa, various stages of necrotizing vasculitis involve all layers of the arterial walls; foci of myocardial necrosis of various sizes can occur in association with these lesions; cardiac hypertrophy related to hypertension and pericarditis related to uremia, may also be found. In Wegener's granulomatosis, pericarditis, inflammatory infiltrates, necrotizing granulomas, and vasculitis have been observed in the heart.

Clinical study of Thai patients with ankylosing spondylitis

Sixty-one Thai patients with ankylosing spondylitis (AS), diagnosed in accordance with Rome and New York criteria for AS, were studied. The cases includes idiopathic AS (46 cases), Reiter's syndrome AS (8 cases) and psoriatic spondylitis (7 cases). The vast majority of patients were male (Male:Female = 11.2:1), and in over three-fourths the age of onset was between 10 and 39. Low back pain and peripheral arthritis as the initial manifestations were observed in 78.68 and 55.73% of patients respectively. Peripheral arthritis was evident during the course of illness in 72.13% of cases, oligoarticular arthritis being predominant (68.97%). Heel pain, tendonitis and plantar pain were noted in 19.67, 4.92 and 3.28% respectively. Most patients had lumbosacral and thoracic spine involvements, and only 49.18% showed involvement of the cervical spine. Bilateral sacroiliitis was noted in 98.36%. Uveitis was evident in 11.47% while evidence of aortic insufficiency was noted in 3.28%. An association with HLA-B27 was encountered in 91.07% of all cases. In general, the clinical features of AS in Thai patients are similar to those reported elsewhere, but an association with inflammatory bowel disease and Behcet's disease are notably absent.

Trauma and Reiter's syndrome: development of 'reactive arthropathy' in two patients following musculoskeletal injury

Two patients are reported who developed arthropathies with some features of Reiter's syndrome shortly after physical injury. Both were HLA-B27 positive. No other precipitating factors were identified, and the possibility that trauma may have precipitated a reactive arthropathy is discussed.

Distal aortitis complicating Reiter's syndrome

Distal aortitis was diagnosed in a 44 year old man who had previously shown clinical features of Reiter's syndrome. This appears to be the first reported case of distal aortitis associated with Reiter's syndrome.

Bacteriological findings in 25 patients with Reiter's syndrome (reactive arthritis)

Extensive bacteriological testing was performed in 25 patients with complete or incomplete Reiter's syndrome. In 21 patients (84%), evidence of antecedent infection was found, based on culture and/or serological findings. Thus, infection with Chlamydia trachomatis (17 patients), Yersinia enterocolitica, serotype 3 (4 patients), and Campylobacter jejuni (1 patient) was identified.

HLA profile and Reiter's syndrome

The analysis of the clinical and HLA profiles of 99 patients with Reiter's syndrome is reported. Antigen HLA-B27, which has previously been firmly associated with Reiter's syndrome, predisposes patients to develop disease features which reflect articular involvement. The HLA haplotype A2, B27 was found to be at an elevated frequency in our Reiter's syndrome sample, and the latter two antigens are also associated with a general increase in disease severity. Conversely, antigen BW35 appears to be protective against certain features of the syndrome. Patients with certain antigenic profiles (namely A2 and A3 together with B27) tend to develop certain syndrome manifestations earlier in the course of the disease than those with other antigens.

Methotrexate in Reiter's disease

Three cases of severe Reiter's disease were treated successfully with methotrexate after failure of conservative therapy, including systemic corticosteroids in 2 instances. The usefulness and potential hazards of such therapy are discussed, and some evidence that corticosteroids may aggravate the dermatological manifestations of Reiter's disease is presented.

HL-A antigens in clinical medicine

Many autoimmune diseases show a significant association with one or two second segregant series histocompatibility antigens. These associations are of great scientific interest, since they support the concept of HL-A-linked immune-response genes governing specific disease susceptibility. However, with one major exception, the association of HL-A antigens with diseases is not striking enough to provide a worthwhile diagnostic test. The exception is the extraordinarily high incidence of HLA B27 in patients with seronegative spondyloarthropathy best typified by ankylosing spondylitis (AS) and Reiter's disease (RD). In patients with these rheumatic syndromes, the antigen is present in more than 90% of cases compared to an incidence of approximately 6% in normal Caucasians and 4% in black Afro-Americans. The vast majority of rheumatic diseases are readily diagnosable on the basis of a history, physical examination and careful radiographic survey. This applies to most patients with a seronegative spondyloarthropathy, especially when the disease presents as a typical and fully formed clinical syndrome characterized as AS or RD. Sometimes the initial clinical nature may be atypical and only long-term follow-up of the patient will reveal an evolution toward the typical syndrome. In these situations, the correct diagnosis is reinforced by detecting the presence of HLA B27 on the patient's cells. Examination of the patient's family often reveals a high incidence of similar clinical syndromes, nearly always associated with the presence of the antigen. Since tissue typing at the moment is an expensive and relatively unavailable laboratory technic, its widespread and indiscriminatory use as a diagnostic test cannot be encouraged. However, in the clinical settings outlined above, tissue typing provides an invaluable diagnostic test. Presently, the combination of a negative test for rheumatoid factor and a positive test for HLA B27 is one of the strongest diagnostic laboratory profiles available to the physician when faced with a patient with early or atypical rheumatic disease. Aside from the purely clinical setting, the most exciting aspect of the association between these diseases and a specific cell surface antigen lies in the hope that we have a clue to the pathogenesis of a group of common rheumatic disorders. If the cause or causes of spondyloarthropathy can one day be found, the detection of HLA B27 may provide a useful public health measure facilitating preventive medicine. Even now, the detection of susceptible subjects within a family or a population will open the way for early diagnosis and treatment.