Reiter's syndrome. Diagnosis and clinical features

A retrospective case series of 12 patients with chronic reactive arthritis with emphasis on treatment outcome with biologics

Background:

Patients with reactive arthritis frequently present to dermatologists. However, there is paucity of information regarding its clinical aspects and management in dermatological literature.

Objective:

To review the clinical features and management of patients with chronic reactive arthritis admitted to the dermatology department of a teaching hospital.

Methods:

This was a retrospective analysis of patients with reactive arthritis admitted to the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India from January 2016 to February 2018.

Results:

There were 12 males (disease duration 9–180 months). Biologics were used in 9 (75%) patients on 16 different occasions, the most frequent being infliximab (n = 10 times), followed by adalimumab (n = 3), etanercept, secukinumab and itolizumab (n = 1 each), in combination with other systemic agents. Response rate with treatment regimens including biologics (69% responders, 31% partial responders) was statistically significantly better than those without biologics (27% responders, 46% partial responders, 27% nonresponders; P = 0.036), using a composite measure assessing improvement in skin and joint symptoms. Biologics were discontinued on 50% of the occasions, after a median of 3.5 months (range 1.5–7.5 months) because of satisfactory response (n = 4), therapeutic fatigue (n = 3) or adverse event (n = 1). After biologic discontinuation, the response was sustained for a median of 5 months (range 3–6 months) before disease exacerbation. The number of treatment switches increased with the follow-up duration (median three switches per patient, range 1–8). The median follow-up duration was 10.5 months (range 4–76 months).

Conclusion:

Biologics produce rapid improvement in skin and joint symptoms in chronic reactive arthritis, but the response is not long-lasting. Patients with chronic reactive arthritis have a waxing and waning course despite regular treatment.

Limitations:

The limitations are retrospective design, small sample size and lack of a validated outcome measure.

Reactive Arthritis in India: A Dermatologists' Perspective

Background:

The mucocutaneous lesions in Reiter syndrome (RS) or reactive arthritis are seen quite frequently.

Materials and Methods:

The case records of patients admitted with the diagnosis of RS from January 2006 to December 2010 were reviewed. Data regarding the demographic details; course of musculoskeletal, mucocutaneous, and ophthalmic involvement; body surface area affected; morphology of lesions; investigations undertaken; and treatment instituted were recorded. Based on these, the disease was classified as complete or incomplete RS.

Results:

The case records of 11 patients were evaluated. There were seven males and four females. Only two patients had complete RS, whereas nine patients had incomplete RS. Arthritis and mucocutaneous involvement were seen in all 11 patients, whereas preceding urethritis/dysentery was seen in 4 patients and eye symptoms in 4 patients. Enthesitis was seen in eight patients (72.7%). Circinate balanitis/vulvitis was present in six patients and keratoderma blenorrhagicum in eight patients. The most frequent radiologic finding was juxta-articular osteopenia in eight patients.

Conclusion:

RS may not show the typical triad in all cases, although musculoskeletal disease is seen in a significant proportion of patients. In the absence of typical signs and symptoms, cutaneous manifestations may help establish the diagnosis of RS.

Reactive arthritis responding to antiretroviral therapy in an HIV-1-infected individual

Reactive arthritis (ReA) is an autoimmune seronegative spondyloarthropathy that occurs in response to a urogenital or enteric infection. Several studies have reported a link between ReA and HIV infection. We report a case of an HIV-1-infected patient diagnosed with a disabling ReA who failed to respond to conventional therapy but whose symptoms resolved rapidly after starting antiretroviral therapy (ART). Clinicians may not be cognizant to this phenomenon and so this case report serves to remind clinicians that initiation of antiretroviral therapy should be considered in HIV-infected patients with ReA who are refractory to standard therapy.

Antineutrophil cytoplasmic antibodies testing in a large cohort of unselected greek patients

Objective. To retrospectively evaluate ANCA testing in a cohort of unselected Greek in- and outpatients. Methods. In 10803 consecutive serum samples, ANCA were tested by indirect immunofluorescence (IIF) and ELISA. ELISA in inpatients was performed only on IIF positive sera. Results. Low prevalence (6.0%) of IIF positive samples was observed. Among these samples, 63.5% presented perinuclear (p-ANCA), 9.3% cytoplasmic (c-ANCA) and 27.2% atypical (x-ANCA) pattern. 16.1% of p-ANCA were antimyeloperoxidase (anti-MPO) positive, whereas 68.3% of c-ANCA were antiproteinase-3 (anti-PR3) positive. Only 17 IIF negative outpatients' samples were ELISA positive. ANCA-associated vasculitides (AAV), connective tissue disorders and gastrointestinal disorders represented 20.5%, 23.9%, and 21.2% of positive results, respectively. AAV patients exhibited higher rates of MPO/PR3 specificity compared to non-AAV (93.8% versus 8%). Conclusions. This first paper on Greek patients supports that screening for ANCA by IIF and confirming positive results by ELISA minimize laboratory charges without sacrificing diagnostic accuracy.

Emerging role of antioxidants in the protection of uveitis complications

Current understanding of the role of oxidative stress in ocular inflammatory diseases indicates that antioxidant therapy may be important to optimize the treatment. Recently investigated antioxidant therapies for ocular inflammatory diseases include various vitamins, plant products and reactive oxygen species scavengers. Oxidative stress plays a causative role in both non-infectious and infectious uveitis complications, and novel strategies to diminish tissue damage and dysfunction with antioxidant therapy may ameliorate visual complications. Preclinical studies with experimental animals and cultured cells demonstrate significant anti-inflammatory effects of a number of promising antioxidant agents. Many of these antioxidants are under clinical trial for various inflammatory diseases other than uveitis such as cardiovascular, rheumatoid arthritis and cancer. Well planned interventional clinical studies in the field of ocular inflammation will be necessary to sufficiently investigate the potential medical benefits of antioxidant therapies for uveitis. This review summarizes the recent investigations of novel antioxidant agents for ocular inflammation, with selected studies focused on uveitis.

A review of pediatric uveitis: part II. Autoimmune diseases and treatment modalities

Uveitis is a manifestation of complex processes that can represent an infectious process or a dysfunction of the immune system that may have grave effects on the eye. Although infectious causes, once properly identified, may be successfully treated by addressing the inciting organism with recognized interventions, the immune-modulated chronic forms of uveitis often provide more complex challenges in management. Recent strides in understanding the inflammatory pathway and better bioengineering capabilities have resulted in some new modalities of treatment.

An eye on sexually transmitted diseases: sexually transmitted diseases and their ocular manifestations

Ocular examination should be a part of the routine assessment of the patients seen at sexually transmitted diseases (STD) clinics due to the importance of these organs in the general wellbeing of patients. It is essential to keep an open eye on ocular signs and symptoms of patients with a history of exposure to common STD pathogens, to ensure prompt investigation and management of ocular complications of the STDs, which, if left unnoticed, otherwise could subject the patients to a great deal of anxiety and distress.

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.

Reactive arthritis: defined etiologies, emerging pathophysiology, and unresolved treatment

ReA is unique in that it is one of the few disease states of which there is a known trigger. This insight into disease initiation has led to great advances in the pathophysiology. Despite this detailed knowledge, the proper treatment remains elusive. In the years to come it is possible that the specific treatment will be dictated by the triggering microbe.

Acute Monarthritis: Diagnosis and Management

The diagnosis for an acute monarthritis may still be elusive, even after an extensive initial evaluation. For example, what should be done for a patient who has a paucity of extra-articular findings on physical examination and an inflammatory synovial fluid with negative Gram's stain, cultures, and crystals? Conservative management is always prudent. Assume the joint is infected and treat as such until proven otherwise, because infection carries the highest morbidity and mortality of all the common acute monarthopathies.

Reactive arthritis or post-infectious arthritis?

The term 'reactive arthritis' was first used in 1969 to describe the development of sterile inflammatory arthritis as a sequel to remote infection, often in the gastrointestinal or urogenital tract. The demonstration of antigenic material (e.g. Salmonella and Yersinia lipopolysaccharide), DNA and RNA, and, in occasional cases, evidence of metabolically active Chlamydia spp. in the joints has blurred the boundary between reactive and post-infectious forms of arthritis. No validated and generally agreed diagnostic criteria exist, but the diagnosis of reactive arthritis is mainly clinical based on acute oligoarticular arthritis of larger joints that develops within 2-4 weeks of the preceding infection. In about 25% of patients, the infection can be asymptomatic. Diagnosis of the triggering infection is very helpful for the diagnosis of reactive arthritis. This is mainly achieved by isolating the triggering infection (stools, urogenital tract) by cultures (stool cultures for enteric microbes) or ligase reaction (Chlamydia trachomatis). However, after the onset of arthritis, this is less likely to be possible. Therefore, the diagnosis must rely on various serological tests to demonstrate evidence of previous infection, but, these serological tests are unfortunately not standardized. Treatment with antibiotics to cure Chlamydia infection is important, but the use of either short or prolonged courses of antibiotics in established arthritis has not been found to be effective for the cure of arthritis. The long-term outcome of reactive arthritis is usually good; however, about 25-50% of patients, depending on the triggering infections and possible new infections, subsequently develop acute arthritis. About 25% of patients proceed to chronic spondyloarthritis of varying activity.

Concurrence of Sjögren's syndrome in a patient with Chlamydia-induced reactive arthritis; an unusual finding

A 40-year-old Korean man presented with painful swelling and tenderness of both ankle joints as well as the plantar surfaces of both feet, along with inflammatory back pain, and a purulent discharge from the urethral orifice. The patient also complained of sicca-like symptoms including dry eyes and dry mouth. An immunological analysis revealed a high titer of rheumatoid factor, positive results for antinuclear antibody and anti-Ro antibody, and a positive result for HLA-B27. An antibody titer for Chlamydia was also significantly increased. Positive results of the Schirmer's test and for keratoconjunctivitis sicca were confirmed by an ophthalmologist. These clinical manifestations were compatible with Chlamydia-induced reactive arthritis (ReA) accompanied by Sjögren's syndrome (SS). This is the first report of the combination of these two distinct disease entities in the Korean population.

Reiter's syndrome (reactive arthritis) and travelers' diarrhea

Reiter's syndrome [also called reactive arthritis (ReA)] is the triad of arthritis, urethritis, and conjunctivitis. Two cases of Reiter's syndrome triggered by travelers' diarrhea are presented. Health care providers should suspect ReA in travelers with joint symptoms and antecedent diarrheal disease.

Cat-scratch disease-associated arthropathy

OBJECTIVE

To characterize the articular manifestations of cat-scratch disease (CSD) and to evaluate the long-term clinical outcome of those manifestations.

METHODS

A community- and hospital-based surveillance study of CSD was conducted in Israel between 1991 and 2002. CSD was defined as present in a patient when a compatible clinical syndrome and a positive confirmatory finding of Bartonella henselae (by serology and/or polymerase chain reaction) were identified. CSD patients with arthropathy (arthritis/arthralgia) that limited or precluded usual activities of daily living constituted the study group. Patients were followed up until > or =6 weeks after resolution of symptoms, or if symptoms persisted, for >/=12 months. CSD patients without arthropathy served as controls.

RESULTS

Among 841 CSD patients, 24 (2.9%) had rheumatoid factor-negative arthropathy that was often severe and disabling. Both univariate and multivariate analyses identified female sex (67% of arthropathy patients versus 40% of controls; relative risk [RR] 2.5, P = 0.047), age older than 20 years (100% of arthropathy patients versus 43% of controls; RR 4.9, P = 0.001), and erythema nodosum (21% of arthropathy patients versus 2% of controls; RR 7.9, P = 0.001) as variables significantly associated with arthropathy. Knee, wrist, ankle, and elbow joints were most frequently affected. Ten patients (42%) had severe arthropathy in the weight-bearing joints, which substantially limited their ability to walk, and 4 of these patients were hospitalized. All of the patients had regional lymphadenopathy, 37.5% had nocturnal joint pain, and 25% had morning stiffness. Nineteen patients (79.2%) recovered after a median duration of 6 weeks (range 1-24 weeks), whereas 5 patients (20.8%) developed chronic disease persisting 16-53 months (median 30 months) after the onset of arthropathy.

CONCLUSION

This is the first comprehensive study of arthropathy in CSD. CSD-associated arthropathy is an uncommon syndrome affecting mostly young and middle-age women. It is often severe and disabling, and may take a chronic course.

[Reiter's syndrome after Salmonella infection]

Two patients with Reiter's syndrome, after Salmonella infection were treated on the Infections disease ward at Clinical hospital center in Kragujevac. In the first patient, ten days after the onset of Salmonella infection, signs of edema and pain in the right ankle occurred, accompanied by expressed conjunctivitis. Within next two months consecutive metatarsophalanges changes joint of the right foot have appeared. In the second patient, two weeks after the onset of Salmonella infection, edema of the left hand joints and a week later edema of the right hand and right ankle joints appeared. In both patients inflammatory syndrome was expressed (high erythrocyte sedimentation rates, fibrinogen, C-reactive protein) along with negative rheumatoid factors and positive antigen HLA-B27. Outcome of the disease in both cases was favourable upon receiving nonsteroid antirheumatic therapy. Signs of arthritis disappeared after three months. No signs of recurrent arthritis have been seen during the next four years in the first and next two years in the second patient.

HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations

Current evidence supports the concept that reactive arthritis (ReA) is an immune-mediated synovitis resulting from slow bacterial infections and showing intra-articular persistence of viable, non-culturable bacteria and/or immunogenetic bacterial antigens synthesized by metabolically active bacteria residing in the joint and/or elsewhere in the body. The mechanisms that lead to the development of ReA are complex and basically involve an interaction between an arthritogenic agent and a predisposed host. The way in which a host accommodates to invasive facultative intracellular bacteria is the key to the development of ReA. The details of the molecular pathways that explain the articular and extra-articular manifestations of the disease are still under investigation. Several studies have been done to gain a better understanding of the pathogenesis of ReA; these constitute the basis for a more rational therapeutic approach to this disease.

Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome

PURPOSE

To investigate the spectrum of ocular involvement, to examine the clinical outcome, and to analyze the influence of treatment in patients with chronic ocular manifestations of Reiter's syndrome (RS) referred to a tertiary care ocular immunology service.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Twenty-five patients with RS evaluated at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary from 1981 through 2001.

METHODS

Charts of patients were reviewed and data on age, gender, follow-up time, ocular symptoms, extraocular involvement, ocular complications, therapy, and visual acuities were recorded.

MAIN OUTCOME MEASURES

Visual acuity, ocular complications, disease progression, clinical outcome, and systemic treatment.

RESULTS

Twenty-five patients (20 male and 5 female) diagnosed with RS, with a mean age at presentation to our service of 37 years, were studied. The mean follow-up was 48.5 months. Eighty-five percent of patients tested were positive for human leukocyte antigen B27. Sixty-four percent of patients had a positive family history. All patients had oligoarthritis and enthesitis, most commonly affecting the back (56%), Achilles tendon (52%), and sacroiliac joint (24%). Eighty percent had a history of infection, most frequently urethritis (68%). Forty-four percent had a history of mucocutaneous lesions. All patients demonstrated ocular involvement at the time of diagnosis (68% with unilateral and 32% with bilateral disease), 84% had evidence of uveitis, 3% had scleritis, 2% had conjunctivitis, and 1% had pars planitis and iridocyclitis. During follow-up, the ocular complications included conjunctivitis (96%), anterior uveitis (92%), posterior uveitis (64%), keratitis (64%), cataract (56%), intermediate uveitis (40%), scleritis (28%), cystoid macular edema (28%), papillitis (16%), and glaucoma (16%). Systemic treatment for ocular inflammation was initiated in all patients. Ninety-six percent were treated with nonsteroidal anti-inflammatory agents. Eighty-eight percent were treated with corticosteroids, 64% requiring systemic prednisone. Immunosuppressive therapy was initiated in 52% of patients, with all receiving methotrexate. Seven patients required more than one immunosuppressive agent. The mean initial visual acuity was 20/25 in the right eye and 20/30 in the left eye. The mean final visual acuity was 20/25 in the right eye and 20/25 in the left eye.

CONCLUSIONS

Reiter's syndrome may be associated with chronic recurrent ocular inflammation. Systemic therapy (including immunosuppressive treatment) typically is required to control the ocular inflammation and to prevent progressive visual loss.

Reactive arthritis: newer developments

Reactive arthritis (ReA) is characterized by an aseptic inflammatory articular involvement occurring in a genetically predisposed individual secondary to an infectious process localized outside the joint. ReA usually refers to an acute or insidious oligoarthritis process after enteric (enteroarthritis) or urogenital (uroarthritis) infection. Conventional antirheumatic therapeutic modalities based on nonsteroid anti-inflammatory drugs, sulfasalazine, and steroids are effective in the majority of patients. In more refractory cases, the use of second-line agents including methotrexate and more recently biological agents such as etanercept and infliximab has been found highly effective. The role of antibiotics remains not well established, although they appear to be effective in acute ReA of urogenital origin.

Pustular skin disorders: diagnosis and treatment

The differential diagnosis for pustular skin disorders is extensive. The distribution of the lesions and the age of the patient are characteristics that may provide strong clues to the etiology of cutaneous pustular eruptions. In adults, generalized pustular dermatoses include pustular psoriasis, Reiter's disease and subcorneal pustular dermatosis. Medications can cause generalized pustular eruptions, such as in the case of acute generalized exanthematous pustulosis; or more localized reactions, such as acneiform drug eruptions, which usually involve the face, chest and back. Localized pustular eruptions are seen on the hands and feet in adults with pustulosis palmaris et plantaris and acrodermatitis continua (both of which may be variants of psoriasis); on the face in patients with acne vulgaris, rosacea, and perioral dermatitis; and on the trunk and/or extremities in patients with folliculitis. A separate condition known as eosinophilic folliculitis occurs in individuals with advanced human immunodeficiency disease. Severely pruritic, sterile, eosinophilic pustules are found on the chest, proximal extremities, head and neck. Elevated serum immunoglobulin E and eosinophilia are often concurrently found. In neonates, it is especially important to make the correct diagnosis with respect to pustular skin disorders, since pustules can be a manifestation of sepsis or other serious infectious diseases. Generalized pustular eruptions in neonates include erythema toxicum neonatorum and transient neonatal pustular melanosis, both of which are non-infectious. Pustules are seen in infants with congenital cutaneous candidiasis, which may or may not involve disseminated disease. Ofuji's syndrome is an uncommon generalized pustular dermatosis of infancy with associated eosinophilia. As in adults, neonates and infants may develop acne or scabies infestations. In this article, we review the most common pustular dermatoses and offer a systematic approach to making a diagnosis. We also report the most up-to-date information on the treatment of these various cutaneous pustular conditions.

Diseases of the foreskin, penis, and urethra

Diseases of the foreskin, penis, and urethra are uncommon conditions that constitute a small percentage of emergency department visits. However, it is important that the emergency physician recognize and treat these conditions and understand which conditions require urologic consultation. Rapid and proper treatment in the emergency department can alleviate patient discomfort, increase patient satisfaction, and prevent future morbidity.

Sexually-acquired reactive arthritis

Reactive arthritis is the most frequent cause of acute peripheral arthritis in young men. The aetiopathogenesis of reactive arthritis is reviewed, together with the varied clinical features. Finally the treatment and prognosis of this challenging condition are discussed.