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Overview |
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Definition |
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Reiter's syndrome is a reactive arthritis, either sexually transmitted
(Chlamydia trachomatis or Ureaplasma urealyticum) or follows
enteric bacterial infection (dysenteric) and classically has a triad of
symptoms: arthritis, conjunctivitis, and urethritis. Mouth and skin ulcerations
are now recognized as a fourth feature. Only a third of patients present with
the triad, making Reiter's syndrome difficult to diagnose. Differing clinical
manifestations depend on gender, genetics, and race. |
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Etiology |
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The syndrome has arthritic features appearing one to three weeks after the
triggering infection. Infectious agents have been found in affected joints, but
etiology of joint involvement is unknown. Microbial antigens within the synovium
suggest possible continuing infection or that the arthritis is caused by the
persistence of antigens.
- HLA-B27 gene—20% of people with the gene get
Reiter's; about 80% of people with Reiter's are
HLA-B27-positive
Dysentery triggers:
- Salmonella—6.4% to 6.9% develop Reiter's;
60% are HLA-B27-positive or have B27 cross-reactive antigens
- Shigella—0.2% to 2% develop Reiter's; most
are HLA-B27-positive
- Campylobacter—occasionally
- Yersinia—mainly in Scandinavia; 60% to 80%
are HLA-B27-positive
Sexually transmitted disease triggers (1% to 3% following nongonococcal
infections):
- Chlamydia—50% of Reiter's patients have
antibodies to C. trachomatis; 50% are HLA-B27-positive; a
T-cell-mediated, chlamydial antigen-specific immune response is being
researched.
- Reiter's is not in itself a sexually transmitted
disease.
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Risk Factors |
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- Sexual intercourse with chlamydia-infected partner
- White males ages 20 to 40
- HLA-B27 gene and associated infective pathogens
- Food poisoning, bacterial
dysentery
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Signs and Symptoms |
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Not every symptom type occurs for each patient.
- Arthritic disorders—pain, swelling,
stiffness, redness
- Spondyloarthropathy—joints of the spine and
sacroiliac
- Small joints of the fingers and toes (digital periostitis;
"sausage digits"), wrists, feet (plantar fasciitis), or ankles (Achilles
tendinitis)
- Conjunctivitis—affects 40%; usually brief,
mild
- Keratitis, corneal ulceration, scleritis
- Iritis—affects 5%; scarring and permanent
damage can occur; pain and light sensitivity
- Urethritis—affects 33%; burning during
urination may not occur; pus drainage from penis
- Prostatitis—prostate tender on
palpation
- Circinate balanitis—affects 33% of men;
shallow ulcerations on the shaft or glans of the penis; painless
- Keratoderma blennorrhagica—papulosquamous
eruptions on soles, palms, and glans penis; purulent with thick keratotic outer
layer
- Mouth—inflammation of hard and soft palate;
often painless
- Costochondritis—inflammation of the
breastbone cartilage
- Anorexia or weight loss, malaise, morning stiffness,
fever
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Differential
Diagnosis |
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- Ankylosing spondylitis
- Crohn's disease associated arthritis
- Inflammatory bowel disease associated arthritis
- Ulcerative colitis
- Psoriatic arthritis
- Lyme disease
- Gonococcal bacterial
arthritis
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Diagnosis |
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Physical Examination |
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Patient may have fever, severe pain, and weight loss during acute
phase. |
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Laboratory Tests |
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- Serological test—antecedents for yersinia or
chlamydia support diagnosis
- Inflammation—indicated by erythrocyte
sedimentation rate and C-reactive protein levels
- Synovial fluid—>2,000 cells/ml, mostly
polymorphonuclear leukocytes
- Urinalysis or urine culture—determines
bacterial infection
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Pathology/Pathophysiology |
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- Synovial/joint inflammation—cellular
infiltration of polymorphonuclear leukocytes, lymphocytes, and plasma cells;
heterotopic bone formation
- Enthesitis—inflammation and erosion where
the tendons and muscles insert into the bone
- Mucocutaneous lesions—thickening of the
horny layer, acanthosis, parakeratosis
- Intestines—acute and chronic lesions,
inflammation of the colon and terminal portion of the
ileum
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Imaging |
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- X rays—reveal spurs, calcifications,
periosteal thickening, joint and articular margin erosion, sacroiliitis;
enthesitis appears as erosions and reactive new bone formation; abnormalities in
70% of chronic patients
- Scintigraphy—more sensitive in sacroiliac
and enthesitis detection
- Computerized tomography—assesses sacroiliac
and spondylitic involvement
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Other Diagnostic
Procedures |
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Diagnosis of Reiter's is difficult. History of infecting agent helps, but can
occur without trigger. Exclusion of other diagnoses, the presence of spine and
sacroiliac arthritis, and appearance of nonjoint symptoms, especially
urethritis, determines correct diagnosis. Skin lesions typical of Reiter's
permit a more definitive diagnosis. The HLA-B27 genetic marker is not diagnostic
but helps confirm diagnosis. |
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Treatment Options |
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Treatment Strategy |
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Treatment focuses on symptom management. Specialists for each discrete
symptom are usually needed, as each symptom may require a different strategy.
Physical and occupational therapy may help patients improve muscle tone,
maintain mobility, alleviate gait disturbances, and learn to perform tasks with
less stress on joints. |
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Drug Therapies |
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- Nonsteroidal anti-inflammatory drugs
(NSAIDs)—Indomethacin (2 to 3 mg/kg/day, especially
effective in 75 mg bid slow-release); side effects include gastrointestinal
irritation, bleeding, ulceration, headaches, dizziness
- Corticosteroids—oral or local injection into
joint; decreases inflammation and controls pain
- Sulfasalazine—experimental, promising
sulfa-based drug for peripheral arthritis; 2 to 3 g/day; well-tolerated; monitor
blood counts with long-term use for bone marrow suppression
- Methotrexate—orally or by injection for
chronic arthritis; 7.5 to 15 mg/week; experimental; blood and liver tests for
bone marrow and liver toxicity, respectively; contraindicated with acquired
immunodeficiency syndrome (AIDS)
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Complementary and Alternative
Therapies |
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Alternative therapies may be effective at alleviating symptoms. Treatment
strategy is very similar to rheumatoid arthritis, with specific nutrients and
herbs for the eyes and lower urinary tract. |
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Nutrition |
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- Glucosamine sulfate (500 mg tid—higher doses
required for obese patients or those taking diuretics): stimulates cartilage
growth and may be as effective for pain relief as NSAIDs without the side
effects. May take one to three months to see relief. Anecdotal cases find
cartilage regeneration.
- Avoid nightshade family (tomatoes, potatoes, eggplant, peppers,
tobacco); decrease saturated fats and alcohol (inflammatory); increase oily
fish, nuts, and flaxseed (anti-inflammatory); increase fruits and vegetables
(flavonoids); and avoid any allergenic foods.
- Antioxidants: Vitamin C (1,000 to 3,000 mg/day), vitamin E (400 to
800 IU/day), beta-carotene (25,000 IU/day), selenium (200 mcg/day)
- Essential fatty acids (2 tbsps. oil/day or 1,000 to 1,500 mg bid): a
mix of omega-6 (evening primrose) and omega-3 (flaxseed).
- Minerals: zinc (45 mg/day), copper (1 mg/day), bromelain (500 mg
tid)—anti-inflammatory
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Herbs |
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Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried
extracts (capsules, powders, teas), glycerites (glycerine extracts), or
tinctures (alcohol extracts). Unless otherwise indicated, teas should be made
with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or
flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be
used singly or in combination as noted.
Turmeric (Curcuma longa)—anti-inflammatory:
400 mg tid is equally effective as phenybutazone (300 mg/day) for duration of
morning stiffness, walking time, and joint swelling, with greater safety and
tolerability; works especially well with bromelain.
For urethritis:
- Juniper (Juniperus communis): diuretic historically used for
inflammatory conditions of the lower urinary tract; avoid with kidney
disease
- Uva ursi (Arctostaphylos uva ursi): antibacterial and
anti-inflammatory for lower urinary tract, for acute use only
- Horsetail (Equisetum arvense): soothing diuretic with historic
use for rheumatic disease
- Licorice (Glycyrrhiza glabra): anti-inflammatory, soothing,
not for use with hypertension
- Meadowsweet (Filipendula ulmaria): anti-inflammatory with
historic use as a diuretic and for rheumatism
Mix three to four of these herbs in equal amounts and use 1 tsp. of mixture.
Drink 1 cup tea tid or 30 drops tincture tid; use daily during acute flare-up,
and two weeks out of the month as a preventive.
For iritis:
- Horsetail, licorice, meadowsweet (see above)
- Eyebright (Euphrasia officinalis) and bilberry (Vaccinium
myrtillus): historically used for inflammation of the eyes; drink 30 to 60
drops tincture tid, 1 cup tea tid, and use tea to make compresses for acute
relief.
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Acupuncture |
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As with other forms of arthritis, acupuncture may be effective at stimulating
the immune system, and reducing inflammation. |
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Patient Monitoring |
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Patients are sometimes hospitalized during the acute phase. Prolonged
follow-up is necessary to confirm diagnosis, treat changing symptoms, and avoid
further complications. |
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Other
Considerations |
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Complications/Sequelae |
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- Blindness
- Aortic root necrosis
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Prognosis |
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Initial attacks last three to six months. Syndrome manifests within 10 to 30
days of infection. Mean duration is 19 weeks. Fifty percent of people with one
to two attacks have no further symptoms. Most people with a third attack develop
chronic Reiter's syndrome. The intensity of attacks tends to maintain a
consistent pattern, but few (15%) patients have permanent joint damage. Patients
maintain near-normal lifestyles with physical/occupational modifications.
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Pregnancy |
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Drugs must be evaluated for safety during
pregnancy. |
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References |
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Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:368-369.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Company; 1998.
Koopman WJ, ed. Arthritis and Allied Conditions. 13th ed. Baltimore,
Md: Lippincott, Williams & Wilkins; 1996.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998.
Weiss RF. Herbal Medicines. Beaconsfield, England: Beaconsfield
Publishers; 1998:339. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |