Reactive arthritis

Description

Reactive arthritis [archaic eponym: Reiter’s syndrome] systemic, seronegative spondyloarthropathy secondary to a precipitating infection.

Clinical manifestations include the classic triad of arthritis, urethritis and conjunctivitis. Symptoms of arthritis, range from arthralgia to debilitating polyarthritis and usually begin 2-4 weeks (but potentially up to 12 weeks) following an infection. Large joints such as the knees and ankles are most often affected. Inflammation at bony insertion sites of ligaments and tendons (enesthitis) is common.

• Ocular involvement (5-30%): Ranges from asymptomatic conjunctivitis to anterior uveitis or amnio conjunctivitis with severe ocular pain, redness, photophobia, and visual impairment (5%).
• Skin lesions (5-30%): Papulosquamous, psoriasiform lesions are more common in disease initiated by urogenital rather than enteric infections. Circinate balanitis (penis) and keratoderma blennorrhagica (soles of the feet and palms). Up to 30% of patients (usually following urogenital infection) will have superficial mucosal ulcers (buccal mucosa, palate, lips, or tongue).
• Risk: HLA-B27+ve individuals are at increased risk of sudden onset; severe symptoms and chronic persisting symptoms (though HLA-B27-ve individuals may still be affected). Immunosupression secondary to HIV and AIDS
• Common causative organisms: Chlamydia trachomatis, Campylobacter, Salmonella, Shigella and Yersinia
• Incidence: most common in men between ages 20 and 50.

History of Reactive arthritis

1494 – DJ Allison postulated in 1980 that Christopher Columbus was the first European patient to develop reactive arthritis. After arriving in the New World, Columbus became ‘lame‘, potentially from an infection such as shigella flexneri, common in the tropics during this time. Traveling between Puerto Rico and Santa Domingo in September of 1494 he presented with a picture of fever, confusion, and severe arthritis of the lower extremities. In 1498, he had a relapse with fevers and acute articular symptoms. Six weeks thereafter, he developed articular inflammation and eye pain:

I have never had such affliction of my eyes with hemorrhage and pain as in this time.

Allison, 1980

1776 – Maximilian Stoll (1742-1788) provided a good description of an association between arthritis, conjunctivitis, and urethritis following a diarrheic illness. [Recount by Huette, 1869]

1818 – Sir Benjamin Collins Brodie (1783-1862) reported case histories of five patients with the symptom complex of urethral discharge, arthritis, and inflammation of the eyes. Further case descriptions were added in the 1836 4th edition of his textbook. Brodie clearly describes a disease pattern of recurrent episodes of acute urethritis, arthritis, and conjunctivitis. The arthritis affected the knees, ankles, and feet predominantly, but one patient had ‘swelling of nearly all the joints‘.

Case 1: In a man aged 45, arthritis and conjunctivitis developed about a week after a urethral discharge. The joints of the feet and knees were first involved and later the right elbow and shoulder were painful but without “any perceptible swelling”. The attack lasted 6 to 7 weeks; 6 months later he had “another attack of the same complaint” lasting about 6 weeks, and after 3 months iritis occurred. He subsequently had a second attack of iritis 4 years later.

Brodie, 1818: 54-60 and cases 2-6: 1836:61-63

1858 – Alfred Jean Fournier (1832-1914) described rhumatisme blenorrhagique, and presented evidence to differentiate between this form of arthritis from rheumatic fever. He presented case reports of 21 male patients; 10 with recurrent attacks, and thirteen with involvement of the eyes. [1868;1(1):120]

1904 – German physician B. Markwald described a patient with both urethritis and conjunctivitis complicating dysenteric infection in his article ‘Ueber seltene Complicationen der Ruhr‘

World War I – Evidence was presented to establish the non-gonococcal origin of some of these cases and for the first time the triad of urethritis, arthritis, and conjunctivitis was separated into the venereal and the post-dysenteric forms:

1916 – Ludwig Waelsch (1867-1924) presented 44 cases of patients with abacterial urethritis of venereal origin, one with rheumatic pains of the knees and ankles, and one with conjunctivitis. [Waelsch 1916]

1916 – Noël Fiessinger (1881-1946) and Edgar Leroy (1883-1965) presented 4 patients with conjunctivitis, urethritis and arthritis. They noted the triad of symptoms following bacillary dysentery. This report appeared eight days prior to the report of Reiter. Fiessinger and LeRoy called it the ‘conjunctival, urethral, synovial syndrome.‘

1916 – Whilst on the Balkan front, Hans Conrad Julius Reiter (1881–1969) treated a German army officer with the symptom triad of – conjunctivitis, urethritis and arthritis following dysentery. He originally deemed the disease to be casued by a spirochetal infection and suggested the name ‘Spirochetosis arthritica‘

1942 – Walter Bauer and Ephraim P. Engleman first used the term ‘Reiter’s syndrome‘, leading to the terms subsequent widespread adoption. [Trans Assoc Am Physicians 1942;57:307-313.]

2003 – Rheumatology journal editors agreed to expunge the term ‘Reiter’s syndrome‘ from the literature, substituting the term ‘reactive arthritis‘

2007 – Engleman et al published a retraction of the suggestion to use the term “Reiter’s syndrome”

We call for repudiating Reiter and reverting to or substituting other terms for the syndrome, such as reactive arthritis, for moral, ethical, and professional imperatives.

Medicine is a moral enterprise. Physicians serve to promote the welfare of their patients. Hans Reiter was a Nazi war criminal responsible for heinous atrocities that violated the precepts of humanity, ethics, and professionalism. We see no acceptable rationale to preserve any professional memory of Reiter within our medical culture, except as a symbol of what our societal values obligate us to reject. We have therefore suggested that the professional and ethical position be that we no longer afford him this recognition 

Panush, Wallace, Dorff, Engleman 2007

Associated Persons

• Sir Benjamin Collins Brodie (1783 – 1862)
• Alfred Jean Fournier (1832 – 1914)
• Noël Fiessinger (1881-1946)
• Edgar Leroy (1883-1965)
• Hans Conrad Julius Reiter (1881–1969)

Alternative names

• Spirochetosis arthritica – original proposed term (Reiter, 1916)
• Fiessinger-Leroy syndrome (Fiessinger-Leroy, 1916)
• Stoll-Brodie-Fiessinger-LeRoy syndrome (Iglesias-Gammara, 2005)
• Archaic: Reiter’s disease (English literature); Reiter’s Syndrome (North America/Latin America) – (rescinded 2003)

References

Original articles

• Stoll M. De l’arthrite dysenterique. [Recount par Huette] Archives générales de médecine. 1869;14:129-130.
• Brodie B. Pathological and Surgical Observations on Diseases of the Joints. Longman. 1818 [Case 1: 54-60][Case 2-5: 60-63] and [Case 6: 1836:61-63]
• Fournier A. Le rhumatisme blenorrhagique. Annales de dermatologie et de syphiligraphie (Paris). 1868;1(1):120, 161, 289, 319.
• Markwald B. Ueber seltene Complicationen der Ruhr. Zeitschrift für klinische Medizin. 1904; 53: 321-325
• Waelsch L. Über chronische nicht gonorrhoische Urethritis.  Archiv für Dermatologie und Syphilis (Berlin) 1916;123(5):1089-1105.
• Fiessinger N, Leroy E. Contribution à l’étude d’une épidémie de dysenterie dans la Somme. Bulletins et mémoires de la Société Médicale des Hôpitaux de Paris. 1916; 40: 2030-2069.
• Reiter H. Ueber eine bisher unerkannte Spirochäteninfektion (Spirochaetosis arthritica) [About an as yet unrecognized spirochete infection] Deutsche medizinische Wochenschrift. 1916;42(50):1535-1536.

Review articles

• Good AE. Reiter’s Disease: A review with special attention to cardiovascular and neurologic sequellae. Seminars in Arthritis and Rheumatism, 1974; 3(3): 253–286. 
• Allison DJ. Christopher Columbus: first case of Reiter’s disease in the old world? Lancet. 1980;2(8207):1309
• Iglesias-Gammara A, Restrepo JF, Valle R, Matteson EL. A Brief History of Stoll-Brodie-Fiessinger-Leroy Syndrome (Reiter’s Syndrome) and Reactive Arthritis with a Translation of Reiter’s Original 1916 Article into English. Cur Rheumatol Rev 2005; 1: 71–79
• Lu DW, Katz KA. Declining use of the eponym “Reiter’s syndrome” in the medical literature, 1998-2003. J Am Acad Dermatol. 2005; 53(4): 720-723
• Panush RS, Wallace DJ, Dorff RE, Engleman EP. Retraction of the suggestion to use the term “Reiter’s syndrome” sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum. 2007; 56(2): 693-694
• Wu IB, Schwartz RA. Reiter’s syndrome: the classic triad and more. J Am Acad Dermatol. 2008; 59(1): 113-121