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

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

1818Sir 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

1858Alfred 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]

1916Noël 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

Reiter Original description 1916

On Oct 14,1916, Lt N was admitted to the reserve hospital with a history of becoming ill with abdominal cramps, diarrhea, and bloody stools on the 21st of Aug. A discharge from the urethra and purulent conjunctival catarrh developed on the 29th of Aug. Rheumatic complaints appeared the following day. On the 31st of Aug the patient was admitted to a field hospital.

The findings on admission included: a red urethral meatus, purulent urethral discharge, dysuria, intense injection of purulent secretion of the conjunctivae, edema of the eyelids, swelling of the right knee with no active movement possible, passive movement produced severe pain. On the 2nd of Sept the evening temperature exceeded 39 C; both knees were swollen and very painful, no active motion was possible, discharge was diminishing. On the 10th of Sept the urethral secretions contained no gonococci. The following day the left foot was swollen. On the 15th of Sept the right elbow and the left hand were swollen, and while the conjunctivitis had disappeared, minute corneal opacities remained. On the 18th of Sept it was necessary to feed the patient because of severe limitation of joint function.

A pure culture of spirochaeta was obtained in the blood from venous puncture on the 21st of Oct. An injection of 0.3 gm of neosalvarsan was made on Nov 3 and Nov 6.

Characteristic of this disease, which I propose to call spirochetosis arthritica, is the course of fever which, if not influenced by aspirin, periodically fluctuated between 37 C in the morning and 39 C at night and is accompanied by regular night sweats. Outstanding clinical symptoms are the severe joint involvement, cystitis and conjunctivitis. For 13 weeks the clinical course remained unchanged, his condition was serious, patient being bedfast, debilitated, with decubiti, and completely unable to take care of himself, even needing assistance in eating. The skin was pale and the hemoglobin content was decreased to 60% to 70%. Salvarsan exerted no influence on the course of the illness. [Reiter, 1916]

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

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

Review articles


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Studied Physiological Sciences BA (Hons), followed by Medicine at the University of Oxford BM BCh. British doctor currently working in emergency medicine in Perth, Australia. Special interests include acute internal medicine and emergency medicine.

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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