Rosen & Barkin's 5-Minute Emergency Medicine Consult (600 page)

• 691.0 Diaper or napkin rash
  
• 782.1 Rash and other nonspecific skin eruption
  
• 782.7 Spontaneous ecchymoses
  

BASICS

• Syndrome classically includes triad of conjunctivitis, urethritis, arthritis
  
• Also known as “Reiter’s syndrome,” although the eponym has fallen out of favor:
  
  • Typically taught as the syndrome of “can’t see, can’t pee, can’t climb a tree”
    

• Exact incidence difficult to determine because of lack of standardized diagnostic criteria
  
• 2 main types:
  
  • Postdysentery:
    
    • Salmonella, Shigella, Campylobacter, Yersinia,
      Clostridium difficile
      
  • Venereal:
    
    • Chlamydia trachomatis, Neisseria gonorrhoeae
      
• Also described after upper respiratory infections, UTIs, BCG treatment for bladder carcinoma
  
• M > F (∼5:1)
  
• Peak onset during 3rd decade
  

DIAGNOSIS

• Urogenital: Occur in >90% of cases, seen in both forms of disease
  
• Arthritis, tendonitis:
  
  • Typically polyarticular, asymmetric
    
  • Knees and ankles most commonly affected
    
  • May also affect fingers, back, sacroiliac joints
    
  • Achilles tendonitis present in 40% of cases
    
• Ophthalmologic: Occur in 30–60% of cases:
  
  • Conjunctivitis is most common:
    
    • Usually bilateral
      
  • Uveitis, keratitis is less common:
    
    • Usually unilateral
      
    • Usually preceded by 1–2 days of eye discomfort
      
• Mucocutaneous:
  
  • More common in patients with HLA-B27 positivity
    

• Symptoms generally within 4 wk of infection, although may be delayed up to 1 yr
  
• Diagnosis made by history and physical exam findings
  
• Only 1/3 have the complete triad of conjunctivitis, urethritis, arthritis
  
• Postdysentery: Usually preceded by symptomatic GI infection, especially in children
  
• Venereal: Often follows asymptomatic infection
  

• General:
  
  • May include fever, fatigue, weight loss, malaise
    
• Urogenital:
  
  • Urethritis
    
  • Cervicitis
    
  • Prostatitis
    
• Extremities:
  
  • Swelling, painful range of motion, erythema may all be present.
    
  • Sausage digit (diffuse swelling of an entire digit) present in ∼15% of cases
    
• Ophthalmologic:
  
  • Conjunctivitis:
    
    • Often with mucopurulent discharge
      
    • Symptoms range from mild irritation to severe inflammation.
      
  • Uveitis:
    
    • Eye pain, redness, photophobia, miosis, blepharospasm
      
• Skin/mucosa:
  
  • Keratoderma blennorrhagicum:
    
    • Begins as erythematous macules and vesicles on palms and soles, progresses to pustules and dark plaques
      
    • Similar in appearance to pustular psoriasis
      
  • Circinate balanitis: Present in >50% of males:
    
    • Plaques, vesicles or papules on glans penis
      
  • Ulcerative vulvitis may be associated with vaginal discharge
    
  • Nail changes, including nail dystrophy, periungual pustules
    
  • Oral lesions, include ulcerations, geographic tongue, palatal erosions, usually painless
    

• Clinical diagnosis is based on characteristic physical exam findings and a history of GI illness, sexually transmitted infection or upper respiratory infection.
  
• Must exclude other serious time-sensitive diagnoses that require prompt treatment
  

No lab tests can confirm the diagnosis:

• CBC may show leukocytosis and mild anemia
  
• ESR and CRP are usually elevated
  
• Urinalysis may show sterile pyuria
  

• No radiology exams can confirm the diagnosis
  
• Plain x-ray can be considered of affected extremities to exclude other diagnoses:
  
  • May show swelling around affected joint, indicating joint effusion
    

Arthrocentesis:

• Should be performed if septic arthritis is considered
  
• Synovial fluid analysis may show leukocytosis, PMN predominance:
  
  • Crystals not present, and indicate other pathologies (gout, pseudogout)
    

• Gonococcal urethritis
  
• Chlamydial urethritis
  
• Syphilis
  
• Gout
  
• Gonococcal arthritis
  
• Septic arthritis
  
• Rheumatoid arthritis
  
• Pustular psoriasis
  
• Behçet disease
  
• Contact dermatitis
  
• Psoriasis
  
• Kawasaki disease (in children)
  

TREATMENT

No specific pre-hospital considerations

• Once other serious infections have been excluded, treatment is symptomatic
  
• No consensus about the role of antibiotics
  
• Rationale for antibiotic treatment is that reactive arthritis is caused by bacterial infection, which may have long-term viability in synovium (especially Chlamydia
  )
  :
  
  • Studies have demonstrated no long-term benefit with doxycycline, ciprofloxacin, azithromycin
    
• Short course of systemic corticosteroids may be helpful in severe or prolonged disease
  
• Arthritis:
  
  • Rest, ice, elevation
    
  • NSAIDs
    
• Conjunctivitis:
  
  • Topical antibiotics may provide symptomatic relief
    
• Urethritis:
  
  • Should be treated if initial infection not recognized or treated
    

No definite role for medication

FOLLOW-UP

Treatment is generally outpatient, once syndrome is recognized and other diagnoses have been excluded.

Most patients with reactive arthritis can be discharged with follow-up with their primary care provider.

Severe uveitis should be referred to ophthalmology for close follow-up.

With primary care provider. Most cases have a prolonged course (3–12 mo), and ∼25% may have recurrent episodes.

Failing to diagnose serious life- or limb-threatening diseases is a pitfall:

• Septic arthritis
  
• Gonococcal arthritis
  
• Kawasaki disease
  

• Carter JD, Hudson AP. Reactive arthritis: Clinical aspects and medical management.
  Rheum Dis Clin North Am
  . 2009;35(1):21–44.
  
• Wu IB, Schwartz RA. Reiter’s syndrome: The classic triad and more.
  J Am Acad Dermatol
  . 2008;59(1):113–121.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conjunctivitis
  
• Iritis/Uveitis
  
• Kawasaki Disease
  
• Septic Arthritis
  
• Urethritis
  

CODES