Picture Quiz
Case history
A 22 year old man presented at the accident
and emergency department with a two week
history of a rash on his penis and the soles of
his feet. He also complained of sore eyes and
of pains in his ankles and left wrist.
Questions
- What other information would you ask for in the history?
- Describe the rash, and give a differential diagnosis for it.
- What is the diagnosis?
Discussion
Reiter's syndrome typically presents in
young men; women account for only 5%
of the total. There is often a history of sexual intercourse two to four weeks before
the onset of symptoms. Genitourinary
involvement may result in urethritis or balanitis in men and urethritis and cervicitis
in women. The urethritis in men differs
from that seen in infections such as gonorrhoea as it is less painful and less productive of discharge. Women often have
no symptoms of their genitourinary
pathogens, but some may notice a slight
vaginal discharge or dysuria.
Conjunctivitis occurs in approximately
one third of cases. The arthritis is typically
polyarticular and asymmetrical and affects
the large joints of the lower limbs. Other
joints may, however, be affected, as in the
patient presented who had a reactive
arthritis of his wrist. Musculoskeletal
involvement in Reiter's syndrome may also
include sacroiliitis and ethesitis (inflammation of the muscular or tendinous
attachment to bone) such as Achilles
tenosynovitis and plantar fasciitis. The
characteristic rash of Reiter's syndrome
known as keratoderma blenorrhagica,
shown here on the feet, which occurs less
frequently on the palms of the hands,
occurs in about 15% of cases. Small superficial painless ulcers are also commonly
seen in the mouth and on the glans penis,
where they are know as circinate balanitis.
Other rare manifestation of Reiter's syndrome include uveitis, keratitis, optic neuritis, aortic insufficiency, and cardiac conduction defects.
There is no specific test to confirm the
presence or absence of a reactive arthritis.
Diagnosis is made on clinical grounds. It is
important to consider and exclude the differential diagnosis of acute gonococcal
arthritis. Taking urethral swabs for gonococcal cultures can do this, and, unlike a
reactive arthritis, gonococcal arthritis will
respond quickly to penicillin treatment
Reiter's syndrome lasts between days
and months. Treatment is based on relieving the symptoms, and the maintenance of
function of the joints. The arthritis usually
responds to non-steroidal anti-inflammatory drugs such as ibuprofen, but occasionally persistent joint disease may
require a second line drug such as
methotrexate. Physiotherapy is essential to
maintain mobility and function of the
joints. The urethritis may respond to the
use of an appropriate course of antibiotics,
but there is no evidence that they affect the
associated reactive arthritis.
Answers
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Kirsty Rogerson, senior house officer, Royal Liverpool University Hospital, Liverpool
studentBMJ 2000;08:45-88 March ISSN 0966-6494
