What is the management for Reiter's syndrome?

Management of Reiter's Syndrome

The management of Reiter's syndrome (reactive arthritis) should begin with NSAIDs as first-line therapy, followed by disease-modifying antirheumatic drugs (DMARDs) for persistent symptoms, with antibiotics indicated when there is evidence of ongoing infection. 1, 2

Initial Evaluation and Diagnosis

• Reiter's syndrome is characterized by the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection, particularly those in the urogenital or gastrointestinal tract 3
• Dermatologic manifestations are common, including keratoderma blennorrhagicum, circinate balanitis, ulcerative vulvitis, nail changes, and oral lesions 3
• The syndrome is more common in men, though cases have been reported in women and children 3
• HLA-B27 genotype is a predisposing factor in over two-thirds of patients with reactive arthritis 2

First-Line Treatment

• High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial treatment of choice for symptomatic relief 2
• For patients with genitourinary infection with Chlamydia trachomatis, doxycycline (100 mg orally twice daily for 7 days) is recommended to potentially shorten the course or prevent onset of arthritis 1, 2
• Antibiotics have not been shown to be effective for reactive arthritis following enteric infections with Salmonella or Shigella 2

Management of Specific Manifestations

Articular Symptoms

• For large joint involvement, intra-articular corticosteroid injections may provide relief 2
• For persistent arthritis despite NSAIDs, disease-modifying antirheumatic drugs (DMARDs) should be considered 4
• Methotrexate is the most commonly used immunosuppressive agent for persistent arthritis 4

Ocular Manifestations

• Conjunctivitis is treated with artificial tears containing methylcellulose or hyaluronate 5
• For anterior uveitis, topical corticosteroids and cycloplegic agents are indicated 4
• Severe ocular inflammation may require systemic corticosteroids and immunosuppressive therapy 4

Mucocutaneous Lesions

• Topical corticosteroids for skin lesions such as keratoderma blennorrhagicum 3
• Oral lesions may respond to topical corticosteroids or antiseptic mouthwashes 3

Second-Line and Refractory Disease Management

• For patients with persistent symptoms despite NSAIDs, systemic corticosteroids may be required 4
• Immunosuppressive therapy with methotrexate should be initiated in patients with refractory disease 4
• For patients requiring more than one immunosuppressive agent, combination therapy may be necessary 4
• TNF-alpha inhibitors such as infliximab have shown success in treating refractory Reiter's syndrome 6

Monitoring and Follow-up

• Regular assessment of disease activity and treatment response is essential 4
• Monitor for ocular complications including anterior uveitis, posterior uveitis, keratitis, and cataract 4
• Long-term follow-up is important as 15-20% of patients may develop severe chronic sequelae 3

Special Considerations

• In HIV-positive patients, treatment can be more challenging and may require more aggressive immunosuppressive therapy 3
• Patients with recurrent ocular manifestations often require systemic therapy to control inflammation and prevent progressive visual loss 4
• The prognosis is variable, with some patients experiencing complete resolution while others develop chronic disease 3

Potential Pitfalls and Complications

• Delayed diagnosis and treatment may lead to chronic destructive arthritis 7
• Undertreatment of ocular manifestations can result in permanent visual impairment 4
• Overuse of corticosteroids can lead to significant side effects; they should be used at the minimum effective dose and duration 5
• Avoid anticholinergic medications that can worsen sicca symptoms in patients with ocular involvement 5