What is Reiter Syndrome?
Reiter syndrome, now called reactive arthritis, is a post-infectious inflammatory condition characterized by the classic triad of arthritis, urethritis, and conjunctivitis that develops after urogenital (typically chlamydial) or gastrointestinal infections, predominantly affecting HLA-B27 positive young men. 1, 2
Clinical Definition and Terminology
- The term "Reiter syndrome" has been replaced with "reactive arthritis" for both ethical reasons (Hans Reiter's Nazi affiliations) and clinical utility, though the eponym persists in medical literature 3
- Reactive arthritis is defined as an infection-induced systemic illness with inflammatory synovitis from which no viable microorganisms can be cultured 4
- The complete Reiter triad (urethritis, conjunctivitis, arthritis) occurs in only 41.7% of patients; 44.2% present with two of three features, making "reactive arthritis" a more inclusive term 5, 4
Epidemiology and Risk Factors
- The condition predominantly affects young men with a male-to-female ratio of 8.5:1 5
- Frequency in the United States is estimated at 3.5 to 5 cases per 100,000 population 2
- HLA-B27 is present in 83.3% of patients, indicating strong genetic susceptibility 5
- The disease occurs after urogenital infections (77.5% of cases) or enteric infections (16.5% of cases) 5
Pathophysiology and Causative Organisms
- Chlamydia trachomatis is the most common urogenital trigger, found in synovial fluid in 54% of tested patients 5
- Ureaplasma urealyticum and Mycoplasma genitalium have been implicated in urethritis-associated cases 6, 7
- Enteric organisms can cause reactive arthritis, particularly in men over 35 years or those practicing insertive anal intercourse 7
- The finding of causative agents in synovial membrane or fluid suggests an infectious rather than purely reactive process 5
Clinical Manifestations
Musculoskeletal Features
- Asymmetrical oligoarthritis of lower extremities is the most frequent presentation, occurring in 69.4% of patients 5
- The arthritis is typically acute or subacute (40.5%), though recurrent (31%) and chronic forms (28.5%) occur 5
Genitourinary Features
- Urethritis with mucopurulent discharge, dysuria, or urethral pruritis 8
- In rare instances, men may develop urethral strictures 6
- Circinate balanitis and ulcerative vulvitis can occur 1
Ocular Features
- Conjunctivitis is treated with artificial tears containing methylcellulose or hyaluronate 9
- Iritis may develop in some patients 3
Dermatologic Features
- Keratoderma blennorrhagicum (hyperkeratotic skin lesions) 1
- Nail changes and oral lesions are common 1
Management Approach
Initial Treatment Strategy
NSAIDs should be initiated as first-line therapy, followed by disease-modifying antirheumatic drugs (DMARDs) for persistent symptoms, with antibiotics indicated when there is evidence of ongoing infection. 9
Antibiotic Therapy
- For documented Chlamydia trachomatis infection: Doxycycline 100 mg orally twice daily for 7 days to potentially shorten the course or prevent onset of arthritis 9, 8
- For suspected chlamydial or gonococcal infection: Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 7
- Alternative for enteric organisms or antibiotic allergies: Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 7
Symptomatic Management
- Ocular symptoms: artificial tears with methylcellulose or hyaluronate 9
- Avoid anticholinergic medications as they worsen sicca symptoms in patients with ocular involvement 9
- Use corticosteroids at minimum effective dose and duration to avoid significant side effects 9
Critical Clinical Pitfalls
- Do not delay treatment: Without proper management, reactive arthritis can progress to chronic destructive arthritis in 15-20% of patients 1, 2
- Reassess if no improvement: Failure to improve within 3 days of treatment requires reevaluation of both diagnosis and therapy 7
- Partner management is essential: Sexual partners should be evaluated and treated if the condition is caused by sexually transmitted pathogens 7
- Enforce sexual abstinence: Patients must avoid sexual intercourse until they and their partners are cured 7
- Consider HIV status: Treatment is particularly difficult in HIV-positive patients, who may have more severe disease 1