Reiter's Syndrome - home health advice

Overview
Definition

Reiter's syndrome is a reactive arthritis, either sexually transmitted (Chlamydia trachomatis or Ureaplasma urealyticum) or follows enteric bacterial infection (dysenteric) and classically has a triad of symptoms: arthritis, conjunctivitis, and urethritis. Mouth and skin ulcerations are now recognized as a fourth feature. Only a third of patients present with the triad, making Reiter's syndrome difficult to diagnose. Differing clinical manifestations depend on gender, genetics, and race.
Etiology

The syndrome has arthritic features appearing one to three weeks after the triggering infection. Infectious agents have been found in affected joints, but etiology of joint involvement is unknown. Microbial antigens within the synovium suggest possible continuing infection or that the arthritis is caused by the persistence of antigens.

* HLA-B27 gene 20% of people with the gene get Reiter's; about 80% of people with Reiter's are HLA-B27-positive

Dysentery triggers:

* Salmonella 6.4% to 6.9% develop Reiter's; 60% are HLA-B27-positive or have B27 cross-reactive antigens
* Shigella 0.2% to 2% develop Reiter's; most are HLA-B27-positive
* Campylobacter occasionally
* Yersinia mainly in Scandinavia; 60% to 80% are HLA-B27-positive

Sexually transmitted disease triggers (1% to 3% following nongonococcal infections):

* Chlamydia 50% of Reiter's patients have antibodies to C. trachomatis; 50% are HLA-B27-positive; a T-cell-mediated, chlamydial antigen-specific immune response is being researched.
* Reiter's is not in itself a sexually transmitted disease.

Risk Factors

* Sexual intercourse with chlamydia-infected partner
* White males ages 20 to 40
* HLA-B27 gene and associated infective pathogens
* Food poisoning, bacterial dysentery

Signs and Symptoms

Not every symptom type occurs for each patient.

* Arthritic disorders pain, swelling, stiffness, redness
* Spondyloarthropathy joints of the spine and sacroiliac
* Small joints of the fingers and toes (digital periostitis; "sausage digits"), wrists, feet (plantar fasciitis), or ankles (Achilles tendinitis)
* Conjunctivitis affects 40%; usually brief, mild
* Keratitis, corneal ulceration, scleritis
* Iritis affects 5%; scarring and permanent damage can occur; pain and light sensitivity
* Urethritis affects 33%; burning during urination may not occur; pus drainage from penis
* Prostatitis prostate tender on palpation
* Circinate balanitis affects 33% of men; shallow ulcerations on the shaft or glans of the penis; painless
* Keratoderma blennorrhagica papulosquamous eruptions on soles, palms, and glans penis; purulent with thick keratotic outer layer
* Mouth inflammation of hard and soft palate; often painless
* Costochondritis inflammation of the breastbone cartilage
* Anorexia or weight loss, malaise, morning stiffness, fever

Differential Diagnosis

* Ankylosing spondylitis
* Crohn's disease associated arthritis
* Inflammatory bowel disease associated arthritis
* Ulcerative colitis
* Psoriatic arthritis
* Lyme disease
* Gonococcal bacterial arthritis

Diagnosis
Physical Examination

Patient may have fever, severe pain, and weight loss during acute phase.
Laboratory Tests

* Serological test antecedents for yersinia or chlamydia support diagnosis
* Inflammation indicated by erythrocyte sedimentation rate and C-reactive protein levels
* Synovial fluid >2,000 cells/ml, mostly polymorphonuclear leukocytes
* Urinalysis or urine culture determines bacterial infection

Pathology/Pathophysiology

* Synovial/joint inflammation cellular infiltration of polymorphonuclear leukocytes, lymphocytes, and plasma cells; heterotopic bone formation
* Enthesitis inflammation and erosion where the tendons and muscles insert into the bone
* Mucocutaneous lesions thickening of the horny layer, acanthosis, parakeratosis
* Intestines acute and chronic lesions, inflammation of the colon and terminal portion of the ileum

Imaging

* X rays reveal spurs, calcifications, periosteal thickening, joint and articular margin erosion, sacroiliitis; enthesitis appears as erosions and reactive new bone formation; abnormalities in 70% of chronic patients
* Scintigraphy more sensitive in sacroiliac and enthesitis detection
* Computerized tomography assesses sacroiliac and spondylitic involvement

Other Diagnostic Procedures

Diagnosis of Reiter's is difficult. History of infecting agent helps, but can occur without trigger. Exclusion of other diagnoses, the presence of spine and sacroiliac arthritis, and appearance of nonjoint symptoms, especially urethritis, determines correct diagnosis. Skin lesions typical of Reiter's permit a more definitive diagnosis. The HLA-B27 genetic marker is not diagnostic but helps confirm diagnosis.
Treatment Options
Treatment Strategy

Treatment focuses on symptom management. Specialists for each discrete symptom are usually needed, as each symptom may require a different strategy. Physical and occupational therapy may help patients improve muscle tone, maintain mobility, alleviate gait disturbances, and learn to perform tasks with less stress on joints.
Drug Therapies

* Nonsteroidal anti-inflammatory drugs (NSAIDs) Indomethacin (2 to 3 mg/kg/day, especially effective in 75 mg bid slow-release); side effects include gastrointestinal irritation, bleeding, ulceration, headaches, dizziness
* Corticosteroids oral or local injection into joint; decreases inflammation and controls pain
* Sulfasalazine experimental, promising sulfa-based drug for peripheral arthritis; 2 to 3 g/day; well-tolerated; monitor blood counts with long-term use for bone marrow suppression
* Methotrexate orally or by injection for chronic arthritis; 7.5 to 15 mg/week; experimental; blood and liver tests for bone marrow and liver toxicity, respectively; contraindicated with acquired immunodeficiency syndrome (AIDS)

Complementary and Alternative Therapies

Alternative therapies may be effective at alleviating symptoms. Treatment strategy is very similar to rheumatoid arthritis, with specific nutrients and herbs for the eyes and lower urinary tract.
Nutrition

* Glucosamine sulfate (500 mg tid higher doses required for obese patients or those taking diuretics): stimulates cartilage growth and may be as effective for pain relief as NSAIDs without the side effects. May take one to three months to see relief. Anecdotal cases find cartilage regeneration.
* Avoid nightshade family (tomatoes, potatoes, eggplant, peppers, tobacco); decrease saturated fats and alcohol (inflammatory); increase oily fish, nuts, and flaxseed (anti-inflammatory); increase fruits and vegetables (flavonoids); and avoid any allergenic foods.
* Antioxidants: Vitamin C (1,000 to 3,000 mg/day), vitamin E (400 to 800 IU/day), beta-carotene (25,000 IU/day), selenium (200 mcg/day)
* Essential fatty acids (2 tbsps. oil/day or 1,000 to 1,500 mg bid): a mix of omega-6 (evening primrose) and omega-3 (flaxseed).
* Minerals: zinc (45 mg/day), copper (1 mg/day), bromelain (500 mg tid) anti-inflammatory

Herbs

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Turmeric (Curcuma longa) anti-inflammatory: 400 mg tid is equally effective as phenybutazone (300 mg/day) for duration of morning stiffness, walking time, and joint swelling, with greater safety and tolerability; works especially well with bromelain.

For urethritis:

* Juniper (Juniperus communis): diuretic historically used for inflammatory conditions of the lower urinary tract; avoid with kidney disease
* Uva ursi (Arctostaphylos uva ursi): antibacterial and anti-inflammatory for lower urinary tract, for acute use only
* Horsetail (Equisetum arvense): soothing diuretic with historic use for rheumatic disease
* Licorice (Glycyrrhiza glabra): anti-inflammatory, soothing, not for use with hypertension
* Meadowsweet (Filipendula ulmaria): anti-inflammatory with historic use as a diuretic and for rheumatism

Mix three to four of these herbs in equal amounts and use 1 tsp. of mixture. Drink 1 cup tea tid or 30 drops tincture tid; use daily during acute flare-up, and two weeks out of the month as a preventive.

For iritis:

* Horsetail, licorice, meadowsweet (see above)
* Eyebright (Euphrasia officinalis) and bilberry (Vaccinium myrtillus): historically used for inflammation of the eyes; drink 30 to 60 drops tincture tid, 1 cup tea tid, and use tea to make compresses for acute relief.

Acupuncture

As with other forms of arthritis, acupuncture may be effective at stimulating the immune system, and reducing inflammation.
Patient Monitoring

Patients are sometimes hospitalized during the acute phase. Prolonged follow-up is necessary to confirm diagnosis, treat changing symptoms, and avoid further complications.
Other Considerations
Complications/Sequelae

* Blindness
* Aortic root necrosis

Prognosis

Initial attacks last three to six months. Syndrome manifests within 10 to 30 days of infection. Mean duration is 19 weeks. Fifty percent of people with one to two attacks have no further symptoms. Most people with a third attack develop chronic Reiter's syndrome. The intensity of attacks tends to maintain a consistent pattern, but few (15%) patients have permanent joint damage. Patients maintain near-normal lifestyles with physical/occupational modifications.
Pregnancy

Drugs must be evaluated for safety during pregnancy.
References

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:368-369.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Company; 1998.

Koopman WJ, ed. Arthritis and Allied Conditions. 13th ed. Baltimore, Md: Lippincott, Williams & Wilkins; 1996.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998.

Weiss RF. Herbal Medicines. Beaconsfield, England: Beaconsfield Publishers; 1998:339.