Description

The classic triad includes arthritis, conjunctivitis/iritis, and either urethritis or cervicitis (“can’t see,” “can’t pee,” “can’t bend my knee”). The diagnosis is primarily clinical, and there are no formal diagnostic criteria.

• The epidemiology is similar to other reactive arthritides, typically characterized by sterile joint inflammation associated with infections originating at nonarticular sites. Active Chlamydia spp. have been detected in the joint fluid of some affected patients, although this is not the norm. A fourth feature (dermatologic involvement) may include buccal ulceration, balanitis, or a psoriasiform skin eruption. (Having only two features does not rule out the diagnosis.)
• Two forms of Reiter syndrome:
  • Sexually transmitted: Symptoms emerge 7 to 14 days after exposure to Chlamydia trachomatis and other sexually acquired pathogens.
  • Postenteric infection (including traveler’s diarrhea)
• In individuals with new or frequent sexual partners, the triggering infection is likely sexually transmitted (rather than enteric). The infection has often been cleared by the time rheumatic symptoms appear, and genital chlamydia is often asymptomatic.
• In individuals with a history of recent enteric illness, the triggering event is more likely to be a bacterial enteric infection rather than sexual transmission.
• System(s) affected: musculoskeletal, renal/urologic, dermatologic/exocrine
• Synonym(s): idiopathic blennorrheal arthritis; arthritis urethritica; urethro-oculo-synovial syndrome; Fiessinger-Leroy-Reiter disease; reactive arthritis

Pediatric Considerations
Juvenile rheumatoid arthritis (RA) has many of the same clinical features as Reiter syndrome.

Pregnancy Considerations
No special considerations; usual drug precautions

Epidemiology

• Predominant age: 20 to 40 years
• Predominant sex: male > female

Incidence

• 0.2–1% incidence after bacterial dysentery outbreaks
• Complicates 1–2% of nongonococcal urethritis cases

Prevalence
~3–5 cases per 100,000 individuals per year

Etiology and Pathophysiology

• The pathophysiology of all the seronegative reactive arthritis syndromes and the immunologic role of infectious diseases as precipitants for clinical illness are incompletely understood.
• Proinflammatory cytokines lead to synovitis. Toll-like receptors (TLRs) have been implicated in the recognition of gram-negative lipopolysaccharide as part of the disease cascade.
• The role of HLA-B27 is incompletely understood, but there is an increased risk of developing reactive arthritis if patients are HLA-B27–positive. In these patients, the disease is more likely to be severe and longer lasting.
• Avoiding precipitant infections and early management of multiorgan inflammation is important.
• C. trachomatis is the most common sexually transmitted infection associated with Reiter syndrome.
• Dysentery-associated Reiter syndrome follows infection with Shigella, Salmonella, Yersinia, and Campylobacter spp. Enteric-associated Reiter syndrome is more common in women, children, and the elderly than the postvenereal form.

Genetics
HLA-B27 tissue antigen is present in 60–80% of patients, suggesting a genetic predisposition.

Risk Factors

• New or high-risk sexual contacts 1 to 4 weeks before the onset of clinical presentation; the primary infection may be subclinical and undiagnosed.
• Food poisoning or bacterial dysentery due to travel or incorrectly prepped/stored food

General Prevention

• Avoidance of infectious precipitants is the most important general precaution (and potentially the most difficult to achieve).
• Safe sexual practices; proper food and water hygiene

Commonly Associated Conditions

• Enteric disease
  • Shigellosis; Salmonellosis; Campylobacteriosis
  • Enteric infection with Yersinia spp.
• Urogenital infection
  • Chlamydia urethritis/cervicitis (2)
  • Mycoplasma or Ureaplasma spp.
• HIV/AIDS