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

1. What other information would you ask for in the history?
2. Describe the rash, and give a differential diagnosis for it.
3. 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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