Reiter's Syndrome

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Category: Inflammatory Spondyarthropathy Published on Wednesday, 25 June 2008 Written by Yong Tsai, MD
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Reiter's Syndrome and the HLA-B27

Did you know that if you have the HLA-B27 gene and unfortunately came down with certaininfections, you could develop a reactive arthritis, meaning joint inflammation in response to infection, called Reiter’s Syndrome?  Well, John did not know, but he found out.

John, a thirty-two year old businessman, did not know that he carried the HLA-B27 gene until he saw his doctor for a swollen and painful left ankle along with pain in the bottom of his feet.  After his doctor asked him about his past medical history, John remembered he had experienced burning upon urination with penile discharge, abdominal cramps and diarrhea just two weeks ago.  He had also seen an ophthalmologist for eye redness and pain the week before.  His doctor ordered some lab work, which revealed that John indeed carried the randomly inherited gene called HLA-B27.John was diagnosed with Reiter’s Syndrome.

SERONEGATIVE SPONDYLOPATHY

Before we continue, I should explain the correlation between Reiter’s Syndrome, inflammatory bowel disease with arthritis, psoriatic arthritis and ankylosing spondylitis, which I have previously written about.  These four interrelated diseases, which are different from rheumatoid arthritis, are known as seronegative spondyloarthropathies, meaning negative for rheumatoid factor and involving the joints of the spine. 

Their presentations are very similar because they all include inflammation of the sacroiliac (tailbone area) joints, ligaments and tendons, association with the HLB-27 gene, involvement of peripheral joints such as the hands, knees, ankles and feet and involvement of the skin, eyes, bowels and genital/urinary tract.  However, despite their similarities, they are still somewhat different: Reiter’s Syndrome has been proven to be triggered by infection, while the others are still unknown.

WHO IS HANS REITER?

During World War I, a German Army doctor named Hans Reiter treated an officer for infectious diarrhea followed by conjunctivitis (inflammation of the eye), urethritis (inflammation of the urethra, the passage that empties the bladder) and arthritis.  Because this condition had no name, he decided to call it Reiter’s syndrome.

COMMON SYMPTOMS:

Normally, Reiter’s Syndrome produces symptoms such as inflamed, painful, red eyes, burning upon urination, penile discharge, abdominal pain and diarrhea followed by one-sided swelling and pain in the larger lower extremity joints, such as the knees, ankles, feet and hands.  Additional symptoms include increased back pain at night, ulcerations of the mouth or under a male’s foreskin and psoriasis on the palms and soles of the feet. 

COMMON VICTIMS:

Even though the cause of Reiter’s Syndrome is unknown, there seems to be a link between people who carry HLA-B27 and infection.  Out of 100,000 people, only 30 cases are reported each year, making the odds of this disease fairly rare.  Reiter’s, a type of reactive arthritis, tends to target young adults between the ages of 20 and 40, three times more men than women and primarily Caucasians.  The long-term outlook for most patients is good and joint pain and swelling usually settles down within weeks to months.  However, it is not unusual that some people experience recurring symptoms over years and occasionally, some may become disabled.

UNDERSTANDING HLA-B27:

HLA-B27 (human leukocyte antigen) is present in only 8% of the general population, however, about 80% of those with Reiter’s Syndrome have the HLA-B27 gene.  This gene, which is inherited, is an antigen located on the outside of our white blood cells that defend our body against infectious bacteria and viruses.  Suspicion has it that the presence of triggering bacteria resembling the B27 gene tricks the good proteins into attacking themselves.  Part of these bacteria has been detected from joint tissues, which provides direct evidence of a relationship between infection and bacteria. However, how they reach joints, tendons and eyes is not yet known.  In the case of Reiter’s Syndrome, it’s somewhat like being at the wrong place at the wrong time: having the HLA-B27 gene and coming down with a particular infection could trigger Reiter’s Syndrome.

ARE ALL INFECTIONS EQUAL?

No, not all types of infection are “triggering infections”.  Those generally associated as being triggers of Reiter’s Syndrome are gastrointestinal infections such as salmonella poisoning and food-borne enteric diseases and genitourinary infections such as chlamydia and other venereal diseases. 

ARTHRITIS WITH INFLAMMATORY BOWEL DISEASE:

Other arthritic conditions, such as ulcerative colitis or Crohn’s disease are also associated with HLA-B27 and develop when the bowels become inflamed.  The relationship between arthritis with inflammatory bowel disease and infection is still unknown.  Peripheral arthritis, which affects one large joint at a time, such as a knee or an ankle, is most common and tends to indicate and precede inflammation of the bowel. Spinal arthritis resembles ankylosing spondylitis, presenting itself several years prior to bowel symptoms and having about a 50% presence of the HLA-B27 gene in those affected.

UP TO DATE TREATMENT:

Adequate doses of traditional NSAIDs (non-steroidal anti-inflammatory drugs) such as Naprosyn or Indocin have proven to be quite beneficial in treating Reiter’s Syndrome and similar types of arthritis. 

New drugs such as Celebrex, Vioxx and Bextra seem to have similar effects as traditional NSAIDs.  DMARDs (disease modifying anti-rheumatic drugs) such as Methotrexate and Sulfasalizine, generally used for treating seronegative spondyloarthropathies, have proven to be helpful for some patients.  Currently, biologic agents such as Enbrel and Remicade are being approved by FDA for their effectiveness in treating ankylosing spondylitis, psoriatic arthritis and inflammatory bowel disease with arthritis.  Occasionally, topical steroid eye drops and systemic corticosteroids are necessary for treating inflammation of the eye.  At this point, the role of the use of antibiotics has not yet been resolved.

Because early detection and proper treatment can control this disease, it is important to begin treatment as soon as possible to prevent joint deformities and damage from occurring.  With the proper tools and knowledge, it is possible to lead a normal life with Reiter’s Syndrome.

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