Reiter's disease

Reiter's disease is a disease of unclear etiology, often associated with B27 antigen tissue compatibility.

Under Reuters syndrome (syn: urethrookulosinovial syndrome, Reiter's disease) is understood as a combination of arthritis of peripheral joints lasting more than one month, with urethritis (in women - cervicitis) and conjunctivitis. Reiter's disease is accompanied by a characteristic lesion of the skin and mucous membranes - blenoraine keratoderma, cincinnar balanitis and stomatitis.

The disease occurs mainly in patients younger than 22 years, 90% of patients - men. In children and the elderly, the disease is extremely rare.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes of Reiter's Disease

The pathogenesis and causes of Reiter's illness are not fully understood. The disease begins 1-4 weeks after the infection - dysentery, salmonellosis or other intestinal infections, non-gonococcal urethritis (chlamydia, ureoplasmosis). Infectious agents play the role of a trigger mechanism, and then autoimmune and other mechanisms are included, with the further course of the disease and its relapses occurring after elimination of the pathogen. 

In 75% of patients, the HLA-B27 allele is found. Reiter's disease is common among HIV-infected people.

[10], [11]

Pathomorphology of Reiter's Disease

In the foci of psoriatic papules, there is a strong edema of the papillary layer of the dermis, acanthosis, parakeratosis with large abscesses of the Munro type and spongioform pustules of Kogoy. Unlike psoriasis, the contents of the pustules consist mainly of eosinophilic granulocytes, the foci of parakeratosis are replaced by cortical elements. In the papillary layer of the dermis, in addition to edema, hemorrhages are noted.

In the lymph nodes - edema, hyperplasia of lymphatic follicles with pronounced germinal centers (B-zone), expansion of vessels in the brain substance, proliferation of stromal cells, among which are plasmocytes, neutrophilic and eosinophilic granulocytes. In sinuses - the phenomenon of inflammation with the expansion of their lumens, around them - deposits of hemosiderin.

In joint capsules, inflammatory changes resembling psoriasis and rheumatoid diseases are also found. But unlike the latter in infiltrates with Reiter's disease, a large number of eosinophilic granulocytes (eosinophilic rheumatoid) are detected.

Symptoms of Reiter's Disease

There are two stages in the development of the pathological process: early infectious and late stage of immune inflammation with a high content of circulating immune complexes, hyperglobulinemia and other signs of impaired immune status. Clinically manifested by urethritis, prostatitis, joint damage, mainly large, conjunctivitis and polymorphous skin eruptions, among which the most common are psoriatic forms and palmar-plantar keratoses, chronic balanoposthitis. Less common are hemorrhagic erosions, changes in the mucous membrane of the oral cavity in the form of edematous erythematous spots and the "geographical" language. Symptoms of internal organs (diarrhea, myocarditis, nephritis, etc.) can be observed. Mostly, young men are ill, the course is acute, many patients recover after the first attack, but relapses are frequent, especially if the urogenital foci of infection or reinfection are preserved. Remissions are long (months or years), chronic course, often relapsing, which can lead to disability, in rare cases, to death.

Symptoms of Reiter's disease are composed of urethritis, arthritis and conjunctivitis. However, skin, mucous membranes, cardiovascular system and other organs can be affected. At the onset of the disease, all the symptoms of the triad are not always present at the same time. In 40-50% of patients, signs of the disease appear after 1-3 months and later.

Urethritis is most often found in this disease and manifests as non-bacterial pyuria, hematuria and dysuria, often complicated by cystitis, prostatitis and vesiculitis. Urethritis and prostatitis can occur with minimal symptoms without causing subjective disorders.

Conjunctivitis and secondary pyoderma of the face in the patient with Peetepa syndrome

Conjunctivitis occurs in 1/3 of the patients and is angular, dorsal and bulbar.

Eyes are reddened and patients feel photophobia. Sometimes keratitis and iridocyclitis develop. There was a decrease in visual acuity and even blindness.

Inflammation of the joint more often has the form of a synovitis with a moderate effusion, swelling of soft tissues and restriction of function. Less common are arthralgia or, conversely, severe deforming arthritis. Arthritis of the knee joint is often accompanied by a profuse exudation into the joint cavity. Even the rupture of the synovial membrane of the knee joint and the outflow of fluid into the calf muscles are possible. For Reiter's disease asymmetric sacroileitis and lesion of intervertebral joints are characteristic, which are detected radiological. Sometimes joint damage is accompanied by a febrile condition. Body temperature is often subfebrile.

With Reiter's disease, skin damage is found in almost 50% of patients. Skin rashes can be diverse, but the most common and typical are zircinar balanitis and erosions of the mouth with areas of desquamation of the whitish-colored mucous membrane, which are sometimes located on the tongue, resembling a "geographical" language, and in the sky - zirconium uranite. Patogmonichnym is "blennoreiynaya" keratoderma. Keratodermia begins with the eruption of red spots on the palms, soles, genitals or other parts of the body. The spots are then transformed into pustules, and later into cone-shaped horny papules or thick, covered with crusts, plaques. Common keratoderma, as well as psoriasis rashes usually accompany severe forms of Reiter's disease. Sometimes subungual hyperkeratosis, thickening, fragility of nail plates are noted. The cardiovascular system is most often affected from the internal organs, (myo- or pericarditis, aortic insufficiency), less often pleurisy, glomerulonephritis or pyelonephritis, phlebitis, lymphadenitis, various gastrointestinal disorders, neuralgia, neuritis, peripheral paresis. In severe conditions, functional disorders of nervous activity are possible in the form of depression, irritability, sleep disturbances, etc. Occasionally, there are cases of spontaneous cure after 2-7 weeks. The acute form, like prolonged, results in complete clinical remission, regardless of the severity of the disease. The chronic form, in which sacroiliac and vertebral joints are involved in the process, can form ankylosis and persistent joint and ligamentous lesions, leading to disability and disability.

Differential diagnosis

The disease should be distinguished from pustular psoriasis, rheumatoid arthritis, Behcet's disease.

[12], [13], [14], [15], [16]

Treatment of Reiter's Disease

In the acute stage of Reiter's disease, antichlamydial drugs are prescribed: azithromycin (azimed) in g once or doxycycline 100 mg twice a day for 7 days, or roxithromycin (roxibel) 150 mg 2 times a day for 5 days. Simultaneously, detoxifying, desensitizing, anti-inflammatory drugs are prescribed. In very severe cases, oral glucocorticosteroid preparations are recommended.

In the stage of immune disorders (autoimmunization), along with the above drugs, immunosuppressive agents and cytostatics are used.

It is necessary to examine sexual partners. Even in the absence of clinical signs of urogenital infection, they are prescribed preventive treatment of Reiter's disease.