Reiter's disease

Reiter's disease is a disorder of unknown etiology, often associated with the histocompatibility antigen B27.

Reiter's syndrome (syn.: urethrooculosynovial syndrome, Reiter's disease) is a combination of arthritis of the peripheral joints lasting more than one month, with urethritis (in women - cervicitis) and conjunctivitis. Reiter's disease is accompanied by characteristic lesions of the skin and mucous membranes - blenorrheal keratoderma, cincinar balanitis and stomatitis.

The disease occurs mainly in patients under 22 years of age, 90% of patients are men. In children and the elderly, the disease is extremely rare.

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Causes of Reiter's disease

The pathogenesis and causes of Reiter's disease are not fully understood. The disease begins 1-4 weeks after an infection - dysentery, salmonellosis or other intestinal infections, non-gonococcal urethritis (chlamydia, ureaplasmosis). Infectious agents act as a trigger, and then autoimmune and other mechanisms are activated, and the further course of the disease and its relapses can occur even after the elimination of the pathogen.

The HLA-B27 allele is found in 75% of patients. Reiter's disease is common among HIV-infected individuals.

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Pathomorphology of Reiter's disease

In the foci of psoriasiform papules, there is severe edema of the papillary layer of the dermis, acanthosis, parakeratosis with large abscesses of the Munro type and spongiform 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), dilation of vessels in the medulla, proliferation of stromal cells, among which are plasma cells, neutrophils and eosinophils. In the sinuses - inflammation with expansion of their lumens, around them - hemosiderin deposits.

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

Symptoms of Reiter's disease

There are two stages in the development of the pathological process: the early infectious stage and the late stage of immune inflammation with a high content of circulating immune complexes, hyperglobulinemia and other signs of impaired immune status. Clinically, it manifests itself as urethritis, prostatitis, joint damage, mainly large ones, conjunctivitis and polymorphic skin rashes, among which the most common are psoriasiform lesions 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 "geographic" tongue. Symptoms of damage to internal organs (diarrhea, myocarditis, nephritis, etc.) may be observed. Mostly young men are affected, the course is acute, many patients recover after the first attack, but relapses are not uncommon, especially when urogenital foci of infection or reinfection persist. Remissions are long (months or years), the course is chronic, often recurring, which can lead to disability, and in rare cases to death.

Symptoms of Reiter's disease consist of urethritis, arthritis and conjunctivitis. However, the skin, mucous membranes, cardiovascular system and other organs may be affected. At the onset of the disease, all 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 or later.

Urethritis is the most common complication of this disease and is manifested by nonbacterial pyuria, hematouria 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 a patient with Reiter's syndrome

Conjunctivitis occurs in 1/3 of patients and can be angular, dorsal and bulbar.

The eyes may be reddened and patients feel photophobia. Keratitis and iridocyclitis sometimes develop. Decreased visual acuity and even blindness are noted.

Joint inflammation most often takes the form of synovitis with moderate effusion, soft tissue swelling and limitation of function. Less common are arthralgia or, on the contrary, severe deforming arthritis. Arthritis of the knee joint is often accompanied by abundant effusion into the joint cavity. Even a rupture of the synovial membrane of the knee joint and the outpouring of fluid into the calf muscles are possible. Reiter's disease is characterized by asymmetric sacroiliitis and damage to the intervertebral joints, which are detected radiologically. Sometimes joint damage is accompanied by a feverish state. Body temperature is often subfebrile.

In Reiter's disease, skin lesions are found in almost 50% of patients. Skin rashes can be varied, but the most common and typical are circinate balanitis and erosions of the oral cavity with areas of desquamation of the mucous membrane of a whitish color, which are sometimes located on the tongue, resembling a "geographical" tongue, and on the palate - circinate uranitide. "Blennorrheic" keratoderma is pathognomonic. Keratoderma begins with a rash of red spots on the palms, soles, genitals or other parts of the body. The spots then transform into pustules, and later - into cone-shaped horny papules or thick, crusted plaques. Widespread keratoderma, as well as psoriasiform rashes usually accompany severe forms of Reiter's disease. Sometimes subungual hyperkeratosis, thickening, fragility of the nail plates are noted. Of the internal organs, the cardiovascular system is most often affected (myo- or pericarditis, aortic insufficiency), less often - pleurisy, glomerulonephritis or pyelonephritis, phlebitis, lymphadenitis, various gastrointestinal disorders, neuralgia, neuritis, peripheral paresis. In severe cases, functional disorders of nervous activity are possible in the form of depression, irritability, sleep disorders, etc. Rarely, there are cases of spontaneous recovery in 2-7 weeks. The acute form, like the protracted one, ends in complete clinical remission regardless of the severity of the disease. The chronic form, in which the sacroiliac and vertebral joints are involved in the process, can form ankylosis and persistent lesions of the joints and ligamentous apparatus, leading to limited ability to work and disability.

Differential diagnosis

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

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Treatment of Reiter's disease

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

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

Sexual partners should be examined. Even in the absence of clinical signs of urogenital infection, they are prescribed preventive treatment for Reiter's disease.