Síndrome de Reiter

adfdsReactive Arthritis - Reiter's Syndrome

Author: Werner F. Barth, Kinim Segal

Date: August, 1999

Reactive arthritis, also called Reiter's syndrome, is the most common type of inflammatory polyarthritis in young men. It is sometimes the first manifestation of human immunodeficiency virus infection. An HLA-B27 genotype is a predisposing factor in over two thirds of patients with reactive arthritis. The syndrome most frequently follows genitourinary infection with Chlamydia trachomatis, but other organisms have also been implicated. Treatment with doxycycline or its analogs sometimes shortens the course or aborts the onset of the arthritis. Reactive arthritis may also follow enteric infections with some strains of Salmonella or Shigella, but use of antibiotics in these patients has not been shown to be effective. Reactive arthritis should always be considered in young men who present with polyarthritis. Symptoms may persist for long periods and may, in some cases, cause long-term disability. Initial treatment consists of high doses of potent nonsteroidal anti-inflammatory drugs. Patients with large-joint involvement may also benefit from intra- articular corticosteroid injection. (Am Fam Physician 1999;60:499-507.)

In 1984 in Ontario, Canada, an outbreak of Salmonella typhimurium food poisoning occurred among police officers who were serving as security guards during a papal visit.1 Of the 1,608 police officers involved, 432 had acute gastroenteritis. Within three months following the outbreak, 27 of these officers had developed acute arthritis; over the next four months, it resolved in nine of them. The remaining 18 officers had recurrent symptoms or had developed a chronic arthritis on re-evaluation five years later. These officers had developed reactive arthritis, or Reiter's syndrome. Although this condition was once considered benign and self-limited, that may not always be the case. We review the current understanding of this illness and implications for treatment.

Clinical Features

Reactive arthritis is an aseptic inflammatory polyarthritis that usually follows nongonococcal urethritis or infectious dysentery.2 The classic triad of arthritis, urethritis and conjunctivitis does not occur in all patients (Table 1). Onset typically occurs one to three weeks following the infection and may present acutely or insidiously. Urethritis is often symptomatic in male patients, usually with a mucopurulent discharge, but sometimes presents as gross hematuria secondary to hemorrhagic cystitis. In female patients, nonspecific cervicitis may occur. However, in either sex, urethritis may be asymptomatic.

The arthritis preferentially involves the lower extremities, is asymmetric and frequently associated with a "sausage" digit. The patient whose foot and ankle are shown in Figure 1 was a journalist on assignment in Africa who developed dysentery and, two weeks later, presented with fever, weight loss, polyarthritis and a "sausage" toe. The presence of enthesitis, inflammation of the ligaments and tendons at the sites of their insertion into the bone, is a helpful distinguishing characteristic. It causes heel pain, Achilles tendonitis or pain at the insertion of the patella tendon into the tibial tubercle. Very large knee effusions, in excess of 100 mL, are not unusual. When these effusions develop rapidly, they frequently result in popliteal cysts that may rupture and cause a pseudophlebitis syndrome.

Low back pain is common and is often secondary to inflammatory sacroiliitis. Conjunctivitis is frequently mild, transient and easily