Reiter's Syndrome Following Antibiotic-Associated Colitis

Abstract: Reiter's syndrome following antibiotic-associated colitis. I. B. Puddey, Aust. N.Z. J. Med., 1982, 12, pp. 292–293.
The first case report of Reiter's syndrome following Clostridium difficile induced antibiotic-associated colitis is presented, together with a discussion of previous case reports of arthritis complicating antibiotic-associated colitis.     

Disseminated Yersinia enterocolitica. Case report and review of the literature

Yersinia enterocolitica is an uncommon cause of infectious diarrhea in the United States. Rarely, it is a cause of extraintestinal disease. Yet an association exists between Y. enterocolitica infection and axial arthropathy. We present a patient with long-standing arthritis, consistent with incomplete Reiter's syndrome, who developed Y. enterocolitica colitis with hepatic and pulmonic infection.     

Rheumatologic syndrome in gastrointestinal diseases. Clinical and pathogenetic aspects

Patients with reactive arthritis, sacroiliitis, spondylitis or Reiter's syndrome following intestinal infection from Yersinia, Salmonella, Shigella or Campylobacter organisms have been reported from endemic areas and after epidemic dysenteries. Possession of the antigen HLA B27 affects severity and prognosis of the arthritis and is more often associated with spondylitis and Reiter's syndrome. Articular manifestations are also quite common systemic complications of chronic inflammatory bowel disease. The clinical picture, pathogenetical aspects and treatment of arthritis associated with Crohn's disease, ulcerative colitis and Whipple's disease are reviewed. In only few cases, coeliac disease can be complicated by arthritis. In patients undergoing intestinal bypass surgery systemically absorption of intestinal bacterial antigens and immune complex formation may contribute to the development of bypass-arthropathy and dermatologic manifestations.     

Joint fluid cytology in Reiter''s disease.

The diagnostic value of the finding of cytophagocytic macrophages (CPM) in the joint fluid of patients with Reiter's disease has been re-examined. CPM were found in 46% of Reiter's disease fluids and in 45% of other inflammatory knee joint fluids. Higher CPM scores, on a 4-point grading, were commoner in Reiter's disease but the difference was not statistically significant. Further, although the graded polymorphonuclear leucocyte phagocytosis shown by CPM was greater in Reiter's disease this also was not significant. It is concluded that the presence of CPM in joint fluid is of little discriminating value.     

Acute aortic insufficiency in a patient with presumed Reiter''s syndrome.

Cardiac disease is rare in patients with Reiter's syndrome. There have been 15 reported cases of aortic insufficiency in patients with Reiter's syndrome, with the aortic insufficiency developing over several years. This paper reports the case of a black HLA-B27 negative woman who presented with Reiter's syndrome and acute aortic insufficiency. An antecedent streptococcal infection is suggested as the inciting factor. To our knowledge, this is the first report of Reiter's syndrome in a black woman with acute aortic insufficiency.     

An "experimental" epidemic of Reiter's syndrome revisited. Follow-up evidence on genetic and environmental factors.

The relation between a specific infective event (shigellosis), a specific disease entity (Reiter's syndrome), and a specific histocompatibility antigen (HL-A B27) is documented by follow-up study of an epidemic of post-Shigella Reiter's syndrome. Five of the original 10 patients have been traced, HL-A typed, and clinically assessed 13 years after the initial episode. One of the 5 has minimal disease, remains symptom-free, and is HL-A B27-negative. The remaining 4 have followed a chronic course, have persistent active disease, and are HL-A B27-positive. It is estimated that after this single episode of shigellosis, from one sixth to one third of the persons who were HL-A B27-positive developed Reiter's syndrome. The prognosis for postdysenteric Reiter's syndrome must be guarded, especially in the subject who is B27-positive.     

Reiter''s disease in three boys.

Three cases of Reiter's disease occurring in boys under the age of 16 are reported. One of these presented with a Salmonella enteritidis diarrhoea. This conforms to the 'dysenteric' form of Reiter's disease usually seen in Europe and rarely reported in England. Another presented with a monarticular arthritis of the knee, and the third has developed a chronic relapsing erosive arthritis as a result of sexually acquired Reiter's disease--an occurrence not previously reported in this age group. We draw attention to the frequency of diarrhoea in these children and the sex incidence of 1 female to 4--5 males, which agrees more with Reiter's disease of dysenteric origin than that acquired venereally.     

An unusual motor neuropathy occurring during quiescent Reiter's disease. A case report

A patient with a history of typical Reiter's disease developed a reversible, unilateral ascending motor neuropathy at a time when the disease was otherwise quiescent. This appears to be a case of isolated Reiter's neuropathy.     

Methotrexate in Reiter''s disease.

Three cases of severe Reiter's disease were treated successfully with methotrexate after failure of conservative therapy, including systemic corticosteroids in 2 instances. The usefulness and potential hazards of such therapy are discussed, and some evidence that corticosteroids may aggravate the dermatological manifestations of Reiter's disease is presented.     

Reiter's disease and the histocompatibility antigen, HL-A 27.

HL-A27 were found in 31 of 48 patients with Reiter's disease (65%) as compared with 8% of 2 103 health controls. It is suggested that HL-A27 is closely related to the inheritance of a special immune response leading to an increased susceptibility to a special type of reactive arthritis which Reiter's disease has in common with ankylosing spondylitis and a certain type of psoriatic arthritis.     

Evaluation of arthritis in Reiter's disease by bone scintigraphy and radiography

Summary Tc-99m MDP bone scans were used to evaluate the articular inflammation in 38 patients with Reiter's disease and compared with clinical examination and radiologic findings. Our data showed that Reiter's disease predominantly involves the lower limbs, especially the heels, which may be a characteristic feature of Reiter's disease. Bone scans revealed a high diagnostic sensitivity in the detection of clinical arthritis in all peripheral joints, especially in the small joints of the four limbs. The diagnostic sensitivity of radiography was generally lower than bone scintigraphy. In the presence of positive radionuclide findings, clinical arthritis was found in most joints. The scintigram, however, detects a greater number of abnormalities than does clinical assessment in the sternoclavicular joints, shoulders, metacarpophalangeal joints, and tarsals. Because of its high sensitivity, bone scintigraphy is capable of detecting subclinical arthritis, and might provide more objective evidence of early inflammatory joint disease and additional information regarding the pattern of joint involvement. In view of the advantages of low patient radiation exposure, high sensitivity, and the ability to survey the whole body, we consider bone scintigraphy as useful and better than radiography in the detection of early articular inflammation and in establishing the extent and pattern of arthritis in Reiter's disease.     

Decreased activity of Reiter's syndrome after urethrectomy

Reiter's syndrome is a chronic rheumatic disease that develops after infective urethritis or gastroenteritis and has a strong association with the HLA-B27 antigen. How these factors interact remains unclear. We present a patient with Reiter's syndrome who exhibited 2 novel features: unusually severe urethritis that produced strictures requiring surgery, and dramatic regression of his rheumatic manifestations following a urethrectomy.     

Atrioventricular conduction disturbance as an early feature of Reiter''s syndrome.

Atrioventricular (A-V) conduction disturbances in Reiter's syndrome are usually described in longstanding disease. This report deals with two male patients with Reiter's syndrome who developed an A-V block early in the course of the disease. One of these patients developed a second degree A-V block, Wenckebach type, which has not been described before at an early stage of this syndrome.     

Relapsing Clostridium difficile Colitis and Reiter''s Syndrome

We describe a patient with recurrent Clostridium difficile-associated colitis who suffered severe arthritis and urethritis with each of three episodes of diarrhea. Although immune complex formation was demonstrated in synovial fluid, neutralizing antibodies to C. difficile cytotoxin A and B were not found in either serum or synovial fluid. Cholestyramine did not prevent a third episode of colitis which followed the use of amikacin. This patient was HLA-B27 positive; she developed sacroiliitis, tenosynovitis, oligoarthritis, culture negative urethritis, and cervicitis. With the successful treatment of each episode of diarrhea, these additional symptoms resolved. The close temporal correlation between recurrences of C. difficile-associated colitis and these other symptoms strengthens evidence from other reports which suggests that colonic infections with C. difficile may precipitate the Reiter's syndrome. Evidence from this case does not support the contention that antibodies to C. difficile toxins are implicated in producing joint inflammation.     

REITER'S SYNDROME--A POSSIBLE CONSEQUENCE OF ARTIFICIAL INSEMINATION?

Artificial insemination by donor (AID) has been complicatedby the transmission of several genital infections. We describethe case of a man with Reiter's syndrome whose illness followedAID treatment of his wife. KEY WORDS: Reiter's disease, Artificial insemination (human donor), Urethritis     

Reiter's syndrome in Greenland. A clinical and epidermiological study of two communities

Patients with post-venereal Reiter's syndrome, living in the districts of Egedesminde and Jakobshavn in Greenland, were ascertained from medical records and patient examinations. Fifty-one patients were found to have definite Reiter's syndrome according to the ARA proposed criteria. The prevalence of the disease is 1.08% in Egedesminde and 0.34% in Jakobshavn. Annual incidences and prevalences show a marked increase between 1960 and 1983. Retrospective follow-up data on all patients show that the disease recurs in over 85% of cases for which the follow-up period is 10 years or longer.     

Postvenereal Reiter's syndrome in Greenland.

Reiter's syndrome is very frequent in the Inuit of Greenland, because of high frequencies of venereal disease and HLA-B27. The authors report the results of the epidemiologic work and of the study of the effects of antibiotic treatment of venereal infection. In Reiter's syndrome patients, treatment of venereal infections by erythromycin or tetracycline was associated with a significant reduction in the rate of postvenereal arthritic flares.     

Antibodies to peptidoglycan in patients with spondylarthritis: a clue to disease aetiology?

Although the aetiology of the spondylarthritic diseases, ankylosing spondylitis and Reiter's syndrome, is obscure, a clue to the pathogenesis might be an animal model, adjuvant arthritis. Rats with this disease develop a spectrum of pathology with marked similarity to the spondylarthritides. Since peptidoglycan, a major cell wall component of most bacteria is causally implicated in adjuvant arthritis, we sought evidence that peptidoglycan exposure accompanies both Reiter's syndrome and ankylosing spondylitis. Antibodies to the D-Ala-D-Ala moiety of peptidoglycan were measured by a sensitive and specific ELISA. Antibodies were elevated significantly in patients with ankylosing spondylitis or Reiter's syndrome, but not in patients with rheumatoid arthritis or degenerative joint disease in comparison with normal controls. The findings should be considered preliminary, since only a minority of patients had increased antibody titres. However, the findings are compatible with the hypothesis that peptidoglycan is causally related to spondylarthritis. Antibodies to other moieties in the peptidoglycan molecule might be a more sensitive test for significant exposure.     

Postsalmonella reactive phenomena in 2 patients with ankylosing spondylitis: no modification of the underlying disease

HLA-B27 related disease occurs in 2 main forms, ankylosing spondylitis (AS) or reactive arthropathy/Reiter's syndrome. These entities often "breed true" within families or distinct ethnic groups. Reactive arthropathy/Reiter's syndrome may be complicated by AS, but little is known about the impact on AS of a de novo reactive arthropathy occurring at a later date. We describe 2 patients with AS who developed postsalmonella reactive phenomena several years after the onset of their primary disease. In both patients the intestinal salmonella infection did not modify the course of the AS.     

Two familial cases of malignant Reiter's syndrome

A Cambodian man and his son concomitantly developed malignant Reiter's syndrome soon after their arrival in France. In both cases generalized skin lesions of pustular psoriasis and systemic features were present. The son died after 2 years of unresponsive continuously progressive disease. The father received pulses of high dose immunosuppressants that worked rapidly and prevented a life threatening course. These 2 cases illustrate the pathophysiologic hypothesis of Reiter's syndrome, emphasizing the role of environmental triggering factors and the relationship between spondylarthropathies in B27 positive patients. Fatal cases of Reiter's syndrome are very rare in the review of the literature.