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.     

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.     

The co-occurrence of Reiter's syndrome and acquired immunodeficiency

Thirteen patients who had the co-occurrence of severe Reiter's syndrome and the acquired immunodeficiency syndrome (AIDS) or its syndromes were studied. The arthritis was reactive in three patients and without defined cause in the others. Nine patients had HLA-B27. The two syndromes appeared simultaneously in four patients, suggesting a common biologic process, and in the others the immunodeficiency either preceded or followed the arthritis. Reiter's syndrome occurring in the setting of this profound immunodeficiency suggests that helper T cells were not involved in the pathogenesis of the rheumatic disease. Difficulties were encountered in the diagnosis of either syndrome in the presence of the other. Two patients with Reiter's syndrome developed Kaposi's sarcoma and fulminant AIDS after receiving methotrexate, which emphasizes the need for caution in the use of immunosuppressive therapy in Reiter's syndrome. An additional patient with undifferentiated spondylarthropathy subsequently developed psoriasis in conjunction with the onset of AIDS.     

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.     

Cardioinhibitory carotid sinus hypersensitivity in subjects with symptomatic sinus dysfunction

Cardioinhibitory carotid sinus hypersensitivity is present in about one third of patients affected by sinus dysfunction. Aim of the study was to evaluate whether carotid sinus hypersensitivity is related to a well defined (intrinsic or extrinsic) sinus node damage. Fifty-four patients with ecg signs of sinus dysfunction underwent an electrophysiological study and carotid sinus massage. Spontaneous heart rate and corrected sinus node recovery time were measured in basal condition, after adrenergic blockade (propranolol 0.2 mg/Kg i.v.) and after autonomic blockade (propranolol 0.2 mg/Kg i.v. plus atropine 0.04 mg/Kg i.v.). The association between sinus dysfunction and cardioinhibitory carotid sinus hypersensitivity was found in 18/54 pt. (16 men, 2 women; mean age +/- 1 SD 63.6 +/- 14.5 years). The remaining 36 patients (19 men, 17 women; mean age +/- 1 SD 65.8 +/- 9.8 years), affected by sinus dysfunction alone, were used as controls. No electrophysiological differences between the two groups were found; particularly, an abnormal intrinsic heart rate (according to Jose values) or an abnormal intrinsic corrected sinus node recovery time (greater than 385 msec.) were present in 83% of the patients in both groups. Among sinus dysfunction clinical features, heart rate, presence of spontaneous syncope, sino-atrial block or sinus arrest and organic heart disease were similar in the two groups while the percentage of patients with spontaneous atrial tachyarrhythmias (bradi-tachy syndrome) was significantly smaller (11% vs 44%; p less than 0.01) in carotid sinus hypersensitivity group. In conclusion, in sinus dysfunction patients, the presence of carotid sinus hypersensitivity cannot be used as a criterion to differentiate a subgroup with peculiar clinical and electrophysiological sinus node characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Agranulocytosis and liver damage associated with pyrazinobutazone with evidence for an immunological mechanism

Agranulocytosis and liver injury is described in a patient with Reiter's syndrome of 3 years duration who received pyrazinobutazone for 6 weeks before the development of the clinical picture reported. Other causes of agranulocytosis and hepatic damage were excluded and a lymphocyte transformation test to the drug revealed significant lymphocyte proliferation in response to the drug. This suggests a hypersensitivity reaction as the mechanism for this previously unrecognized association of adverse effects to pyrazinobutazone.     

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.     

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.     

A follow-up study of 48 patients with Reiter's syndrome

A follow-up study of 48 patients with Reiter's syndrome was carried out in an attempt to clarify the clinical course of the disease. The mean age at the onset of Reiter's syndrome was 27.1 years (range 15 to 52 years) and when seen at follow-up 32.5 years (range 19 to 58 years). The average time from the onset of the first attack of peripheral arthritis to the time of follow-up was six and a half years (range 0.5 to 27 years). Only three patients had diarrhea prior to the onset of Reiter's syndrome. At follow-up 22 per cent of the patients were asymptomatic, 24 per cent had recurrent minor symptoms, 24 per cent had recurrent moderate symptoms, and 30 per cent had recurrent major symptoms. However, even in the last group, all patients were in functional classes 1 or 2 between the flares of disease. No patients in the series were in functional class 3 or 4, and 30 per cent were in class 1.     

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.     

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     

Psoriasis and psoriatic arthritis associated with human immunodeficiency virus infection

It has been well established that psoriasis, psoriatic arthritis, and Reiter's syndrome can occur in patients with HIV infection. These arthocutaneous diseases tend to occur in temporal proximity to the development of AIDS and ARC, and their clinical manifestations are unusually severe. The appearance or exacerbation of psoriasis, arthritis, or Reiter's syndrome in a high-risk person should alert the clinician to possible underlying HIV infection. Treatment should be dictated by the severity of the skin and musculoskeletal disease as well as by the status of the immune system. Zidovudine appears to be effective in many diseases, especially psoriasis, and nonsteroidal antiinflammatory drugs are the mainstay for arthritis. Immunosuppressive agents such as methotrexate and azathioprine are contraindicated because they exacerbate immunodeficiency and promote infections. Epidemiologic studies suggest that the prevalence of these diseases, especially Reiter's syndrome, may be higher in HIV-positive populations than previously thought, especially in those patients with AIDS and ARC. Immunogenetic factors like HLA-B27 are important in the predisposition to Reiter's syndrome associated with HIV infection; however, it is not clear what role they play in HIV-associated psoriasis. Mechanisms underlying these observations remain unclear, although potential insights into the pathogeneses of psoriasis and Reiter's syndrome may be gained through future studies. Already it seems likely that CD4-positive helper T-cells, the target of HIV, are not necessary for the expression of psoriasis or Reiter's syndrome, and because of HLA class I associations, a role for CD8 positive cytotoxic T lymphocytes can be suspected. Infections, promoted by the profound immunodeficiency of AIDS, seem to be the most plausible explanations for the cutaneous and articular complications of HIV infection.     

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.     

HIV infection is not associated with Reiter's syndrome: data from the Johns Hopkins Multicenter AIDS Cohort Study

Reiter's syndrome has been reported to occur in up to 10% of patients with HIV infection. However, no properly controlled epidemiological studies have been conducted to determine whether HIV infection is an independent risk factor or whether the immunodeficiency induced by HIV infection is permissive for infection with other arthritogenic organisms. The prevalence and incidence of Reiter's syndrome were determined in 1133 homosexual/bisexual men enrolled in the Johns Hopkins Multicenter AIDS Cohort Study. There was no difference in the prevalence of Reiter's syndrome at entry into the study in 1984 between 357 HIV-positive and 776 HIV-negative men: five per 1000 in both groups. During 5 years' follow-up, one case of Reiter's syndrome developed among each group of HIV-positive and HIV-negative men. These data fail to support a direct etiological role for HIV infection in the development of Reiter's syndrome.     

Followup study on patients with Reiter's disease and reactive arthritis, with special reference to HLA-B27

An analysis of 160 patients with Reiter's disease, 144 with yersinia arthritis, and 9 with salmonella arthritis was performed, Complete or incomplete Reiter's syndrome was observed in one-third of the patients with yersinia arthritis and in most of those with salmonella arthritis. During the followup period, chronic back pain and joint symptoms were frequent in all the patient groups. Patients who were HLA-B27 positive had a more severe acute disease (more frequent back pain, urologic symptoms, mucocutaneous manifestations, and a longer duration of the disease) and more frequent chronic back pain and sacroiliitis.     

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.     

Reiter's syndrome associated with HLA-B51

A 22-year-old Japanese man developed polyarthritis with fever and urethritis. He was diagnosed as Reiter's syndrome since he was found to have uveitis and persistent aseptic pyuria. Although, he was negative for HLA-B27 or any other HLA-B27 cross-reactive MHC class I antigens, he was positive for HLA-B51. The laboratory examination showed significant elevation of serum IgG and IgA anti-Chlamydia antibodies. He was successfully treated with a combination of doxycycline, naproxen, salazosulfapyridine and methotrexate with a decrease in IgG and IgA anti-Chlamydia antibodies. Previous studies provided evidence that HLA-B51 itself might be involved in the development of Behcet's disease, which shares common features with Reiter's syndrome, such as uveitis, skin lesions, and polyarthritis. It is therefore suggested that combination of Chlamydia infection and HLA-B51 might play a role in the pathogenesis of Reiter's syndrome in our patient.     

Exaggerated carotid sinus massage responses are related to severe coronary artery disease in patients being evaluated for chest pain

Background: Previous studies have reported that carotid sinus massage responses are associated with advancing age and carotid or coronary artery disease. Hypothesis: This study was undertaken to investigate the potential role of carotid sinus hypersensitivity as a marker for the presence of coronary artery disease, and especially left main stem disease, in patients who were referred for evaluation of chest pain. Methods: Toward this end, carotid sinus stimulation with simultaneous recordings of the electrocardiogram and aortic pressure was performed before coronary arteriography in 150 selected consecutive patients (mean age 59.4 ± 9 years) who were referred for evaluation of chest pain. Results: Coronary artery disease was present in 118 patients (78.7%); of these, 35 had single‐vessel disease, 35 had double‐vessel disease, 33 had triple‐vessel disease, and 15 had left main stem with or without such vessel disease. Carotid sinus hypersensitivity was found in 40 patients (26.6%). The incidence of hypersensitivity in patients with single‐, double‐, or triple‐vessel disease and left main stem disease was 8.5, 14.2, 57.5, and 73.3%, respectively. Stepwise multiple logistic regression analysis revealed that left main stem disease was significantly and independently related to the presence of carotid sinus hypersensitivity (p < 0.05). In addition, the presence of hypersensitivity had 73.3% sensitivity, 86.2% specificity, and 96.3% negative predictive value for the presence of left main stem disease. Conclusion: In patients being evaluated for suspected ischemic heart disease, carotid sinus massage responses are related to severe coronary disease. The absence of hypersensitivity may reflect absence of left main stem disease.     

Vasculitis in Reiter's syndrome

Summary A patient is described with both Reiter's syndrome and cutaneous vasculitis characterised by livedo reticularis. The development of the Reiter's syndrome immediately preceded the onset of vasculitis. It is suggested that Reiter's syndrome is a previously unrecognised potential cause of vasculitis in which infection may initiate the vasculitic reaction.