Kembara Xtra - Medicine - Reiter Syndrome

Kembara Xtra - Medicine - Reiter Syndrome 
Reiter syndrome is a multisystem, seronegative inflammatory condition that typically affects the skin, lower genitourinary (GU) tract, eyes, joints, and lower genitalia. It is an autoimmune postinfectious process. Axial joint symptoms and dermatologic manifestations are frequent (e.g., spine, sacroiliac joints).


The "can't see; can't pee; can't bend my knee" triad factors  comprises arthritis, conjunctivitis/iritis, and either urethritis or cervicitis.
Similar to other reactive arthritides, it  is characterized by sterile joint inflammation brought on by infections that start at extraarticular locations. A psoriasiform skin eruption, buccal ulceration, or balanitis are examples of a fourth feature (dermatologic involvement).
(A diagnosis cannot be ruled out if only two symptoms are present.) There are two types of Reiter syndrome: - Sexually transmitted disease.After being exposed to Chlamydia trachomatis and other sexually transmitted infections, symptoms start to show up 7 to 14 days later.
- Postenteric illness, such as diarrhea due to travel.
 The triggering illness is probably sexually transmitted (as opposed to enteric) in those who have just started dating or had frequent sexual partners.
 A bacterial enteric infection rather than sexual transmission is more likely to be the precipitating event in those with a history of recent enteric sickness.
Systems impacted: muscular-skeletal, renal-urologic, and exocrine-dermatologic Synonym(s): reactive arthritis, urethro-oculosynovial syndrome, idiopathic blennorrheal arthritis, arthritis urethritica, Fiessinger-Leroy-Reiter illness Child Safety Considerations
Many of the clinical characteristics of Reiter syndrome are shared by juvenile rheumatoid arthritis (RA).

Pregnant women's issues
No extra concerns; standard drug safety measures

0.2-1% incidence after bacterial dysentery epidemics
Complicates 1-2% of nongonococcal urethritis episodes
 3 to 5 cases per 100,000 people per year
Predominant age: 20 to 40 years Predominant sex: male > female 

Pathophysiology and Etiology 

We still don't fully understand the pathophysiology of all seronegative reactive arthritis syndromes and the immunologic significance of infectious illnesses as causes of clinical illness. Synovitis is caused by pro-inflammatory cytokines. Gram-negative lipopolysaccharide is recognized by toll-like receptors (TLR) as a component of the illness cascade. Precipitant infections should be avoided, and multiorgan inflammation should be treated quickly. Inflammatory joint, ocular, or urinary tract symptoms do not seem to be helped by antibiotic treatment after the commencement of the illness.
The most frequent sexually transmitted infection linked to Reiter syndrome is C. trachomatis, which is followed by infections with Shigella, Salmonella, Yersinia, and Campylobacter spp. Compared to the postvenereal type, enteric-associated Reiter syndrome is more prevalent in women, children, and the elderly.
Genetics
60-80% of patients have HLA-B27 tissue antigen, which may indicate a hereditary susceptibility.


Risk Elements 
New or risky sex encounters. The initial infection may be asymptomatic and undiagnosed one to four weeks before the onset of clinical manifestation.
dysentery caused by bacteria or food poisoning is one of the risks.

Basic Prevention 
The most crucial general precaution—and maybe the most challenging to follow—is to avoid infectious precipitants due to the immune-response aspects of this condition.
 Safe sexual conduct; good food- and water-handling techniques

Accompanying Conditions 
Chlamydia urethritis/cervicitis (3)[C] - Mycoplasma or Ureaplasma spp. Urogenital infection - Shigellosis, Salmonellosis, Campylobacteriosis - Enteric infection with Yersinia spp. HIV/AIDS

The traditional symptoms are not always present, and HLA-B27 testing is not necessary for the diagnosis. Clinical presentation with inflammation in the joints, eyes, and GU (the "classic triad"), as well as negative serologic tests for rheumatoid factor.
HISTORY
Having the clinical condition in addition to
Urethritis can develop 1–15 days after sexual exposure, and symptoms can include diarrhea, dysentery, urethritis, or genital discharge. Exposure risks can also include past travel or migration patterns and potential infectious exposure.
Reiter syndrome begins between 10 to 30 days following a STI or intestinal infection, and symptoms last an average of 19 weeks.

Asymmetric arthritis of the musculoskeletal system is most common in the knees, ankles, and metatarsophalangeal joints. - Enthesopathy, which includes plantar fasciitis, digital periostitis, polydactylitis, and Achilles tendinitis (inflammation at the site where a tendon inserts into bone). - Spondyloarthropathy (involvement of the spine and sacroiliac joint)  Cystitis, prostatitis, and urethritis of the urogenital tract (rare)
Cervicitis and balanitis are typically asymptomatic.
Eye: One or both eyes may develop conjunctivitis; scleritis, keratitis, and corneal ulceration are seldom seen; uveitis and iritis are rarely seen; skin: Mucocutaneous lesions (small, painless superficial ulcers on the tongue, oral mucosa, or glans penis) - Keratoderma blennorrhagica, which can be mistaken for psoriasis due to its hyperkeratotic skin lesions on the palms, soles, and nail beds. Cardiovascular: pericarditis, murmur, conduction abnormalities, and aortic incompetence may infrequently occur.
Nervous system: Occasionally, meningoencephalitis, peripheral neuropathy, cranial neuropathy, and neuropsychiatric abnormalities. Constitutional - Fever, malaise, anorexia, and weight loss - Patient can appear dangerously unwell (e.g., fever, rigors, tachycardia, and painfully sore joints).

Differential diagnosis: rheumatoid arthritis and other seropositive arthritides Ankylosing spondylitis, inflammatory bowel disease-related arthritis, psoriatic arthritis, and juvenile RA are some examples of arthritis.
Rheumatic fever and bacterial arthritis, especially gonococcal

Laboratory Results 
Negative rheumatoid factor on blood tests
- 10,000 to 20,000 cells/mm3 of leukocytes
- Predominance of neutrophils
- Increased CRP and/or ESR
Anemia that is moderately normochromic and normocytic
- Hypergammaglobulinemia
Leukocyte count in synovial fluid ranges from 1,000 to 8,000 cells/mm3.
- Negative bacterial culture
 Supplemental tests
- Positive stool tests for Campylobacter spp., Shigella, Yersinia, or Salmonella or positive cultures, antigens, or PCR results for C. trachomatis.
- Acute retroviral syndrome (HIV serology positive)
- Possessive for HLA-B27 (not necessary for diagnosis) - Substances that may affect test results: The isolation of the bacterial pathogens may be impacted by antibiotics.
- The rheumatoid factor is low.
X-ray: Proliferation and thickening of the periosteum
- Articular bony spurs; articular border erosions
- Persistent joint damage
- Spinal syndesmophytes; sacroiliitis
Diagnostic Procedures/Other HLA-B27 Histocompatibility Antigen: HLA testing is not required or advised for the diagnosis of Reiter syndrome that is not associated to HIV in 60–80% of cases.
If STI screening is clinically necessary, do so.
Screening for gastrointestinal infections is typically unnecessary and rarely helpful.
Interpretation of Tests
Villous development within joints, hyperemia, and inflammation are symptoms of seronegative spondyloarthropathy, which is comparable to ankylosing spondylitis, enteric arthritis, and psoriatic arthritis.  Seminal vesiculitis and prostatitis Psoriasis-like skin biopsies

Management 

Symptoms guide the choice of treatment.
Iritis needs to be treated, although conjunctivitis doesn't have a specific treatment.
Lesions on the mucosa do not need to be treated.
Physical therapy (PT) promotes healing.
During the acute stage, arthritis may become evident and incapacitating.

First Line of Medicine
NSAIDs, such as indomethacin, naproxen, and others; systemic or intra-articular corticosteroids for refractory arthritis and enteritis - Inhibitory conditions
GI bleeding, gastritis, ulcerative colitis, renal insufficiency, and a particular bacterium that needs to be treated:
- Doxycycline 100 mg PO BID for 7 to 14 days for C. trachomatis (Note: Whether or not Reiter syndrome is present, all STIs should be treated.) - Ciprofloxacin 500 mg PO BID for 5–10 days in cases of Salmonella, Shigella, Yersinia, and Campylobacter infections (Note: Emerging antimicrobial resistance will reduce the efficacy of ciprofloxacin. Antibiotic treatment does not shorten the duration of an infection or the carrier status (only for Salmonella).) - Antibiotic effectiveness is unknown as a result of the inconsistent findings of antibiotic treatment trials for reactive arthritis.
GI distress: antacids
Intraocular steroids for iritis Topical steroids for keratitis

Second Line: NSAIDs like aspirin
Sulfasalazine shows promise but has not received FDA approval.
Immunosuppressive therapy is generally contraindicated in HIV-related Reiter syndrome. Specialty consultation is advised, especially if considering immunomodulatory agents like sulfasalazine, methotrexate, or azathioprine or for treatment with anti-TNF medications (etanercept and infliximab), which have shown benefit in isolated case reports.
 Antibiotics' potential use is being studied; their efficacy in treating seronegative arthritis has not yet been established. No published data backs up the idea that antibiotics improve Reiter syndrome patients' long-term prognosis.


Referral 
problems involving the joints and the eyes; complex instances; consider consulting with rheumatology and ophthalmology 

Admission may be required during the acute phase of the disease, depending on the severity of the condition and any accompanying consequences.

Regular Treatment 
Limiting activity till joint inflammation goes away
patient observation
Watch the way your body reacts to anti-inflammatory medications.
Keep an eye out for problems, especially while using immunosuppressive medications and sulfasalazine.


Patient Education: Inform patients of the dangers of exposure and recurrence. Home Physical Therapy: 


Prognosis In situations involving the heel, eye, or heart, the prognosis is dismal.

Complications 
Ankylosing spondylitis appears in 30–50% of people who test positive for the HLA-B27 antigen, and it is a chronic or recurrent condition in 5–50% of patients.
 Aortic root necrosis; Urethral strictures; Cataracts and blindness.

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