Diagnostic Radiology/Musculoskeletal Imaging/Joint Disorders/Reiter syndrome

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Definition[edit]

Reiter's Syndrome is an inflammatory spondyloarthropathy, characterized by the classic triad of nongonococcal urethritis, conjunctivitis, and arthritis. Term Reiter's arthritis has been replaced by Reactive Arthritis because of Dr Reiter's experiments in Nazi concentration camps.

Etiology[edit]

RS generally occurs about 1 to 3 weeks after a systemic infection. Chlamydia trachomatis is the bacteria most often associated with Reiter's syndrome, but several different bacteria acquired through the digestive tract, including Salmonella, Shigella, Yersinia, and Campylobacter, are associated with Reiter's syndrome as well.


RS is usually self-limited, and generally lasts less than 6 months. The disease tends to remit, but recurs intermittently in 35% of cases, and 25% of patients will have chronic low grade symptoms. These recurrences may manifest as only one of the constellation of symptoms seen in the acute attack.


Although the reason why only some people are affected after infection is unclear, the HLA-B27 haplotype has been found to increase a person's chance of developing Reiter's syndrome. Approximately 80% of people with RS are HLA-B27 positive.

Clinical Findings[edit]

Mild constitutional symptoms generally appear within 1-3 weeks. Urethritis may be postdysenteric or post venereal. Muscuoskeletal symptoms are mainly myalgias, asymmetric joint stiffness in lower extremity or low back pain.

A scoring system for diagnosis of Reiter's like spondyloarthropathy exists. Two or more of the following establishes the diagnosis ( one from musculoskeletal system) .

  1. Asymmetric oligiarthritis predominantly of the lower extremity
  2. Sausage shaped finger (dactylitis), toe, heel pain, or other enthesitis
  3. Cervicitis or acute diarrhea within one month of arthritis
  4. Conjunctivitis or iritis
  5. Genital ulceration or urethritis

Radiologic Findings[edit]

Skeletal abnormalities develop in up to 80 % of patients. Initial attacks of pain subside, only to recur later, leaving progressive changes at joints and entheses (sites of musculo tendinous insertions). The classic radiographic findings are:

  1. Normal mineralization (osteoporosis in acute phase)
  2. Periostitis
  3. Ill define erosions
  4. Bilateral asymmetric distribution
  5. Joint space narrowing
  6. Fusiform soft tissue swelling

The imaging appearance is similar to psoriatic arthritis. However the distinction is made based on the distribution. Reiter's prdominantly involves the lower extremity primarily feet, ankle, knee and SI joints.

Feet[edit]

Reiter's arthritis has a prediliction for MTP joints and first IP joint over the DIP and PIP joints. The arthritis is initially seen involving one joint only. There may be swelling of the entire digit giving the appearance of a sausage. Early on a periostitis of the phalanges may be noted. Later on uniform joint space narrowing, and marginal erosions with adjacent bone proliferation occur.

Calcaneus is involved in more than 50% of patients, hence the name "lover's heel". Painful erosions and reactive spurs are very common at the attachment sites of Achilles tendon and plantar aponeurosis in calcaneus.

Ankle[edit]

Usually there is fluffy periostitis of tibia and fibula with soft tissue swelling. Uniform joint space loss may occur and erosions are less frequent.

SI Joint[edit]

Bilateral asymmetric involvement is characteristic. Erosive changes are first seen on the iliac side of the true synovial joint. Because of the asymmetry, radiographically it may appear as unilateral involvement and indistinguishable from septic arthritis. However bone scan may show uptake in both SI joints. Ankylosis is less frequent.

Spine[edit]

Involvement is typically around thoraco lumbar junction (lower three thoracic or upper three lumbar). Early involvement occurs as paravertebral ossification. As the disease progresses large bulky bony bridges form between adjacent vertebral bodies.

Differential Diagnosis[edit]

Involvement is typically around thoraco lumbar junction (lower three thoracic or upper three lumbar). Early involvement occurs as paravertebral ossification. As the disease progresses large bulky bony bridges form between adjacent vertebral bodies.


Sclerosis and ill-definition of both SI joints is noted in this patient with Reiter's syndrome

Fig. 1 Sclerosis and ill-definition of both SI joints is noted in this patient with Reiter's syndrome.


Bony proliferation (arrows) is noted along the anterior margin of the lumbar spine in this patient with Reiter's syndrome

Fig. 2 Bony proliferation (arrows) is noted along the anterior margin of the lumbar spine in this patient with Reiter's syndrome.


Erosion of the 3rd and 5th metatarsal heads is noted

Fig. 3 Erosion of the 3rd and 5th metatarsal heads is noted.


Prominent erosion of the posterior calcaneus is noted adjacent to the retrocalcaneal bursa

Fig. 4 Prominent erosion of the posterior calcaneus is noted adjacent to the retrocalcaneal bursa.

Treatment[edit]

Three therapies are used in Reiter’s syndrome: NSAIDS for acute inflammation, antibiotics for infection, and sulfasalazine or methotrexate for chronic disease

Prognosis[edit]

The prognosis for patients with Reiter's is generally good. Most people will have complete recovery of the initial illness 2 - 6 months after symptom onset. Approximately 20% of Reiter's patients will have mild, chronic symptoms that usually present as back pain and arthritis. There are a small percentage of people who will develop persistent, severe deforming arthritis. For these unfortunate few, treatments are generally not effective.

References[edit]

  • Reiter syndrome by Leah Kiviat, M.D. & Ravi Konchada, M.D., University of Washington Department of Radiology
  • Reiter's Syndrome
  • Barth WF, Segal K. Reactive arthritis (Reiter's syndrome). Am Fam Physician. 1999 Aug;60(2):499-503, 507.
  • Reiter syndrome Scoggins T, Boyarsky I www.emedicine.com/emerg/topic498.htm
  • Brower AC, Flemming DJ, Reiter's disease in Arthritis in Black and White, Second edition.