Not Your Typical Low Back Pain - Page #4
 

Working Diagnosis:
Reiter syndrome (also known as reactive arthritis)

Treatment:
His C. trachomatis was treated with doxycycline 100 mg orally twice daily for 14 days. Low back pain treated with indomethacin 50 mg orally three times daily and physical therapy. He was counseled on safe sex and food safety.

Outcome:
He was compliant with his treatment and tolerated it well. He was completely pain free three weeks after initiation of treatment. He underwent a short course of physical therapy and returned to full activity. No further routine follow up is warranted. His prognosis is variable: he may remain disease free with no further sequelae, however, he is also at risk for recurrence of symptoms, as well as chronicity.

Author's Comments:
Reiter's syndrome (RS) is a seronegative multisystem inflammatory disorder classically involving joints, eyes, and the lower GU tract. Spine involvement is also common. Dermatologic manifestations are also seen.

The incidence is 4.6/1000. It most frequently occurs in patients in their fourth or fifth decade of life, but can occur at any age. RS that develops after venereal infections occurs more frequently in males (ratio 9:1) RS that develops after bowel infection occurs in equal frequency in males and females

Etiology is from an infectious precipitant. There are two forms of infectious precipitant: 1) Venereal- Chlamydia trachomatis 2) GI infections- Salmonella, Campylobacter, Shigella.

RS is strongly linked to HLA-B27 (60-80%). HLA-B27 is commonly seen in patients with RS, but not all patients with RS have HLA-B27 gene. HLA-B27 may predict more severe and prolonged form of disease. RS is a clinical diagnosis and HLA-B27 is not used for diagnosis

Despite knowing the initiating event (infection) and genetic constitution (HLA-B27) of RS, we do not yet understand the pathogenesis of this disorder. There is a theory of cross reactivity: there are similar peptides in HLA-B27 and bacteria, so the immune system attacks self.

Onset of symptoms usually 1-4 weeks after infection, in most cases, infectious etiology not always clinically apparent, especially in GI infections since they will usually resolve by then. The classic triad of features is arthritis, urethritis, and conjunctivitis. Musculoskeletal manifestations include axial arthritis and/or peripheral arthritis (usually knee, ankle, or feet). Low back pain will be seen in 50% of patients. Dactylitis is less common. Enthesitis may also be seen, most commonly of the Achilles tendon. Extraarticular signs and symptoms include conjunctivitis, genitourinary tract symptoms or gastroenteritis, oral ulcers, and aortitis. Dermatologic manifestations include keratoderma blennorrhagica, which are waxy papular pustular lesions. These are seen commonly on palms and soles.

Identify infectious cause (C. trachomatis, or stool cultures which usually is negative at the onset of arthritis. Other lab features may include: mild normocytic anemia, leukocytosis (10-15k), elevated ESR, negative Rh factor, negative ANA. Joint aspiration will be sterile and negative for crystals. Radiologic studies may have positive findings if arthritis is present greater than 3 months- erosive bony changes. Bottom line is there is no agreement on how to diagnose RS based on labs. Lab testing is used to confirm infectious cause and to exclude other causes of arthritis (LOE C)

American College of Rheumatology has produced different methods of diagnosis with corresponding sensitivity and specificity.

Treat acute C. trachomatis infections in patients and their partners, this will decrease subsequent arthritis (LOE A). Options for treatment include azithromycin 1 g orally as single dose or doxycycline 100 mg po bid x 7 days. Antibiotics are not indicated for enteric infections, and it does not affect subsequent episodes of arthritis (LOE A). NSAIDs can be used for pain control, but do not affect the course of illness (LOE B). NSAID of choice is indomethacin 25-50 mg po qid. Corticosteroid injections may also be attempted. Physical therapy is indicated to improve mobility and strength, and prevent stiffness. Disease-modifying antirheumatic drugs may be used in patients with persistent symptoms (>3-6 months). Sulfasalazine is well tolerated and effective.

RS usually runs a self limited course of 3-12 months (LOE B). 10-20% may continue to have chronic and destructive and disabling arthritis 2 years after the onset of symptoms (LOE B). Mortality from RS is not common and results from cardiac complications such as aortitis (LOE B).

Editor's Comments:
Reiter's syndrome, also known as reactive arthritis, is a condition that typically includes arthritis, nongonococcal urethritis, and conjunctivitis. The lack of urinary and eye symptoms and physical findings on exam make this case unique. Karrela et. al. reported that reactive arthritis and anklyosing spondylitis appear to be identical.

References:
1) Yu, David. “Reiter Syndrome.” UpToDate.com. October 20, 2011.
2) Barth, Werner. “Reactive Arthritis (Reiter’s Syndrome).” Aafp.org. August 1, 1999.
3) Shaughnessy, Allen. “Reiter’s Syndrome.” Essentialevidenceplus.com. July 1, 2011.
4) Hakala, Markku. “Reactive Arthritis.” Essentialevidenceplus.com. March 29, 2011.
5) Bykerk, Vivian. “Reactive Arthritis.” American College of Rheumatology. February, 2012.

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