D r. M. P. Vora, M.B.B.S., D.V.D.,
Hon. Senior Venereologist, St. George’s Hospital, Bombay
The Indian Practitioner
A monthly journal of Medicine, Surgery & Public Health
Vol. 40, No. 5 of May 1957;
Pages: 375 - 380
R eiter , a German physician was the first to observe in 1976 a symptomatic triad of abacterial urethritis, conjunctivitis and polyarthritis and to conceive this syndrome as a new entity. After the publication of his report, similar cases seen to have increased lately but this increase is merely relative. Formerly practitioners’ interest in such cases was very scant and they were mainly occupied with the problems of common venereal diseases such as syphilis, gonorrhoea and chancroid. Recent advances in their clinical knowledge and observations in the field of venereology have made them more conscious and vigilant to spot out the existence of manifestations of unknown etiology and to rule out safely the presence of various bacteria, fungi, spirochaetes, protozoa and metazoa. Being better equipped, their interest has now considerably increased and they have become alive to the existence of unusual conditions and non-specific syndromes.
Although the number of cases of this syndrome is not appreciably high, one is convinced about its existence and occasional occurrence. The writer has seen two cases since 1949. Hollander(6) and his associates were impressed by the apparent frequency of patients with arthritis of acute onset who presented ourulent abacterial urethritis with or without accompanying conjunctivitis.
Aetiology and pathology of this condition are not completely understood and are still matters of discussion and speculation. Reiter(10) attributed this condition to spirochaetes but his observation has not been confirmed. Harkness(5) demonstrated inclusion bodies in the discharges from the urethra and conjunctiva in five cases. Coutts(2) attributes this condition to the infection by the virus of lymphogranuloma venereum. Dienes(3) and Smith cultured pleuro-pneumonia-organisms from the urethra of a man suffering from this syndrome. Beigback(1) regards this syndrome as an allergic reaction to dysenteric infection for in most of his cases the serum could agglutinate Flexner organisms. Many physicians have observed cases arising in the course or during the convalescence from bacillary dysentery. Schuermann(12) and Kruspe(8) observed conjunctivitis, iridocyclitis, urethritis and arthritis in relation to bacillary dysentery. In 1916 Fieddinger(4) and Lerosy and in 1928 Worms(14) and Sourdille observed occulo-urethro0articular syndrome secondary to the same type of intestinal infection. Although these clinical facts are unquestionable, there are many cases of this syndrome without any apparent connection with dysentery. Kristjansen(7) and Rosenblum(11) have both recorded cases of this syndrome with an undoubted venereal origin. Lever(9) and Crawford and Tourain(13) have described cases in women more frequently bit they did not notice urethritis but acute non-bacterial cystitis in them.
Some authors have denied the venereal origin of the syndrome while others have maintained the existence of venereal origin. One cannot ignore the fact that the female genital tract harbours agents which may become pathogenic or remain non-pathogenic according to various conditions. One has also to bear in mind less frequent modes of sexual gratifications such as ‘fellatio’ cunnilinctus or cunnilingus and sodomy. Cases in which diarrhoea or dysentery is present suggest a possible gastro-intestinal entrance of the infective agent, either venereally or nonvenereally. Majority of the patients are young adults who have reached sexual maturity. These observations lead one to think the possibility of two identical syndromes very probably both of venereal origin - one associated with the various types of dysentery the primary focus of infection being in the bowel and not urethra, and the other identical syndrome associated with venereal origin, in which the primary focus of infection is in the urethra. However, there is a real need for clear distinction between cases of venereal origin and those of purely non-venereal dysenteric origin.
Venereal syndrome is contracted by either usual mode of sexual intercourse or by other methods of sexual gratifications such as fellatio (apposition of the mouth to the male genital organs), cunnilinctus or cunnilingus (apposition of the mouth to the female genital organs), and sodomy and the primary focus of infection is an abacterial inflammation either of the urethra or of the bowel according to the region involved. Both the venereal and dysenteric syndromes are due either to virus or pleuropneumonia-like organisms and the portal of entry of the infective agent is either the urethra or the bowel. Virus and inclusion bodies have been isolated from the urethra and conjunctiva and cultures have been proved to be positive for pleuropneumonia-like ‘L’ organisms.
The true syndrome of Reiter is one in which the primary focus of infection is an abacterial urethritis of venereal origin, with blood borne complications. The syndrome may be complete or incomplete. The term, Reiter’s disease should appropriately be applied to the cases of venereal origin and not to those of purely dysenteric origin and all cases of primary abacterial urethritis or enteritis together with one or more blood borne complications such as conjunctivitis, arthritis, should be properly included under this head as long as they result in the course of sexual gratification.
The primary focus of infection in majority of cases is a non-gonococcal abacterial urethritis. However, the urethra is sometimes the seat of primary mixed infection of both gonorrhoeal and abacterial urethritis. In the latter, use of penicillin eliminates the gonococcal element of the urethral discharge but the non-gonococcal element often persists. In such circumstances acute arthritis with or without the development of other blood borne complications, may follow days or weeks later. In none of these cases it is possible to demonstrate gonococci in the urethral discharge or prostate-vesicle secretions. It is also equally reasonable to suppose that there may be occasionally a primary mixed infection with abacterial component and organisms other than gonococci.
The incubation period is about 5 to 30 days. The symptoms forming the triad may appear in any order, but in most cases the first manifestation is urethritis followed by conjunctivitis and polyarthritis. The first two symptoms are of shorter duration as compared to articular manifestations. Fever of moderate intensity and occasional diarrhoea may be present.
Urethritis maybe mild with no pain or frequency or acute accompanied by pain, frequency and an abundant clear, tenacious urethral discharge. The discharge is invariably free from bacteria and contains pus cells and epithelial cells. The urethra presents a typical urethroscopic picture. Protruding into the lumen of the urethra are wedge-shaped excrescences, lying superficial to the mucous membrane of the roof and lateral walls of the anterior urethra, with no involvement of the sub epithelial connective tissue. With the passage of time these excrescences stimulate cobblestones or trachoma nodules.
Conjunctivitis - is usually bilateral and of catarrhal type. In severe cases episcleritis, keratitis and iritis have been observed. All these affections have usually a favourable evolution. Examination of the smears does not reveal any organisms.
Arthritis is one of the most constant features of this syndrome. It is often acute with intense pain and sometimes associated with effusion. Usually several joints are involved preferably knee, ankle, wrist and small joints of hand and feet. The attack of arthritis is more persistant, recurrent and fleeting in character, synovial effusion sets in rapidly but is frequently sterile on culture. In the early stage, the X-ray picture of the joint shows increase in the joint space, while in the later stages, diffused or localised areas of osteoporosis in the region of the articular ends especially of the small joints of the feet and hand, are observed. The metacarpophalangeal joints may assume spindle shape.
Balanitis circinata is occasionally associated with arthritis. Various kinds of localised or generalised skin rashes such as keratodermia, nodular or pustular lesions of the soles of the feet have been reported. Pyrexia of moderate intensity is often noticed. Generalised adenopathy especially of the axillary and inguinal nodes has been recorded. Rare manifestations such as prostatitis, cystitis, haematuria, and myositis have been reported. Recurrence of the syndrome after weeks or months is a constant feature. Partial syndrome is not uncommon and may appear singly or associated with gonorrhoea or non-specific bacterial urethritis.
Laboratory Findings - The erythrocyte sedimentation rate is slightly raised. Mild hypochromic anaemia and moderate leucocytosis are observed. Gonococcal Fixation test and Wassermann reaction are negative. In the writer’s observation there is increase in the serum globulin and decrease in the serum albumen.
Differential Diagnosis - (1) Gonorrhoea - This symptomatic triad may occur in gonococcal infection, but in this case smears will gonococci, the incubation period is small, the gonococcal complement fixation test is positive, and the urethritis precedes the triad and will respond rapidly to either sulpha drug or penicillin. (2) Syphilis - Secondary syphilis might be confused on account of fever, rash, arthritis and conjunctivitis. Penile lesions may be present in both. A careful examination, blood test for syphilis, dark-field examination for Tr. pallida will settle the diagnosis. (3) Rheumatic Fever - This may be simulated by fever, polyarthritis, of fleeting nature etc., which are a common feature to both diseases. Response to salicylates is typical in rheumatic infection. Reiter’s syndrome does not respond to salicylates. Treatment - Adequate treatment of the primary focus of infection by instituting daily urethrovesical irrigations with warm Potassium permanganate or oxycyanide of mercury 1 in 8000 solution. If found necessary on urethroscopy, weekly urethral dilations for 6 to 8 sessions. Penicillin and salicylates are both ineffective. Streptomycin 1gm. intramuscularly twice a day for 8 to 10 days is quite effective. T.A.B. Vaccine 25 to 300 million organisms intravenously in gradually increasing dosage according to the reaction on alternate day. Minimum of three to five bouts of fever are recommended. Recently steroid compounds have been used with encouraging results. Prednisone or Prednisolone in doses 20 to 30 mg. per day in divided doses as an initial step is suggested. Thereafter the dose may be reduced as symptoms clear.
Mr. J.M. Mohamedan, age 33, male, married, two children 8 and 5 years old respectively, sailor by profession.
This patient was admitted in the hospital on 15-6-1949 for fever, swollen and painful joints - left shoulder, the right wrist, urethritis and conjunctivitis of the right eye. Duration four days. The family history and personal history revealed nothing of importance. Past history - He had one previous attack of urethritis about 8 weeks ago. For this he was treated on board the ship with sulpha drug tablets for five days. No urethral smear was taken and examined then. He gave history of exposure to infection ten weeks before the date of admission in the hospital. General examination showed paleness and slightly anaemic condition. Circulatory and respiratory systems were both normal. Spleen and Liver were not palpable. Central nervous system - normal, Skin normal, Lymph nodes not palpable.
Reports of the investigations carried were as follows:-
Urine -Trace of albumen, pus cells 5 per field under high power. No organisms.
Culture- staphylococcus albus and aureus isolated.
Urethral smear - showed pus cells, a few epithelial cells and no organisms.
Stools - Nothing abnormal.
Blood W.R. and Kahn both negative
R.B.C. count - 3.5 million per cmm., Hb 70%
W.B.C. count - 14300 per cmm., Diff. count - polymorph 89%, lymphocyte 9% eosinophil 2%
E.S.R. - slightly raised.
Blood culture sterile, Blood slide - no M.P.
Weil Felix Reaction - Negative.
Widal - serum agglutinates B.typhosus, H. suspension 1:125 Clot culture negative
Blood proteins -
Serum albumen 3.1% (normal 3.9 to 4.7 gms.%)
Serum globulin 3.7% (normal 1.7 to 2.5 gms.%)
Screening of the chest - normal
X-ray of the right knee showed effusion.
Urethroscopy - a few trachoma-like nodules seen on the roof of the anterior urethra.
Treatment and follow-up:-
On admission he was prescribed
Mist. Alkaline Oz 1 T.D.S., Sulphadiazine tablets 2, five times a day for five days, Argyrol eye drops, and urethral irrigations.
On 23/6 he was seen by the physician and was prescribed Mist. Sodi salicylates gr. XX per dose four times a day. No improvement.
On 24/6 He had recurrence of joint pain. Right knee and right great toe were involved. Patellar tap could be elicited. Temperature 101 oF continuous type, effusion rt. Knee on x-ray. Fluid sterile on culture.
Crystalline sodium penicillin in aqueous solution 50,000 units intramuscularly three hourly 100 injections on the recommendation of the physician was given.
On 4/7/49 Left eye showed signs of acute conjunctivitis. He was seen by the ophthalmic surgeon and sixty more injections of penicillin were given on his advice.
On 15/7 No improvement.
On 25/7 Streptomycin 1 gm. twice a day intramuscularly for 5 days was ordered. In addition a course of three I.V. injections of T.A.B. vaccine on alternate days was given. There was a great and dramatic improvement. The patient felt very much relieved. No fever. No recurrence.
On 19/8/ 49 he was discharged from the hospital as fit. The patient was followed for a month and his last blood W.R. was reported negative.
A case of Reiter’s Disease is reported. The patient had a symptomatic triad of acute abacterial urethritis, right conjunctivitis and polyarthritis involving left shoulder and right wrist joints. While in the hospital he had a recurrence of syndrome affecting left conjunctiva, right knee and right great toe. Penicillin and salicylates had no effect; but administration of streptomycin and T.A.B. Vaccine intramuscularly had a dramatic effect.
My thanks are due to Dr. R. Banerji, M.D. ( Cal.), M.R.C.P. (Lond.), D.T.M. & H ( Eng.), the officiating superintendent, St. George’s Hospital, Bombay for his kind permission to publish this case.