Sexually Transmitted Diseases - I. I. Mavrov 2005

Sexually Transmitted Diseases
Reiter's Syndrome

Reiter's syndrome, an infectious-allergic condition, is characterized by the classic triad of acute urethritis, Conjunctivitis, and typically polyarthritis affecting primarily the large JOINTS OF THE lower extremities, and occasionally the joints of the spine and hands (see insert, pl. IX, 1-3). It generally develops against a Background of genetic predisposition in individuals who have suffered from nonspecific urethritis, dysentery, or yersiniosis.

Three clinical courses of the disease are distinguished: acute, protracted, and chronic. In the acute course, all signs of musculoskeletal involvement completely disappear within 6 months. When the attack lasts from 7 to 12 months, the disease is classified as protracted. In the chronic course, the articular syndrome persists for more than a year.

We conditionally divide all patients with Reiter's syndrome into three groups:

1) without impairment of organ and system Functions; 2) with minor functional impairments of the joints, Kidneys, Liver, cardiovascular, respiratory, or nervous systems; 3) severely ill patients with concomitant damage to other Organs (cardiac pathology, Hypertension, diabetes, anemia, Bronchial Asthma, Sepsis, etc.).

It develops in 2-4 % of patients with non-gonococcal genitourinary infections. Currently, the etiological relationship between Chlamydia and Reiter's syndrome is established in 40-60 % of cases through the isolation of these microorganisms from the Urethra, joints, and conjunctival sac of patients.

Chlamydia strains isolated from the joints of individuals with Reiter's syndrome differ in their antigenic and certain biological characteristics from many Chlamydia strains that cause localized chlamydial infections. This may be one of the factors explaining why the disease does not develop in all patients with urogenital chlamydial infection.

Reiter's syndrome is a relatively frequent joint disorder that predominantly affects men. However, cases in women and children do occur. It arises on The basis of genetic predisposition (with an 80-95 % association with the HLA-B27 transplantation antigen). It is characterized by infectious-allergic mechanisms of a complex and largely unclear etiopathogenesis. A lymphogenic pathway of microorganism dissemination from the Genitourinary system to the joints is hypothesized.

Currently, The Link Between the incidence of the disease and Sex Hormones has been proven. This is attributed, in particular, to the patients' hormonal status, which affects both the uneven incidence rate between men and women and the differences in Clinical presentation, supporting METABOLISM/2.html">THE CONCEPT OF sex hormone influence on autoimmune processes.

Immunopathological reactions play a crucial role in the Pathogenesis of Reiter's syndrome, which evolves through two phases: an infectious (early) phase and an autoimmune (late) phase. Inflammation of the Prostate Gland and frequently the Seminal Vesicles, which accompanies Reiter's syndrome, is regarded not only as a consequence of a chronic focus of infection but also as a factor leading to bodily sensitization. The likelihood of such sensitization is confirmed by the detection of Antibodies to prostate tissue, synovial membrane, Skin, and conjunctiva in patients.

Because many patients exhibit skin and mucous membrane lesions (balanitis, keratoderma on the soles and palms, nail changes, etc.) In addition to the three classic signs (urethritis, Arthritis, and conjunctivitis), literature often distinguishes four symptoms of this condition. Reiter's syndrome is characterized by spontaneous remissions and relapses if the urogenital source of infection persists in the absence of appropriate therapy.

As a rule, the initial sign of the disease is urethritis, appearing 1-3 weeks prior to other manifestations, frequently following casual sexual intercourse. The severity of urethritis varies considerably. Subacute urethritis is most common; in approximately 25 % of patients, it runs an asymptomatic or paucisymptomatic course with scanty discharge, typically without dysuric signs.

Urethritis in men is generally complicated by prostatitis, with the potential development of vesiculitis, and less frequently, involvement of the Epididymis. Urethroprostatitis can persist for a long time, serving as a background for The Development of other symptoms, The sequence of which can be diverse and highly variable.

Musculoskeletal involvement most frequently begins acutely, presenting with pain and fever that can sometimes reach 39–40 °C. A gradual onset of arthritis, characterized by joint pain and Swelling that escalate over several days or even weeks, is significantly less common. In most cases, joints are recruited into the pathological process sequentially, at intervals of a few days or weeks. Asymmetry of involvement is characteristic, especially early in the disease when the number of inflamed joints is small.

In a fully developed clinical picture, an average of 4–6 joints are affected, though some cases may present as monoarthritis or polyarthritis involving the majority of the peripheral joints. With polyarthritis, the condition frequently becomes symmetrical. The joints most commonly affected are the toes, metatarsus, as well as the ankle and knee joints. Reiter's syndrome can affect any joint, including the temporomandibular, sternoclavicular, manubriosternal joints, and even the laryngeal cartilages.

Reiter's syndrome is characterized by pronounced exudative phenomena, with fluid effusion into the joint cavities and infiltration of the periarticular Tissues. The latter drives the Development of the 'sausage-like' finger and toe deformity typical of this condition. The skin over the affected joints is often hyperemic, occasionally with a cyanotic tinge. Such skin discoloration is particularly common during inflammation of the small joints.

The majority of patients exhibit 'pararticular' inflammatory processes (bursitis, tenosynovitis, periarthritis). Particularly frequent are calcaneal bursitis, plantar fasciitis, and Achilles tendinitis, which exhibit a persistent course and require prolonged therapy. In some cases, subcalcaneal or Achilles bursitis dominates the clinical picture of musculoskeletal involvement, and occasionally serves as its sole manifestation (S. V. Shubin, 1990).

Joint dysfunction is usually associated with exudative phenomena and pronounced pain. Morning stiffness is reported by approximately half of the patients, with its frequency and severity increasing in proportion to the duration of joint inflammation. Atrophy of the Muscles adjacent to the affected joints frequently develops. In severe cases, significant Muscle wasting and weight loss are observed.

Clinical signs of spinal involvement are frequently detected, and sacroiliac joint involvement less commonly so. Spinal lesions are typically focal in nature. Only in cases of a prolonged, multi-year inflammatory process might spinal dysfunction be linked to The formation of paravertebral ossification or intervertebral syndesmophytes.

Conjunctivitis, most commonly unilateral, is detected in 55–65% of patients at any stage of the disease, though predominantly at its onset. Aside from transient subacute conjunctivitis—whose chlamydial Etiology is not always established—some patients experience more severe ocular complications, such as episcleritis, keratitis, iritis, iridocyclitis, and uveitis.

Skin and mucosal lesions in Reiter's syndrome are characterized by polymorphism. They initially present as pustular eruptions, subsequently evolving into squamoprustive forms and keratoderma. Most frequently (in 40–45% of patients), circinate balanitis or balanoposthitis is observed, persisting for several weeks or months. Less commonly, palmoplantar keratoderma, psoriasiform rashes on various PARTS OF THE body, nail changes, and painless oral erosions—circumscribed whitish areas with a grayish-white or reddish border—may occur.

Internal Organs are also frequently affected in Reiter's syndrome. During the acute phase, signs of myocarditis are detected in a subset of patients. Endocarditis develops very rarely, predominantly involving the aortic valve. Renal involvement is occasionally observed, running a course akin to focal Glomerulonephritis, Pyelonephritis, and, exceptionally, amyloidosis, which can prove fatal.

A significant proportion of patients exhibit marked hyperhidrosis, which is presumably related to Autonomic Nervous system dysfunction. Peripheral neuritis is identified less frequently. Cases of severe meningitis and meningoencephalitis are documented. Gastrointestinal tract involvement is particularly characteristic of the epidemic form of Reiter's syndrome.

Laboratory findings include an elevated ESR, occasionally neutrophilic leukocytosis, C-reactive protein, and increased Blood levels of fibrinogen, seromucoid, as well as alpha- and beta-globulins. Rheumatoid factor is typically negative. Examination of the synovial fluid reveals a Cell count ranging from 3,500 to 20,000 per 1 µl. The synoviocytogram shows neutrophils at 30–70%, lymphocytes at 20–65%, and macrophages at 20–35%.

X-ray Examination of the joints reveals epiphyseal Osteoporosis of the affected joints in 40–50% of patients, cystic radiolucencies, and joint space narrowing, most commonly seen in the metatarsophalangeal and interphalangeal joints of the feet. Asymmetrical sacroiliitis is observed in 30–50% of patients, 'fluffy' Calcaneal Spurs in some patients with a history of subcalcaneal enthesopathy or Achilles bursitis, and erosive Changes in the small joints of the feet.

In this pathology, a reliable increase in erythrocyte calcium levels has been established against the backdrop of normal plasma calcium concentrations. Studies on Homeostasis coupled with calcium metabolism have revealed that individuals with Reiter's syndrome experience hypokalemia, manifested by low potassium levels in erythrocytes and Blood Plasma, and consequently, low calciuresis. It is likely that intracellular calcium accumulation disrupts cellular functional activity, which, as is well known, leads to intracellular loss of K⁺ ions and the intensification of Lipid Peroxidation processes.

We observed a significant decrease in erythrocyte sodium levels and an increase in its urinary excretion in patients with Reiter's syndrome compared to a control group of apparently healthy individuals, while diuresis remained within the normal range. During Clinical Recovery, sodium homeostasis normalizes, particularly with the resolution of articular inflammation symptoms.

Reiter's syndrome is characterized by decreased calciuria. This impairment is accompanied by a statistically significant increase in plasma and erythrocyte magnesium levels alongside a reduction in the daily urinary excretion of this ion. It can be hypothesized that renal impairment in patients with Reiter's syndrome is associated with disruptions in either Glomerular Filtration or tubular reabsorption.

Following a course of etiotropic therapy for uncomplicated urogenital chlamydia, calcium metabolism parameters normalize completely; however, this is not observed in Reiter's syndrome. This Supports the hypothesis that the disease involves a pathogenetic imbalance between gradient-dependent and active calcium transport mechanisms.