Orthopedics - Oleksa A.P. 2006

Joint Diseases
Arthritis of Unknown Etiology
Reiter's Syndrome (Fiessinger-Leroy-Reiter syndrome)

This syndrome is characterized by a classic triad of clinical manifestations: Arthritis, urethritis, and Conjunctivitis.

The exact Etiology of the disease remains unclear. It is widely believed to be of infectious, non-gonococcal origin, potentially linked to pleuropneumonia-like organisms (PPLOs), given the presence of intracellular inclusions and L-forms of Bacteria.

According to Shatkin et al. (1976), Bitchuk et al. (2001), and other researchers, chlamydiae play a primary role in The Development of the syndrome, having been detected in the Urethra, synovial membrane biopsies, and synovial fluid. Histological findings reveal fibrinous exudates, cellular infiltration, and vascular Changes in the synovial membrane, along with synovial Cell layer thickening, all indicative of an active inflammatory process.

Anokhin et al. (1984) associate the onset of Reiter's Syndrome with the potential involvement of sexually transmitted *Ureaplasma urealyticum*.

The condition has also been linked to pathogens causing dysentery, salmonellosis, yersiniosis, and other infections.

Russell A.S. (1977) notes that urogenital infections predominate in adults, whereas enteric infections are more common in children.

Regarding its Pathogenesis, Reiter's syndrome is classified as a reactive arthropathy occurring in genetically predisposed individuals. The HLA-B27 antigen is detected in 78% of patients, and a hereditary predisposition is further suggested by the higher incidence rates among males and male children.

Isolated pediatric cases are relatively rare (1%, according to Studenikin M.Y. and Yakovleva A.A., 1987) and are typically accompanied by joint involvement.

The disease typically begins subacutely or acutely, initially manifesting as urethritis and conjunctivitis, followed by joint inflammation (synovitis). However, this sequence is variable and not strictly fixed. Urethritis and arthritis may appear first, followed by conjunctivitis. Urethritis and cystitis remain constant Features of the condition, presenting with frequent urges to urinate, a burning sensation during urination, and mucous urethral discharge, particularly in the morning.

Catarrhal conjunctivitis affecting both eyes is characterized by persistence and chronicity, occasionally lasting for a month or longer. In approximately one-third of adult patients, conjunctivitis may be accompanied by uveitis, episcleritis, or keratitis (Shubin S.V., 1984).

Joint involvement typically manifests 1 to 4 weeks after the onset of the disease. As a rule, febrile synovitis develops most frequently in the knee joint, less commonly in the ankle or FOOT joints, and, if left untreated, can spread to the upper extremities. Spinal involvement has been reported in both adults and children, alongside sacroiliitis, which, according to Anokhin V.N. (1984) and Shubin S.V. (1984), occurs in 25–50% of adult patients.

Arthritis in Reiter's syndrome presents with pronounced synovitis and pain caused by elevated intra-articular pressure. It tends to wax, wane, and recur, consistently coinciding with flare-ups of urethritis. In roughly half of the patients, the arthritis follows a chronic course (Studenikin M.Y., Yakovleva A.A., 1987). In medical literature, peripheral joint involvement in Reiter's disease is referred to as reactive arthritis, spinal joint involvement as reactive spondyloarthritis (Nasonova V.A., Bunchuk K.V., 1997), or chlamydia-induced arthritis (Istomin A.G., Khvisyuk A.N., Sitenko T.A., 1999), although Bitchuk et al. (2001) advocate for the broader term 'arthropathy', and Movchan A.S. et al. (2000) suggest 'seronegative spondyloarthropathy'.

A characteristic feature of this syndrome is its frequent association with adjacent bursitis, achillodynia, fasciitis, and fibroostitis (Wagenhäuser K., 1976).

The Diagnosis of Reiter's syndrome is primarily based on the classic triad of clinical signs: arthritis, urethritis, and conjunctivitis.

Radiological imaging typically reveals no initial pathological changes in the affected joints, although long-standing chronic cases may eventually show localized Osteoporosis and joint destruction.

Routine laboratory Blood tests generally show no significant deviations from normal limits. Rheumatoid factor is absent in both the blood serum and the synovial fluid.

Analysis of the synovial fluid reveals elevated cell counts (leukocytosis) with a neutrophil predominance, confirming an inflammatory response. Chlamydiae are frequently, though not invariably, detected.

Diagnostic evaluation can be aided by detecting elementary bodies in urethral smears, as well as confirming the presence of the HLA-B27 histocompatibility antigen.

Treatment. Once the diagnosis is promptly established or in the event of a relapse, patients should be prescribed a course of antibacterial therapy combined with a comprehensive regimen of other pharmacological agents (analgesics, immunostimulants, corticosteroids, nonsteroidal anti-inflammatory drugs, chondroprotectors, and Vitamins), alongside general supportive therapy. Among Antibiotics, chlamydiae are most sensitive to Tetracyclines, fluoroquinolones, carbapenems, macrolides, and rifampicins. It is generally advisable to combine two antibiotics from different classes, rotating them every 10 days.

In cases of excessive joint effusion, immobilization and joint aspiration (arthrocentesis) are necessary, as reducing intra-articular pressure promptly relieves pain. Joint punctures must be repeated as needed for decompression until the inflammatory process subsides under METABOLISM/18.html">The Influence of pharmacotherapy.

Depending on which symptom dominates their Clinical presentation, patients may initially seek care from an orthopedist, urologist, or ophthalmologist. Clinicians unfamiliar with this specific pathology tend to treat the condition strictly within their own specialty, failing to connect all three Components of the syndrome.

We were once consulted on a patient admitted to a regional orthopedic-traumatology department due to a persistent synovial fistula of the knee that failed to close following joint drainage. The patient suffered from chronic synovitis, and repeated aspirations had proved ineffective. Reviewing the medical history, we found an entry by a urologist, followed three days later by one from an ophthalmologist, who had independently prescribed treatments for urethritis and blepharoconjunctivitis, respectively. In the presence of all three specialists, the diagnosis was refined, and a comprehensive treatment regimen specific to Reiter's syndrome was initiated. The knee joint was immobilized with a plaster splint and additionally drained using a thin rubber nipple tube with a compression bandage applied over the fistula site. Within two weeks, the fistula closed, and the drainage tube was removed. Following the completion of comprehensive syndrome therapy, the patient was discharged home in satisfactory condition.