REITER'S SYNDROME: Diagnosis and Clinical Features

The occurrence of arthritis following an acute diarrhea or a urethral discharge was intriguing enough to be mentioned early in ancient medical literature. Hippocrates noted that, "A youth does not suffer from gout until after sexual intercourse, " gout meaning acute arthritis at this time. He also mentioned that diarrhea which stops suddenly may create deposits in the chest and the joints. Clinical descriptions improved when microbiological techniques allowed differentiation of septic from aseptic arthritis. The first description of an identified infectious agent triggering aseptic arthritis was made during the first World War by Fiessinger and Leroy in 1916 who reported an outbreak of Shigella dysenteriae and described four of the dysenteric patients as suffering from what they called an "oculo-urethro-synovial" syndrome. 26 Hans Reiter also in 1916 described the same oculo-urethro-synovial triad in a young officer and discussed the role of a treponema called "treponema arthritidis." 47 During the second World War and the period of confusion that has followed, epidemics of dysentery 41,45 were associated with new cases of what is now called "Reiter's syndrome" (RS). Further observation of these cases showed an unsuspected frequency of relapses and chronic evolution, often unrelated to new infectious episodes. 19 During the same period, the curing of gonococcal infections with penicillin confirmed the identification of nongonococcal urethritis (NGU) and disrupted the old and heteroclite concept of chronic gonococcal arthritis. Among the different aetiological agents of NGU, Chlamydia trachomatis 7,33 has progressively become recognized as the one most closely associated with a triad similar to that described by Fiessinger, Leroy, and Reiter after diarrhea. "Post-dysenteric or epidemic Reiter" and "post venereal or endemic Reiter's syndrome" were defined and a first set of criteria was proposed. 62 Concurrently, the clinical overlap and genetic links between complete or incomplete Reiter's syndrome, ankylosing spondylitis, and some psoriasis associated arthritis appeared more and more impressive as observation periods lengthened. The association between HLA-B27 antigen, ankylosing spondylitis 12,51 and Reiter's syndrome or reactive arthritis provided strong support to the clinical data. In 1973 and 1974, Aho et al 2 reported aseptic arthritis following gut infection with Yersinia enterocolitica, mostly in HLA-B27 positive individuals, and proposed a new term: "reactive arthritis" which was so popular that it has progressively replaced all the previous terms. During the same period, the clinical overlap and the genetic links between reactive arthritis, ankylosing spondylitis, and other apparent entities were growing more evident and the term "spondyloarthropathies" 42 was adopted by many.