What are the Symptoms of Reiter’s Syndrome?
The three most common symptoms of Reiter’s syndrome are arthritis, conjunctivitis, and urethritis. The onset of symptoms typically occurs one to four weeks following the initial infection and may present acutely or develop slowly over time. Urethritis, a urinary tract inflammation, is often accompanied by symptoms such as a discharge in males, although it may sometimes present as blood in the urine. Females may present with an inflammation of the cervix. Urethritis in either males or females may also be present without symptoms (Barth & Segal, 1999).
Ophthalmic, or eye, manifestations occur in approximately one-third of individuals with Salmonella-associated arthritis (Barth & Segal, 1999). The involvement of the eye in Reiter’s syndrome is most commonly manifested as conjunctivitis, an inflammation of the mucous membrane that covers the eyeball. Conjunctivitis usually appears within a few weeks of the onset of arthritis and urethritis and the symptoms are usually mild, symmetric, and bilateral (Lee et al., 1986; Ostler et al., 1971). Bacterial cultures are negative and the inflammation typically resolves within 10 days without treatment. Conjunctivitis is present in up to 50% of affected individuals and can develop at any time during the course of the disease, although it is more common in reactive arthritis associated with genitourinary or Shigella infections (Kataria & Brent, 2004). Anterior uveitis, an inflammation of the inner eye, is the second most common ocular symptom of Reiter’s syndrome, occurring in up to 12% of affected persons (Ostler et al., 1971). Uveitis is most often acute, unilateral, and recurrent (Lau et al., 1998; Yu et al., 2001). It is more frequent in those who are HLA-B27 positive and in individuals with sacroiliitis, an inflammation of the sacroiliac (sacrum and ilium) joint or region (Kataria & Brent, 2004). Conjunctivitis and uveitis can cause redness of the eyes, eye pain and irritation, and blurred vision. Other ocular conditions also have been associated with Reiter’s, including scleritis, cataract, glaucoma, keratitis, papillitis, retinal and disc edema, and retinal vasculitis (Kiss et al., 2003).
The arthritis associated with Reiter’s syndrome generally occurs rapidly, with joints becoming hot and swollen; large effusions, or collections of fluid, can develop in the knee joint (Hill Gaston & Lillicrap, 2003; Barth & Segal, 1999). Wrists, fingers and other joints can be affected, although with less frequency. Joint pain without inflammation may also occur at sites other than those affected by inflammation. A condition called enthesopathy also commonly occurs, in which the tendon that attaches to the bone becomes inflamed (Barth & Segal, 1999; Kataria & Brent, 2004). Enthesopathies occur in 5 to 21% of individuals with Salmonella-associated arthritis (Barth & Segal, 1999). The heel is the most common site with the development of heel pain and Achilles tendonitis, but pain at the insertion of the patellar (kneecap) tendon into the tibia, the larger of the two bones in the lower leg, may also occur. Some individuals with Reiter’s syndrome may develop heel spurs, bony growths that cause chronic foot pain. Arthritis from Reiter’s syndrome can also affect the joints of the back, causing spondylitis, an inflammation of the vertebrae and the attached disks and ligaments in the spinal column, and asymmetric sacroiliitis (Yu et al., 2001).
The duration of reactive arthritis symptoms can vary greatly. The literature suggests that the majority of affected individuals recover within a year although reactive arthritis can become chronic (Kataria & Brent, 2004, Thomson et al., 1995). Up to 50% of those with reactive arthritis may have recurrent bouts of arthritis and 15 to 30% develop chronic arthritis or sacroiliitis (Yu et al., 2001). In one study, 18 (67%) of 27 individuals who developed reactive arthritis after a Salmonella infection continued to have symptoms at five years of follow-up (Thomson et al., 1995). Symptoms were severe enough to force a change in work for four individuals and another four had objective damage to joints radiographically.
Other symptoms of Reiter’s syndrome may include a painless skin rash on the penis in men called circinate balanitis. Skin rashes on the soles of the feet and, less often, on the palms of the hands or elsewhere may also occur; these rashes are called keratoderma blennorrhagicum (or keratosis blennorrhagica) and are similar to psoriasis. They often begin as clear vesicles (blisters) on a red base and progress to macules (flat lesions), papules (raised lesions), and nodules (firm bumps) (Kataria & Brent, 2004). In addition, some people develop mouth ulcers that come and go. In some cases, these ulcers are painless and go unnoticed.