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DISEASE (SYNDROME) OF THE RATER
Reiter’s disease (Reiter’s syndrome, Fissenge-Leroy’s syndrome, urethro-oculo-synovial syndrome) is an inflammatory process that develops in most cases in close chronological connection with infections of the genitourinary tract or intestines and manifested by the classical triad - urethritis, conjunctivitis, arthritis. Most often, young (20 - 40) men who have undergone urethritis are ill. Women, children and elderly people get sick much less often and, as a rule, after enterocolitis.
ETHIOLOGY AND PATHOGENESIS
In 1916, Hans Reuters first described the medical history of a young German officer who had diarrhea, who had urethritis and conjunctivitis a week later, and then polyarthritis accompanied by high fever. In this case, Reiter’s disease, which developed after enterocolitis, was considered as an epidemic disease, which is more correctly called Reiter’s syndrome. Reuters syndrome develops in an unfavorable epidemiological situation (in military camps, camping trips, etc.), usually in the summer. Much more common is a sporadic (venereal) disease - Reiter’s disease itself, usually associated with so-called non-specific, non-gonococcal urethritis, sometimes combined with gonorrheal lesions of the genitourinary tract. Reiter’s disease occurs in approximately 1% of patients with nonspecific urethritis.
Reiter's disease as a special nosological form has been identified relatively recently, since numerous studies of recent years have shown that microorganisms of chlamydia are the causative agents of inflammatory processes in the genitourinary tract. They can be found in the epithelial cells of the urethra or cervical canal in 60-70% of patients with Reiter’s disease. A number of researchers isolated microorganisms from the joint tissues of patients (Shatkin A.A. et al., 1973). An experimental model of chlamydial arthritis was also obtained (Shcherbakov N.I., 1980).
Chlamydia are microorganisms that are obligate parasites of nucleated cells and have a unique development cycle, during which they use the host cell as a supplier of metabolic energy and a precursor to the synthesis of their own macromolecules. They are widespread in vivo, parasitize in humans and mammals, and cause a wide range of pathological disorders of a localized and generalized nature. The diseases they cause in animals include ornithosis (psittacosis), abortion, vaginitis, bull seminal vesiculitis syndrome, enterocolitis, ophthalmia and conjunctivitis, encephalitis, myocarditis, etc. The most studied chlamydia in humans are trachoma, paratrachoma and ornithosis. Only recently, the attention of researchers has been attracted to the study of their role in venereal, gynecological and arthrological pathology. The venereological nature of chlamydial urethritis is proved by the fact that in most patients they occur 2-4 weeks after accidental sexual intercourse, and signs of infection are often detected in both sexual partners. The introduction of microorganisms into the genitourinary tract is not always accompanied by noticeable clinical manifestations, especially in women. However, when exposed to additional factors, a sub-manifest, or latent, infection is transformed into a clinically expressed disease. So, it is possible that genitourinary or intestinal infections (gonococci, trichomonads, yersinia, salmonella, etc.) can activate latent chlamydial infection in the urogenital organs or intestines, causing the development of a sporadic (and possibly epidemic) form of Reiter’s disease. In particular, S.V.Shubin (1981), while studying cases of Reiter’s disease in patients with a history of gonococcal urethritis, never received bacteriological evidence of gonococcal infection in the genitourinary tract at the stage of arthritis, but at the same time found a chlamydial infection. According to the author, gonococcal infection only contributes to the manifestation of the pathogenic effect of chlamydia. Dekker (1979) believes that infection with, for example, Shigella or gonococcus, can lead to damage to the mucous membranes of the organs of excretion and thereby contribute to penetration into the body of the true causative agent of Reiter's disease.
The infection, which is primarily localized in the urogenital focus, can spread through the lymph or hematogenous pathway to various organs and tissues, including the tissues of the joints, and can also be a source of immune restructuring of the body.
Immunopathological reactions are essential in the chronization of urogenital inflammatory foci and, apparently, act as a leading factor in the chronicity of Reiter's disease. It is believed that arthritis in Reiter’s disease has two phases: infectious (the earliest) and autoimmune, or rather immunopathological (late).
Certain facts have been obtained that testify to the importance of a genetic predisposition to the development of Reiter's disease. Unlike patients with gonococcal arthritis, patients with Reiter's disease in 75-90% of cases are carriers of HLA B 2 7, which is used in the diagnosis and differential diagnosis of urogenic arthritis. In individuals with HLA B27, the disease acquires a more severe or chronic course with a tendency to become involved in the spine. The mechanism of histocompatibility antigen participation in the development of the disease has not been established. It is hypothesized that, on the one hand, this antigen can determine in some people the lack of an immune response (or inadequate immune response) to certain antigenic determinants, in particular the causative agent of the urethro-oculo-synovial syndrome, and, on the other hand, cross-react with the putative pathogen Reiter’s disease or form a complex antigen with it, inducing the production of antibodies against their own tissues.
CLINIC The disease most often begins with symptoms of urethritis, to which conjunctivitis and arthritis join after 1-4 weeks. In turn, in 52-60% of patients, urethritis occurs 14-28 days after accidental sexual intercourse or diarrhea. Unlike gonococcal urethritis, chlamydial only in 4% of cases begins acutely, in 22% - subacute, in 74% - gradually, invisibly. Usually: * scanty mucopurulent discharge from the urethra appears, often noticeable only in the morning, if the patient does not urinate at night. Damage in acute cases is usually limited to the development of the anterior: • urethritis. When chronic, urethritis becomes total, complicated by prostatitis, without causing diuretic disorders or pain. Urogenital infection can manifest itself as acute cystitis, in women with vaginitis, cervicitis, in chronic cases, inflammation of the uterus.
Conjunctivitis is usually bilateral, catarrhal, mild, ephemeral (lasts 1-2 days, so it is often seen), prone to recurrence - 1/3 of patients may develop anterior uveitis, which can cause blindness.
Joint syndrome is more often manifested by polyarthritis (65%), less often by oligoarthritis (29%) or monoarthritis (6%). The process usually begins acutely or subacutely and is characterized by a predominant lesion of the joints of the lower extremities - knee, ankle, small joints of the feet. Joints of the upper extremities are affected relatively rarely. The asymmetric nature of arthritis is characteristic with frequent involvement of the big toe in the joints, which imitates a “pseudogout” attack. Arthritis of the interphalangeal joints of the feet with their diffuse swelling in the form of sausages is especially frequent. Some patients with exacerbation of articular manifestations complain of pain in various parts of the spine while maintaining its function. These pains, as a rule, are insignificant, and sometimes come to light only upon palpation. In some cases, it is possible to state the symptoms of sacroiliitis, however, most often, lesions of the iliac-sacral joints (usually one-sided) and rarely overlying sections of the spine are detected only during radiography.
This disease is so characteristic of tendonitis and bursitis, especially of the lower extremities - Achilles-bursitis, calcaneal bursitis, periostitis of the calcaneal tubercles ("loose" calcaneal spurs) that their detection allows suspecting Reiter's disease in young men even in the absence of other clinical signs.
At the beginning of the process, not all typical signs of the process (Reuters triad) are always observed, but there are only 1-2 cardinal symptoms. Sometimes the sequence of their appearance is disrupted, for example, conjunctivitis or arthritis are the first clinical symptoms, however, urethritis, prostatitis can be asymptomatic.
In addition to the classical triad, important signs are often detected such as damage to the skin and mucous membranes: keratodermic changes mainly on the palms and soles, psoriasis-like rashes, erosion of the glans penis, circular balanitis, ulcerative painless glossitis, stomatitis, proctitis, trophitis nails. Damage to the skin and mucous membranes is so characteristic of this disease that, if any, they speak of Reiter's notebook.
A very important diagnostic sign is the rapid development of severe amyotrophy of the affected limbs. It is characteristic that, despite the severity of the process, amyotrophy can completely disappear in case of successful treatment of arthritis.
A detailed examination of a significant portion of patients can reveal systemic manifestations. So, for example, rhythm and conduction disturbances occur with myocardial damage. Inflammatory or dystrophic changes in the heart muscle can be observed in 43% of patients with Reiter’s disease. Often lymphadenopathy is also found, especially an increase in inguinal lymph nodes: fishing The liver can also be involved in the process, which is manifested mainly by a change in functional tests. The development of nephritis, pyelonephritis and amyloidosis is described. Neuritis, encephalomyelitis, neurosis, and psychosis can also be diagnosed.
Among the general reactions should be noted fever, which is observed in more than half of patients, and mainly with acute and subacute development of the disease. The temperature in the early days can reach 38-40 ° C, sometimes accompanied by chills. Moderate leukocytosis with a shift of the leukocyte formula to the left, a significantly increased ESR, is detected in the blood. RF in patients with urethro-oculo-synovial syndrome is usually not detected.
Synovial fluid in Reiter’s disease contains predominantly neutrophils (^ bC ^ 10 ^ l), cytophocytic macrophages and a high level of complement are often found in it. Ragocytes, like the Russian Federation, are detected extremely rarely and only with a protracted and chronic course. In biopsy samples of synovial fluid, edema, hyperemia with weak lymphoid tissue infiltration (synovitis) can be observed.
Radiological signs of the disease can often be seen with a protracted and chronic course. They are reduced to periarticular or diffuse osteoporosis, asymmetric erosion of the articular surfaces, especially the thumbs of the table and metatarsophalangeal joints. In the later stages of the disease, bone spikes are formed - osteophytes in the area of the heels, iliac, pubic bones, and sciatic tubercles. The defeat of the iliac-articular joints manifests itself in the symptom complex that is usual for the process of this localization. In case of damage to the spinal column, occasionally it is possible to observe the formation of rough asymmetric and limited paravertebral ossifications, usually not numerous.
The DIAGNOSIS of Reiter's disease is based on the following with - '' * signs:
1) the presence of a chronological relationship between genitourinary or intestinal infections and the development of symptoms of arthritis and (or) conjunctivitis;
2) the young age of the sick (up to 40 years);
3) acute asymmetric arthritis, mainly of the joints of the lower extremities (especially the joints of the toes) with enthesopathies or calcaneal bursitis;
4) signs of an inflammatory process in the genitourinary tract and the detection of chlamydia of the oral cavity (painless ulcers) and skin (keratoderma, balanitis);
5) Carriage of HLA B27.
Diagnosis of the disease in the presence of a triad of symptoms is quite simple, but it can be difficult if the previous enterocolitis and urethritis were short-lived and mild. In these cases, even minor pyuria should be given importance, the prostate gland and its juice should be examined to detect signs of inflammation, even ephemeral conjunctivitis that appears during the disease should be given importance, and the peculiarities of the symptoms of musculoskeletal system damage. In the acute course with fever, chills, with the previous detection of gonococci in the discharge of the urethra, it is necessary to carry out differential diagnosis with gonococcal arthritis. The diagnosis of the latter is considered absolutely proven only when gonococci are detected in the synovial fluid and extremely rapid reverse development of arthritis under the influence of penicillin. With gonococcal arthritis, there are no eye symptoms, keratoderma, HLA B27 is not detected. Sometimes in cases of ulcerative lesions of the mucous membranes of the oral cavity and genitals, it is necessary to differentiate Reiter’s disease with Behcet’s syndrome, in which ulcers are extremely painful. With damage to the skin and nails, psoriatic arthritis should be excluded or a combination of psoriasis and Reiter's disease should be recognized.
The total duration of acute cases of the disease is 3-6 months, the process usually ends with the reverse development of all symptoms. However, often the disease can take a protracted or close to chronic course, lasting up to 9-12 months or more.
TREATMENT. Early treatment of the disease at the stage of urethritis-conjunctivitis can prevent the generalization of the disease, the development of recurrent arthritis. For this purpose, sulfonyl amides or broad-spectrum antibiotics are used, especially the tetracycline series, to which chlamydia is especially sensitive.
Of non-steroidal anti-inflammatory drugs for Reiter’s disease, pyrazolone (butadione, rheopyrin, pi-rabutol) and indole derivatives (indomethacin) and other drugs are prescribed, depending on the severity of the inflammatory process, the tolerability of a particular drug. While maintaining inflammation in the joints, especially in the small joints of the feet, heel and heel bursitis, local injections of hydrocortisone or other GKOs are indicated. The systemic reception of GCS should be resorted to only in case of pronounced general and local signs of inflammation, not amenable to treatment with non-steroidal anti-inflammatory drugs, as well as with visceral manifestations of the disease.
Primary prevention measures should be reduced to compliance with the requirements of sanitation and hygiene, thorough treatment of urethritis (not only gonorrheal, but also non-gonococcal), cystitis, pyelonephritis, inflammation of the female genital organs. Secondary prophylaxis of the disease includes the long-term (for 3-5 years) use of basic drugs - quinoline series drugs (delagil, plaquenide), one tablet per day, as well as systemic monitoring and, if necessary, appropriate treatment of urinary tract infections. If patients have chlamydial infection, examination and treatment of their sexual partners, which may be asymptomatic carriers of chlamydia, is necessary.
1. Nasonova V.A., Astapenko M.G. Clinical Rheumatology. -M .-. Medicine, 1989 .-- 209 p.
2. Harrison T.R. Internal illnesses. - M.Meditsina, 1993.
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