StomatologieAspectsofCutaneous Diseases Reiter’s Syndrome
R O B E R T J. G O R L IN , D .D .S., M.S. an d H E D D IE O. SED A N O , D .D.S., D R . O.
o f R eiter’s syndrom e consists o f 1) arthritis, 2) conjunctivitis, an d 3) urethritis. T he original triad has been exp an ded to include o ther lesions, princi pally o f the skin, m ucous m em branes, an d viscera. Sym ptom s suggest gonorrhea, b u t sm ears o f the u rethral discharge are always negative for Neisseria gonorrhea. T he cause is n o t clear, b u t there is suggestive evidence th at an organism o f the genus M ycoplasm a m ay be im plicated. Such organism s have been recovered from synovial fluid b u t have n o t b een carried in subculture. The syndrom e usually occurs in young m en betw een 20 an d 30 years o f age. R arely, it is fou nd in other age groups and in w om en. T he condition is associated with fever in the initial stages an d tends to be self-limited. Prodrom al signs an d sym ptom s m ay be w eight loss, fatigue, nausea, vom iting, an d (in one-third o f the patients) mild, non bloody diarrhea. T h e onset o f the condition is usually associated with a single co m ponent o f the triad. T he com plete syndrom e is m anifested in 70 % o f -patients d uring the first 10 days o f the disease. T he m ost frequ ent sequence o f signs is urethritis, arthritis and conjunctivitis. U rethral involvem ent is characterized by pru ritus an d burnin g sensation associated w ith m ucoid or p u ru len t discharge, an d erythem a o f the m eatus. N u m erous leukocytes are fo und in the discharge b u t no bacteria. The urethritis m ay last from a day to several m onths. A dditional findings m ay be circinate balanitis and T h e c la s s ic t r i a d
Dr. Gorlin is Professor and C hairm an o f the Division o f Oral Pathology, School o f Dentistry, University o f M innesota, M inneapolis, M innesota. Dr. Sedano is Associate Professor, Division o f Oral Pathology, School o f Dentistry, University o f M innesota, M inneapolis, M inne sota.
cystitis at times, the latter resulting in dysuria, abacterial pyuria, and hem aturia. T he m ucosa o f the b la d d e r m ay show superficial m em bran ous sloughs and petechial bleeding. N ephritis has been seen associated with the syndrome. Polyarticular involvem ent is the m ost disabling feature. T he w eight-bearing joints o f the low er extrem i ties are involved w ith greatest frequency, followed by the joints o f the shoulders, fingers and sacrum . T en der ness, pain, swelling and, in som e cases, change in color o f the skin over the jo ints are the m ost freq uent articular m anifestations. A sym m etric arthritic involvem ent o f the sacroiliac joints, toes and heels has been reported in m any patients with the syndrom e. This characteristic m ay aid in the roentgenographic diagnosis o f the condi tion. Patients with severe form s o f the disease show bone atrophy and flecky décalcification. T he synovial fluid m ay contain neutrophils an d have high hem olytic activity o f com plem ent. The first ocular sym ptom s are sm arting, pho toph obia and epiphora, followed by conjunctival erythem a and m ucopurulent discharge. The conjunctivitis, usually bilateral, m ay be so m ild as to be overlooked. T he ocular m anifestations m ay last from a few days to several m onths b u t usually subside w ithin 1 to 4 weeks w ithout sequelae. O ther ocular m anifestations m ay be unilateral nongranulom atous iridiocyclitis and keratitis. The skin lesions, sym m etrical in distribution, are usually found on the palm s and soles, occasionally on the trunk and extremities. The cutaneous lesions are sim ilar to those seen in gonorrhea or pustular psoriasis. They begin as small, red to yellowish papules th at becom e confluent an d hyperkeratinized. The hyperkeratotic crusts are lost after several weeks. T he skin lesions
J. Dermatol. Surg. Oncol 3:3 M ay/June 1977
275
REITER’S SYNDROM E
FIGURE 1. Marked conjunctivitis and circumcorneal flush in a patient with Reiter's syndrome.
FIGURE 2. Red papules on the soles o f a patient with Reiter’s syndrome. Mote similarity to the lesions o f keratosis blennorrhagica and pustular psoriasis.
FIGURE 4. A lesion on the buccal mucosa in a patient with Reiter’s syndrome. Mote the red color, slightly elevated margins, and similarity to the penile changes seen in Fig. 3.
I FIGURE 3. Circi nate balanitis in a patient with Reiter’s syndrome.
"
FIGURE 5. Lesions on the tongue resembling those o f geographic tongue in a patient with Reiter’s syndrome.
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J. Dermatol. Surg. Oncol. 3:3 M ay/June 1977
GORLIN AND SEDANO
ap p ear 4 to 6 weeks after onset o f the disease, usually in patients with severe arthritis, an d m ay last 2 to 4 m onths. The nails o f the fingers an d toes m ay be lost as a result o f subungual keratoses and abscesses. Superficial, painless genital lesions, lim ited to the foreskin and glans, are sm all erythem atous papules with slightly elevated w hite-gray borders. W ith tim e they m ay acquire a m ap-like configuration an d becom e covered with scales. Occasionally the scrotum an d the shaft o f the penis m ay have superficial ulcers. The buccal m ucosa, lips an d gingiva m ay present red, slightly elevated areas w ith w hite circinate borders o f no m ore th a n 1 cm in diam eter. These lesions resem ble those on the penis. O ther lesions m ay be found, espe cially on the palate, in the form o f m ultiple, sm all purpuric spots th a t m ay coalesce. T he tongue m ay present an app earance sim ilar to th a t o f geographic tongue and m ay b e a r superficial erosions th a t becom e prom inent w hen the tongue is coated.
O ther findings m ay be carditis, aortic insufficiency o f rapid onset, an d atrioventricular conduction defects. The histologic findings are nonspecific. T he epithelium is infiltrated with poly m orph onu clear leukocytes. T here are variable degrees o f parakeratinization, spongiosis and hyperplasia. Intraepithélial m icroabscess form ation m ay also be found. T he underlying connective tissue presents a nonspecific chronic inflam m atory infiltrate. REFER EN C ES 1. 2.
3. 4.
Paronen, I. R eiter’s disease: a study o f 344 cases observed in Finland. Acta Med. Scand. [Suppl] 212:1-114, 1948. Reiter, H. U ber eine bisher unerkannte Spirochaten-Infektion (Spirochaetosis arthritica). Dtsch. M ed. W ochenschr. 42:15351536, 1916. Shepard, M.C. Nongonococcal urethritis associated with hum an strains o f “T” mycoplasms. J.A.M.A. 211:1335-1340, 1970. W einberger, H.W. et al. Reiter’s syndrome, clinical and patho logic observations: a long term study o f 16 cases. Medicine 41: 35-91, 1962.
R O B E R T J. G O R L IN , D .D .S., M.S. an d H E D D IE O. SED A N O , D .D.S., D R . O.
o f R eiter’s syndrom e consists o f 1) arthritis, 2) conjunctivitis, an d 3) urethritis. T he original triad has been exp an ded to include o ther lesions, princi pally o f the skin, m ucous m em branes, an d viscera. Sym ptom s suggest gonorrhea, b u t sm ears o f the u rethral discharge are always negative for Neisseria gonorrhea. T he cause is n o t clear, b u t there is suggestive evidence th at an organism o f the genus M ycoplasm a m ay be im plicated. Such organism s have been recovered from synovial fluid b u t have n o t b een carried in subculture. The syndrom e usually occurs in young m en betw een 20 an d 30 years o f age. R arely, it is fou nd in other age groups and in w om en. T he condition is associated with fever in the initial stages an d tends to be self-limited. Prodrom al signs an d sym ptom s m ay be w eight loss, fatigue, nausea, vom iting, an d (in one-third o f the patients) mild, non bloody diarrhea. T h e onset o f the condition is usually associated with a single co m ponent o f the triad. T he com plete syndrom e is m anifested in 70 % o f -patients d uring the first 10 days o f the disease. T he m ost frequ ent sequence o f signs is urethritis, arthritis and conjunctivitis. U rethral involvem ent is characterized by pru ritus an d burnin g sensation associated w ith m ucoid or p u ru len t discharge, an d erythem a o f the m eatus. N u m erous leukocytes are fo und in the discharge b u t no bacteria. The urethritis m ay last from a day to several m onths. A dditional findings m ay be circinate balanitis and T h e c la s s ic t r i a d
Dr. Gorlin is Professor and C hairm an o f the Division o f Oral Pathology, School o f Dentistry, University o f M innesota, M inneapolis, M innesota. Dr. Sedano is Associate Professor, Division o f Oral Pathology, School o f Dentistry, University o f M innesota, M inneapolis, M inne sota.
cystitis at times, the latter resulting in dysuria, abacterial pyuria, and hem aturia. T he m ucosa o f the b la d d e r m ay show superficial m em bran ous sloughs and petechial bleeding. N ephritis has been seen associated with the syndrome. Polyarticular involvem ent is the m ost disabling feature. T he w eight-bearing joints o f the low er extrem i ties are involved w ith greatest frequency, followed by the joints o f the shoulders, fingers and sacrum . T en der ness, pain, swelling and, in som e cases, change in color o f the skin over the jo ints are the m ost freq uent articular m anifestations. A sym m etric arthritic involvem ent o f the sacroiliac joints, toes and heels has been reported in m any patients with the syndrom e. This characteristic m ay aid in the roentgenographic diagnosis o f the condi tion. Patients with severe form s o f the disease show bone atrophy and flecky décalcification. T he synovial fluid m ay contain neutrophils an d have high hem olytic activity o f com plem ent. The first ocular sym ptom s are sm arting, pho toph obia and epiphora, followed by conjunctival erythem a and m ucopurulent discharge. The conjunctivitis, usually bilateral, m ay be so m ild as to be overlooked. T he ocular m anifestations m ay last from a few days to several m onths b u t usually subside w ithin 1 to 4 weeks w ithout sequelae. O ther ocular m anifestations m ay be unilateral nongranulom atous iridiocyclitis and keratitis. The skin lesions, sym m etrical in distribution, are usually found on the palm s and soles, occasionally on the trunk and extremities. The cutaneous lesions are sim ilar to those seen in gonorrhea or pustular psoriasis. They begin as small, red to yellowish papules th at becom e confluent an d hyperkeratinized. The hyperkeratotic crusts are lost after several weeks. T he skin lesions
J. Dermatol. Surg. Oncol 3:3 M ay/June 1977
275
REITER’S SYNDROM E
FIGURE 1. Marked conjunctivitis and circumcorneal flush in a patient with Reiter's syndrome.
FIGURE 2. Red papules on the soles o f a patient with Reiter’s syndrome. Mote similarity to the lesions o f keratosis blennorrhagica and pustular psoriasis.
FIGURE 4. A lesion on the buccal mucosa in a patient with Reiter’s syndrome. Mote the red color, slightly elevated margins, and similarity to the penile changes seen in Fig. 3.
I FIGURE 3. Circi nate balanitis in a patient with Reiter’s syndrome.
"
FIGURE 5. Lesions on the tongue resembling those o f geographic tongue in a patient with Reiter’s syndrome.
276
J. Dermatol. Surg. Oncol. 3:3 M ay/June 1977
GORLIN AND SEDANO
ap p ear 4 to 6 weeks after onset o f the disease, usually in patients with severe arthritis, an d m ay last 2 to 4 m onths. The nails o f the fingers an d toes m ay be lost as a result o f subungual keratoses and abscesses. Superficial, painless genital lesions, lim ited to the foreskin and glans, are sm all erythem atous papules with slightly elevated w hite-gray borders. W ith tim e they m ay acquire a m ap-like configuration an d becom e covered with scales. Occasionally the scrotum an d the shaft o f the penis m ay have superficial ulcers. The buccal m ucosa, lips an d gingiva m ay present red, slightly elevated areas w ith w hite circinate borders o f no m ore th a n 1 cm in diam eter. These lesions resem ble those on the penis. O ther lesions m ay be found, espe cially on the palate, in the form o f m ultiple, sm all purpuric spots th a t m ay coalesce. T he tongue m ay present an app earance sim ilar to th a t o f geographic tongue and m ay b e a r superficial erosions th a t becom e prom inent w hen the tongue is coated.
O ther findings m ay be carditis, aortic insufficiency o f rapid onset, an d atrioventricular conduction defects. The histologic findings are nonspecific. T he epithelium is infiltrated with poly m orph onu clear leukocytes. T here are variable degrees o f parakeratinization, spongiosis and hyperplasia. Intraepithélial m icroabscess form ation m ay also be found. T he underlying connective tissue presents a nonspecific chronic inflam m atory infiltrate. REFER EN C ES 1. 2.
3. 4.
Paronen, I. R eiter’s disease: a study o f 344 cases observed in Finland. Acta Med. Scand. [Suppl] 212:1-114, 1948. Reiter, H. U ber eine bisher unerkannte Spirochaten-Infektion (Spirochaetosis arthritica). Dtsch. M ed. W ochenschr. 42:15351536, 1916. Shepard, M.C. Nongonococcal urethritis associated with hum an strains o f “T” mycoplasms. J.A.M.A. 211:1335-1340, 1970. W einberger, H.W. et al. Reiter’s syndrome, clinical and patho logic observations: a long term study o f 16 cases. Medicine 41: 35-91, 1962.
