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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 114-116

Reiter's disease in a 13-year-old girl


School of Medical Science and Research, Sharda Hospital, Greater Noida, Uttar Pradesh, India

Date of Web Publication30-Mar-2016

Correspondence Address:
Alia Abbas Rizvi
D-189, Sector 41, Noida - 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.175653

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  Abstract 

Reiter's disease or reactive arthritis is characterized by the classic triad of urethritis, arthritis, and conjunctivitis, usually following a genitourinary or gastrointestinal infection. Reiter's syndrome has been reported in children, but they usually do not manifest with the typical triad. Only a few such cases have been reported, and these have affected males predominantly. Furthermore, human leukocyte antigen B27 association in children is not well-established. However, in our case, it was positive. We, herein, report a case of a 13-year-old girl who presented with redness of eyes and joint pains followed by skin involvement is reported. She was managed with topical steroids and keratolytics along with oral nonsteroidal anti-inflammatory drugs and showed complete resolution in 3 weeks.

Keywords: Female, human leukocyte antigen B27, Reiter's disease


How to cite this article:
Rizvi AA, Kanwar AJ, Goel S, Dua S. Reiter's disease in a 13-year-old girl. Indian J Paediatr Dermatol 2016;17:114-6

How to cite this URL:
Rizvi AA, Kanwar AJ, Goel S, Dua S. Reiter's disease in a 13-year-old girl. Indian J Paediatr Dermatol [serial online] 2016 [cited 2019 Nov 19];17:114-6. Available from: http://www.ijpd.in/text.asp?2016/17/2/114/175653


  Introduction Top


Hans Reiter in 1916 described a case of Reiter's syndrome (RS) in a young soldier with conjunctivitis, urethritis, and arthritis, following an episode of dysentery. There are only a few reports of RS affecting children, and most of these involve males.[1],[2] Epidemiological data on RS are scarce, primarily because of its varying clinical features and lack of sensitive and specific diagnostic criteria.[3]

Depending on the preceding infection, RS is classified into postdysenteric and sexually acquired RS, although it has also been reported after respiratory infections, urinary tract infections, and bacilli Calmette–Guerin treatment for bladder carcinoma.[4],[5]

Postulated triggering agents are Chlamydia trachomatis, Shigella flexneri, Salmonella spp, Yersiniaenterocolitica, Campylobacter spp, and perhaps Neisseria gonorrhoeae, or other organisms including the spirochete Borrelia burgdorferi. Numerous studies confirm a high incidence of human leukocyte antigen (HLA)-B27 positivity (60–90%) in patients with RS.

Data suggest that chlamydial Reiter's disease or reactive arthritis (ReA) is underdiagnosed and that asymptomatic chlamydial infections might be a common cause.[6] An important difference between Chlamydia - induced (postvenereal) ReA and postenteric ReA is the presence of viable but aberrant chlamydial organisms in the synovial fluid [7] (so-called Chlamydia persistence).[8] PCR assay to detect C. trachomatis DNA in synovial samples may be a good method for establishing the diagnosis of Chlamydia-induced arthritis in patients with ReA.[9] Arthritis, the single most important criteria of RS, manifests commonly as oligoarticular arthritis affecting the joints of lower extremities.[10],[11] We report a case of Juvenile Reiter's disease in a 13-year-old-girl with atypical cutaneous involvement.


  Case Report Top


A 13-year-old girl presented with fever, painful swelling of the right ankle joint, and ball of toe along with redness of eyes since 15 days, pain in the left shoulder joint since 10 days. Multiple crusted lesions developed over her trunk 5 days after the initial presentation. There was no history of any recent gastrointestinal or genitourinary tract infection.

On general examination, she was febrile (38.1°C) and appeared ill. There were swelling and tenderness of the right ankle and first metatarsophalangeal joint with limited movements. The skin lesions were generalized, bilaterally symmetrical, well-marginated, erythematous, scaly plaques with adherent limpet-like scaling appeared over the chest, back, and gluteal region [Figure 1] and only relatively sparing the scalp, lower trunk, genitalia, and mucous membranes. These progressed in number over the back. She also had bilateral conjunctival injection.
Figure 1: Multiple well-marginated, erythematous, scaly plaques with adherent limpet-like scaling distributed over the chest

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Routine hemogram was within normal limits except for normocytic hypochromic anemia and raised erythrocyte sedimentation rate (18 mm) and C-reactive protein. Urine routine and microscopy revealed pus cells (5–6/hpf) epithelial cells (6–8/hpf). HLA-B27 positivity was seen. Antinuclear antibodies, rheumatoid factor, uric acid, Mantoux test, blood, stool, and urethral cultures were all negative. The HIV (ELISA) test was negative. X-ray of the left shoulder and right foot showed normal radiological findings.

Histopathological section of the skin revealed a psoriasiform picture characterized by hyperkeratosis, parakeratosis, acanthosis, and spongiform macropustules in the stratum Malpighi upper layers and exocytosis of neutrophils in the lower layers [Figure 2].
Figure 2: Psoriasiform hyperplasia with macropustule seen just beneath the hyperkeratotic layer of epidermis (×100)

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Synovial fluid studies were inconclusive, showing only lymphocytic cells. Routine culture was negative. She was managed with topical salicylic acid and mometasone and oral naproxen twice daily for a week. Her joint symptoms subsided in 1 week and skin lesions in 3 weeks [Figure 3]. She was followed up for 3 months after remission and remained asymptomatic.
Figure 3: Resolution of the lesions with postinflammatory hypopigmentation after 3 weeks of intensive therapy

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  Discussion Top


RS is characterized by the classic triad of urethritis, arthritis, and conjunctivitis, usually following a genitourinary or gastrointestinal infection. Young children are more likely to acquire the postdysenteric form whereas, in adolescents, the posturethritic form is the most common.[12] The full triad may not occur in all patients, and does not usually present simultaneously in children.[2]

Lockie reported conjunctivitis as the most common manifestation in children.[13] It is typically described as bilateral and mucopurulent but may range from mild infection to severe inflammation. Nonspecific urethritis is generally limited to a mild, painless, and nonpurulent urethral discharge. Diagnosis of urethritis in young children may be difficult given the milder clinical signs. Urethritis can also be a postdysenteric phenomenon, apparently nonsexually acquired. This may possibly be due to urethral inflammation by mechanisms other than direct infection.[14]

Mucocutaneous lesions occur frequently in RS and may confirm the diagnosis. Balanitis and vulvitis are rare in children and are highly suggestive of Reiter's keratoderma blennorrhagicum manifests initially as macules and vesicles which later develop hyperkeratotic papules and plaques with a pustular center. Oral erosions and ulcers may develop in some patients. HLA-B27 association in children is not well-established. However, in our case, it was positive. Histopathological findings are similar to psoriasis.

There is no specific treatment for Reiter's disease. However, spontaneous remissions are noted in some patients within 6 months. Tetracyclines are used to control underlying infections. Nonsteroidal anti-inflammatory drugs, corticosteroids, antimetabolites such as methotrexate and azathioprine have all been used depending on the severity of the disease and response.

Our patient, a 13-year-old girl, presented with fever, swelling, and pain in the right ankle joint and ball of the toe, and pain in the left shoulder joint followed by conjunctivitis. Skin involvement had manifested with the appearance of lesions of keratoderma blennorrhagicum, which were quite widespread. Typically, asymmetrical oligoarthritis was observed with peripheral involvement affecting the right ankle, the first metatarsal joint, and the left shoulder joint. The early age of presentation, in a female, with widespread cutaneous lesions, HLA-B27 positivity, and the absence of any preceding infection before arthritis are the interesting features of this case.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Sehgal VN, Srivastava G. Reiter's disease: A five year prospective study. Indian J Dermatol 1986;31:67-70.  Back to cited text no. 1
    
2.
Cuttica RJ, Scheines EJ, Garay SM, Romanelli MC, Maldonado Cocco JA. Juvenile onset Reiter's syndrome. A retrospective study of 26 patients. Clin Exp Rheumatol 1992;10:285-8.  Back to cited text no. 2
    
3.
Olivieri I, van Tubergen A, Salvarani C, van der Linden S. Seronegative spondyloarthritides. Best Pract Res Clin Rheumatol 2002;16:723-39.  Back to cited text no. 3
    
4.
Bauman C, Cron RQ, Sherry DD, Francis JS. Reiter syndrome initially misdiagnosed as Kawasaki disease. J Pediatr 1996;128:366-9.  Back to cited text no. 4
    
5.
Faus S, Martinez Montauti JM, Puig L. Reiter's syndrome after administration of intravesical bacille Calmette-Guérin. Clin Infect Dis 1993;17:526-7.  Back to cited text no. 5
[PUBMED]    
6.
Kousa M, Saikku P, Richmond S, Lassus A. Frequent association of chlamydial infection with Reiter's syndrome. Sex Transm Dis 1978;5:57-61.  Back to cited text no. 6
    
7.
Berlau J, Junker U, Groh A, Straube E. In situ hybridisation and direct fluorescence antibodies for the detection of Chlamydia trachomatis in synovial tissue from patients with reactive arthritis. J Clin Pathol 1998;51:803-6.  Back to cited text no. 7
    
8.
Carter JD, Hudson AP. The evolving story of Chlamydia-induced reactive arthritis. Curr Opin Rheumatol 2010;22:424-30.  Back to cited text no. 8
    
9.
Siala M, Mahfoudh N, Fourati H, Gdoura R, Younes M, Kammoun A, et al. MHC class I and class II genes in Tunisian patients with reactive and undifferentiated arthritis. Clin Exp Rheumatol 2009;27:208-13.  Back to cited text no. 9
    
10.
Rothe MJ, Kerdel FA. Reiter syndrome. Int J Dermatol 1991;30:173-80.  Back to cited text no. 10
    
11.
Hickling P, Wright V. Seronegative arthritides. In: Weatherall DJ, Ledingham JC, Warrell DA, editors. Oxford TextBook of Medicine. 1st ed. London: Oxford University Press; 1984. p. 16.19.  Back to cited text no. 11
    
12.
Ansell BM. Reactive arthritis/Reiter's syndrome in children. Clin Exp Rheumatol 1994;12:581-2.  Back to cited text no. 12
[PUBMED]    
13.
Lockie GN, Hunder GG. Reiter's syndrome in children. A case report and review. Arthritis Rheum 1971;14:767-72.  Back to cited text no. 13
[PUBMED]    
14.
Amor B. Reiter's syndrome. Diagnosis and clinical features. Rheum Dis Clin North Am 1998;24:677-95, vii.  Back to cited text no. 14
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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