Reiter syndrome (& conjunctivitis, arthritis, balanitis, urethritis)
The finding of 3+ leukocytes on
urinalysis suggests a diagnosis of
urethritis for the sexually
active adolescent boy described in the vignette. Urethritis usually is
categorized as gonococcal
or nongonococcal.
Pathogens causing nongonococcal urethritis include Chlamydia trachomatis,
Ureaplasma urealyticum, and Trichomonas vaginalis. Mycoplasma genitalium and
herpes simplex virus (HSV) also have been associated with urethral infections,
but lesions such as ulcers or blisters frequently accompany HSV infections.
In approximately 20% of cases of urethritis, the organism is unknown.
Signs and symptoms of
urethritis
include dysuria, urinary frequency, and urethral
discharge. Inflammation is confirmed by the presence of at least five
polymorphonuclear leukocytes (PMNs) per high-power field on a Gram stain of a
urethral smear or greater than 10 PMNs per
high-power field in the centrifuged sediment of a first void urine. More
specific tests may be undertaken to detect Neisseria gonorrhoeae and C
trachomatis, although the presence of gram-negative intracellular diplococci in
the urethral discharge supports the presumptive diagnosis of gonococcal
urethritis. The absence of gram-negative intracellular diplococci with at least
five PMNs per high-power field is indicative of nongonococcal urethritis. It
is important to remember that in at least 50% of gonococcal infections, there is
simultaneous infection with another sexually transmitted disease (STD) such as C
trachomatis.
The teenage boy described in the vignette displays some of the physical findings
typical of Reiter syndrome, which
is characterized by conjunctivitis,
arthritis, nonbacterial
urethritis or
cervicitis,
and mucocutaneous
lesions. The mucocutaneous lesions include
balanitis; painless
ulcerations on the tongue,
palate, pharynx, and buccal mucosa;
onycholysis; and skin vesicles or
papules that can mimic psoriasis (keratoderma blennorrhagicum).
Although the exact etiology is unknown, Reiter syndrome is believed to occur as
a result of an autoimmune response to an STD, most commonly C trachomatis
or an enteric bacterial infection. Individuals who have human leukocyte antigen
(HLA)
B-27 are at increased risk of developing Reiter syndrome.
Lymphadenitis, nephritis, pancreatitis, and pneumonitis are not present
in patients who have Reiter syndrome, but may be associated with other
arthritides.
References:
Lappa S, Moscicki AB. The pediatrician and the sexually active
adolescent: a primer for sexually transmitted diseases. Pediatr Clin
North Am. 1997;44:1405-1445
Neinstein LS. Reiter's syndrome. In: Adolescent Health Care: A
Practical Guide. 3rd ed. Baltimore, Md: Williams & Wilkins;
1996:606-609