Acute onset of rash and oligoarthritis

Diagnosis: Reiter’s syndrome

This young man had Reiter’s syndrome (RS), a form of reactive arthritis that comprises a small subset of cases within the larger family of rheumatoid factor- seronegative spondyloarthritides—conditions noted primarily for inflammation of the axial skeleton.¹

Of historical interest is the fact that this diagnosis shares its name with the man who first described it, Hans Reiter, a Nazi physician who tested unapproved vaccines and performed experimental procedures on victims in concentration camps. The infamous legacy of Reiter’s name has led to the proposal that the syndrome be referred to by another, more descriptive name.² For the sake of simplicity, we’ll refer to the syndrome by the abbreviation RS.

Look for elements of the classic triad

RS is notoriously inconsistent in its presentation. Only a third of patients will develop the “classic triad”—that is: peripheral arthritis lasting at least 1 month, urethritis (or cervicitis), and conjunctivitis. Nearly half of patients will have only a single element of the triad.³

Patients with RS will complain of generalized malaise and fever and will often describe dysuria with concomitant urethral discharge. If conjunctivitis is present, the patient will report reddened, sensitive eyes. Pain will often originate from axial bones, lower extremities (in an oligoarticular asymmetrical pattern), swollen digits, and the heels (from enthesopathy).

Skin manifestations are often very noticeable and include psoriasiform lesions ( FIGURE 3 ) on the palms, soles, and glans penis. Specifically, you’ll see keratoderma blenorrhagicum ( FIGURE 4 ), brown and red macules/papules with pustular or hyperkeratotic features, on the palmar and plantar surfaces. Erythematous and scaly lesions resembling psoriatic plaques often appear elsewhere on the body. On the uncircumcised penis, these shallow ulcerations have a micropustular, serpiginous border and are referred to as balanitis circinata. However, they may also appear psoriasiform in nature on circumcised men, as was the case with our patient.

Coincident findings include onycholysis and subungual hyperkeratosis, lesions mimicking migratory glossitis, and anterior uveitis.

FIGURE 3
Psoriasiform plaque

FIGURE 4
Keratoderma blenorrhagicum