Case Studies

 Case 10.5 Reiter's disease

A 19-year-old man presented with acute swelling of his right knee and left ankle and extremely painful heels. On questioning, he admitted to a penile discharge and dysuria for 4 days. On examination, he had bilateral Achilles tendonitis and his right knee and left ankle were red, hot and tender. He had aphthous-like mouth ulcers and ulcers around the glans penis. There were no skin lesions and, in particular, no evidence of keratoderma blenorrhagica or subungual pustules.

On investigation, he was found to have a raised erythrocyte sedimentation rate (60mm/h) but a normal haemoglobin and white-cell count. A latex test for rheumatoid factor was negative. X-rays of the joints were normal. Joint fluid aspirated from the right knee showed a polymorphonuclear leucocytosis but no organisms. Gonococci were not cultured from the urethral pus or from the joint fluid but chlamydial DNA was detected by the polymerase chain reaction (PCR). Tissue typing showed him to be HLA-B27 positive. A diagnosis of Reiter's disease was made. He was given diclofenac for symptomatic relief of the arthritis and tendonitis. Four days later, he developed bilateral conjunctivitis and some photophobia. However, 6 weeks later he had fully recovered and did not relapse. His chlamydial urethritis was treated with doxycycline and his partner was screened for sexually-transmitted infection.