AUTHOR INFORMATION

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Authored by Thomas Scoggins, MD, Staff Physician, Department of Emergency Medicine, Blount Memorial Hospital

Coauthored by Igor Boyarsky, DO, Director of Triage, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center, University of California at Los Angeles

Thomas Scoggins, MD, is a member of the following medical societies: American College of Emergency Physicians, and Flying Physicians Association

Edited by Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Robert E O'Connor, MD, MPH, Director of Education and Research, Department of Emergency Medicine, Christiana Care Health System; Professor of Emergency Medicine, Thomas Jefferson University

Author's Email:	Thomas Scoggins, MD
Editor's Email:	Dana A Stearns, MD

eMedicine Journal, February 15 2007, VOLUME 8, Number 2

INTRODUCTION

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Background: In 1916, Hans Reiter described the classic triad of arthritis, nongonococcal urethritis, and conjunctivitis.

What used to be known as Reiter syndrome is now referred to as reactive arthritis (ReA). This change has occurred in part because of Hans Reiter's affiliation and activities with the Nazis during WWII.

Reactive arthritis refers to acute nonpurulent arthritis complicating an infection elsewhere in the body.

Reactive arthritis falls under the rheumatic disease category of seronegative spondyloarthropathies, which includes ankylosing spondylitis, psoriatic arthritis, the arthropathy of associated inflammatory bowel disease, juvenile-onset ankylosing spondylitis, and juvenile chronic arthritis.

Pathophysiology: Reactive arthritis is triggered following enteric or urogenital infections. Reactive arthritis is associated with human leukocyte antigen (HLA)–B27, although HLA-B27 is not always present in an affected individual, particularly in the presence of HIV.

Bacteria associated with reactive arthritis are generally enteric or venereal and include the following: Shigella flexneri, Salmonella typhimurium, Salmonella enteritidis, Streptococcus viridans, Mycoplasma pneumonia, Cyclospora, Chlamydia trachomatis, Yersinia enterocolitica, and Yersinia pseudotuberculosis. Bacteria or their components (RNA, DNA) have been identified in synovial fluid cells, synovial biopsy specimens, and circulatory monocytes.

Frequency:

• In the US: Frequency is estimated at 3.5 cases per 100,000. (Because of uncertainty of diagnosis and variations in definitions, epidemiologic features are difficult to calculate.)

  An estimated 1-3% of all patients with a nonspecific urethritis develop an episode of arthritis. Prevalence of inapparent chlamydial infections may make incidence even higher.

  After outbreak of S enteritidis, 29% had reactive arthritis.

• Internationally: In Norway, an annual incidence of chlamydia-induced reactive arthritis of 4.6 cases per 100,000 population and an incidence of enteric bacteria–induced reactive arthritis of 5 cases per 100,000 population were reported in 1988-1990.

  Occurrence appears to be related to the prevalence of HLA-B27 in a population and the rate of urethritis/cervicitis and infectious diarrhea.

Mortality/Morbidity: Most patients have severe symptoms lasting weeks to 6 months. Approximately 15-50% have recurrent bouts of arthritis. Chronic arthritis or sacroiliitis occurs in 15-30% of cases.

Race: Reactive arthritis is reported most frequently in whites. When reactive arthritis occurs in black persons, it is frequently B27-negative.

Occurrence appears to be related to HLA-B27 prevalence in the population.

Sex: The male-to-female postvenereal ratio is traditionally 5-10:1. The postenteric ratio is 1:1.

Age: The peak onset is in persons aged 15-35 years; reactive arthritis is rarely seen in children. Cases in children are almost entirely postenteric.

CLINICAL

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History:

• Symptoms generally appear within 1-3 weeks but can range from 4-35 days from onset of inciting episode of urethritis/cervicitis or diarrhea.

• Constitutional symptoms (usually mild)

• Fever (usually low grade)

• Malaise

• Musculoskeletal

• Myalgias (early)

• Asymmetric joint stiffness, primarily involving the knees, ankles, and feet (wrist may be early target)

• Low back pain with radiation to the buttocks or thighs

• Symptoms worse with rest or inactivity

• Urethritis associated with reactive arthritis may be postdysenteric or postvenereal, with frequency, dysuria, urgency, and urethral discharge. It may be mild or inapparent.

• Ophthalmologic

• Erythema

• Burning

• Tearing

• Photophobia

• Pain

• Decreased vision (rare)

• Patients may have mild recurrent abdominal complaints after precipitating episode of diarrhea.

Physical:

• A scoring system for diagnostic points in Reiterlike spondyloarthropathies exists. Two or more of the following points establishes diagnosis (one of which must pertain to the musculoskeletal system):

• Asymmetric oligoarthritis, predominantly of the lower extremity

• Sausage-shaped finger (dactylitis), toe or heel pain, or other enthesitis

• Cervicitis or acute diarrhea within 1 month of the arthritis

• Conjunctivitis or iritis

• Genital ulceration or urethritis

• Musculoskeletal

• Oligoarthritis affecting mainly lower extremities with low-grade inflammation.

• Knee may become markedly edematous.

• Distinctive arthropathy of reactive arthritis includes local enthesopathy, which is inflammation at the tendinous insertion into bone, rather than synovium (common in insertions into calcaneus, talar, and subtalar joints).

• Sausage finger or toe is caused by uniform inflammation.

• Urogenital

• Meatal edema and erythema and clear mucoid discharge

• Prostatic tenderness (up to 80%) and vulvovaginitis

• Dermatologic

• Balanitis circinata - Shallow painless ulcers at meatus and glans penis; moist on uncircumcised patients; may harden and crust on circumcised patients, causing pain and scarring

• Keratoderma blennorrhagica - Hyperkeratotic skin, which begins as clear vesicles on erythematous bases and progresses to macules, papules, and nodules (found on soles of feet, toes, palms, scrotum, trunk, and scalp)

• Nail thickening and ridging and superficial oral ulcers

• Ophthalmologic signs - Conjunctivitis (most common), with mucopurulent discharge, chemosis, lid edema, and iritis

• Occurs in the majority of reactive arthritis because of Shigella infection. Occurs in approximately 35% of postvenereal cases.

• Cardiac signs - Aortic regurgitation caused by inflammation of aortic wall and valve

Causes:

• Nongonococcal venereal disease (most often Chlamydia) and infectious diarrhea (Shigella, Salmonella, Yersinia) precipitate reactive arthritis.

• HLA-B27 contributes to the pathogenesis of the disease.

DIFFERENTIALS

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Arthritis, Rheumatoid
Conjunctivitis
Gonorrhea
Gout and Pseudogout
Inflammatory Bowel Disease
Iritis and Uveitis
Rheumatic Fever
Sarcoidosis
Syphilis
Tendonitis
Tenosynovitis
Tick-Borne Diseases, Lyme

Other Problems to be Considered:

Septic arthritis
Other reactive arthritides and spondyloarthropathies

WORKUP

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Lab Studies:

• Documentation of specific bacterial infection

• Cervical or urethral swab may be performed. Look for Chlamydia in every case of reactive arthritis, preferably by direct florescent antibody, enzyme immunoassay, or DNA probe for ribosomal RNA. Culture techniques are unreliable; however, serology is useful in some cases.

• Obtain stool cultures even when bowel symptoms are inapparent or mild.

• Arthrocentesis and fluid analysis often are needed to rule out an infectious process, especially in monoarticular arthritis with constitutional symptoms.

• Acute cases

• Neutrophilic leukocytosis

• Elevated C-reactive protein or C3 and C4 (nonspecific)

• Erythrocyte sedimentation rate (ESR) - Usually elevated during acute phase of disease

• Chronic cases - Mild normocytic anemia

Imaging Studies:

• Plain radiography - May show no abnormalities early in the disease

• Asymmetric, oligoarticular, and more common in the lower extremities pattern of joint involvement

• Juxta-articular osteoporosis in acute episodes of arthritis - Erosions have indistinct margins and are surrounded by periosteal new bone.

• Spinal pattern - Unilateral or bilateral sacroiliitis, asymmetric paravertebral comma-shaped ossification involving the lower thoracic and upper lumbar vertebrae

Other Tests:

• Test results for rheumatoid factor and antinuclear antibody are negative. (Test results usually are not available during the ED evaluation.)

• HLA-B27 may be useful when extra-articular features are not present. The presence of antigen correlates with axial disease, carditis, and uveitis. (Test results usually are not available during the ED evaluation.)

• Consider referral for HIV testing in patients presenting with history, symptoms, or findings suggesting increased risk for the disease.

Procedures:

• Synovial fluid: Macrophages with vacuoles filled with nuclear debris and whole leukocytes may be found but are nonspecific.

• Synovial biopsy: Nonspecific inflammatory changes; infectious antigens have been found in synovium; immunohistochemistry, polymerase chain reaction, and molecular hybridization may become more useful. (Procedure usually is not performed during the ED evaluation.)

TREATMENT

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Emergency Department Care:

• Treatment based on symptoms

• Physical therapy during recovery phase

Consultations:

• Consult a rheumatologist to discuss appropriate additional tests and medications for symptomatic relief or microbiologic cure and to ensure follow-up treatment.

• Consider an infectious disease (ID) consultation for consideration of empiric antibiotic therapy as well as for patients with coincident manifestations of coincident AIDS-defining illnesses.

MEDICATION

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Mainstays of therapy for joint symptoms are nonsteroidal anti-inflammatory drugs (NSAIDs).

Sulfasalazine may be used for patients who do not experience relief with NSAIDs or who have contraindications to NSAIDs.

No published data are available on the effectiveness of selective COX-2 inhibitors; however, COX-2 inhibitors may be tried in patients who do not tolerate NSAIDs.

Extra-articular manifestations are treated individually. Second-line therapies for reactive arthritis, such as systemic or intra-articular steroids, are left to the discretion of the consulting rheumatologist. Antibiotic treatment is indicated for cervicitis or urethritis but not generally for postdysenteric cases.

Cytotoxic therapy, such as methotrexate or azathioprine, is reserved for severe cases and should not be started in the ED. HIV testing must be completed first.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs) -- Although most NSAIDs are used primarily for their anti-inflammatory effects, they are effective analgesics and are useful for relief of mild to moderate pain. To relieve joint symptomatology, a month's treatment at maximum dose is needed before full effectiveness can be evaluated.

Drug Name	Indomethacin (Indocin) -- DOC; however, other nonsteroidal drugs often are effective. Rapidly absorbed and metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.
Adult Dose	25 mg PO qid; increase to 50 mg qid prn
Pediatric Dose	1-2 mg/kg/d PO, divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Contraindications	Documented hypersensitivity (because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients whom aspirin, iodides, or other NSAIDs induce hypersensitivity); GI bleed; renal insufficiency
Interactions	Probenecid may increase concentrations and possibly toxicity of NSAIDs; indomethacin may decrease effect of beta-blockers, hydralazine, and captopril; also may decrease diuretic effects of furosemide and thiazides; may prolong PT when coadministered with anticoagulants; monitor PT closely and instruct patients to watch for signs and symptoms of bleeding; indomethacin may increase serum lithium levels and risks of methotrexate toxicity, such as stomatitis, bone marrow suppression, and nephrotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; low WBC counts occur rarely, are transient, and usually return to normal while therapy continues; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuing the drug

Drug Category: Topical corticosteroids -- These agents are used for dermatologic manifestations, such as keratoderma blennorrhagica and circinate balanitis.

Drug Name	Hydrocortisone valerate (Cortaid, Dermacort, Westcort) -- Topical corticosteroids are adrenocorticosteroid derivatives suitable for application to skin or external mucous membranes and have mineralocorticoid and glucocorticoid effects, resulting in a nonspecific anti-inflammatory activity.
Adult Dose	Apply sparingly to affected areas bid/qid
Pediatric Dose	Apply as in adults
Contraindications	Documented hypersensitivity; avoid as monotherapy in primary bacterial infections such as cellulitis, angular cheilitis, impetigo, erysipelas, erythrasma (clobetasol), paronychia, or treatment of rosacea, perioral dermatitis, or acne; do not use on face, groin, or axilla
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Systemic absorption of topical corticosteroids may cause reversible HPA-axis suppression, Cushing syndrome, hyperglycemia, and glycosuria; conditions that augment systemic absorption include application of potent steroids, prolonged use, use over large surface areas, and addition of occlusive dressings

Drug Category: Antibiotics -- Empiric antimicrobial should cover all likely pathogens in the context of the clinical setting.

Drug Name	Erythromycin ophthalmic ointment (EryPed) -- Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Adult Dose	Apply 1-cm ribbon under lid; not to exceed q4h
Pediatric Dose	Apply as in adults
Contraindications	Documented hypersensitivity; epithelial herpes simplex keratitis, fungal and mycobacterial infections of the eye, and patients using steroid combinations after uncomplicated removal of a corneal foreign body
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Do not use topical antibiotics in ocular infections that are likely to become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms; such overgrowth may lead to a secondary infection; take appropriate measures if superinfection occurs

Drug Name	Doxycycline (Doryx, Vibramycin, Vibra-Tabs) -- Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.
Adult Dose	100 mg PO bid for 3 mo
Pediatric Dose	<8 years: Not recommended >8 years: 2-5 mg/kg/d PO once or divided bid; not to exceed 200 mg/d
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate may decrease doxycycline bioavailability; tetracyclines may increase the hypoprothrombinemic effects of anticoagulants; prothrombin activity should be monitored in patients taking both of these types of medications concurrently; coadministration of tetracyclines may decrease pharmacologic effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Avoid prolonged exposure to sunlight or tanning equipment because a photosensitivity reaction may occur; use lower than usual doses in patients with renal impairment; if therapy is prolonged, drug serum level determinations may be advisable; use of tetracyclines during tooth development (last one half of pregnancy through 8 y) may cause permanent discoloration of teeth; never administer outdated tetracyclines; degradation products of tetracyclines are highly nephrotoxic and have, on occasion, produced a Fanconilike syndrome

Drug Name	Ciprofloxacin (Cipro) -- DOC for improvement in clinical parameters, except joint involvement, in enterogenic reactive arthritis. Ciprofloxacin is a bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA-gyrase in susceptible organisms.
Adult Dose	250-500 mg PO bid
Pediatric Dose	<18 years: Not recommended >18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may interfere with GI absorption of fluoroquinolones, resulting in decreased serum levels (administer antacids 2-4 h before or after taking fluoroquinolones) Cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin may reduce therapeutic effects of phenytoin; probenecid may reduce ciprofloxacin renal clearance by 50% and increase serum concentration by 50%; ciprofloxacin may increase theophylline and caffeine concentrations and prolong their duration of action; ciprofloxacin may increase nephrotoxic effect of cyclosporine; digoxin serum levels may be increased when used concurrently with ciprofloxacin; digoxin levels should be monitored; ciprofloxacin may increase effects of anticoagulants; prothrombin time should be monitored
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions, including renal, hepatic, and hematopoietic; patients with renal function impairment may require a dose adjustment; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms; such overgrowth may lead to a secondary infection; take appropriate measures if superinfection occurs

Drug Category: Anti-inflammatory agents -- These agents are used when NSAIDs do not control arthritis and for inflammatory lesions of intestinal mucosa.

Drug Name	Sulfasalazine (Azulfidine) -- Useful in management of ulcerative colitis and acts locally in colon to decrease inflammatory response and systemically inhibits prostaglandin synthesis.
Adult Dose	1000 mg enteric-coated PO bid
Pediatric Dose	<2 years: Not established >2 years: 40-60 mg/kg/d PO in 3-6 divided doses; follow with a maintenance dose of 20-30 mg/kg/d divided qid
Contraindications	Documented hypersensitivity; GI or GU obstruction
Interactions	Sulfasalazine decreases effect of iron, digoxin, and folic acid, and, conversely, increases effect of oral anticoagulants, oral hypoglycemic agents, and methotrexate
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Use caution in patients with renal or hepatic impairment, blood dyscrasias, or urinary obstruction

FOLLOW-UP

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Further Inpatient Care:

• Inpatient care may be considered with patients who are unable to tolerate PO administration of medications, who are unable to ambulate because of significant joint involvement, who have intractable pain, or who have concomitant disease requiring admission.

In/Out Patient Meds:

• Nonsteroidal anti-inflammatory agents may control painful arthralgias. Patients must be instructed on compliance and possible need for adjustment to dose or to another agent.

• Empiric antibiotics may be considered after appropriate cultures have been taken. Treat urethritis or cervicitis but generally not diarrhea.

Complications:

• Recurrent arthritis (15-50%)

• Chronic arthritis or sacroiliitis (15-30%)

• Ankylosing spondylitis (30-50% of HLA-B27–positive patients)

• Urethral stricture

• Cataracts

• Aortic root necrosis

Prognosis:

• Signs and symptoms usually remit within 6 months. However, a significant percentage of patients have recurrent episodes of arthritis (15-50%), and some patients develop chronic arthritis (15-30%).

• Postdysenteric cases are associated with a better prognosis than postchlamydial cases.

• Poor prognosis is associated with hip arthritis, sedimentation rate higher than 30, poor efficacy of NSAIDs, oligoarthritis, onset when patients are younger than 16 years, and sausage finger or toe.

Patient Education:

• For excellent patient education resources, visit eMedicine's Arthritis Center, Sexually Transmitted Diseases Center, and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Knee Pain and Chlamydia.

MISCELLANEOUS

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Medical/Legal Pitfalls:

• Septic arthritis must be ruled out if suspected.

• HIV should be considered, particularly before institution of immunosuppressive therapy.

Special Concerns:

• Some pediatric cases involving ocular chlamydial infection have been reported.

• Reactive arthritis was the first rheumatologic disease noted in association with HIV.

TEST QUESTIONS

Section 10 of 11

CME Question 1: A 20-year-old man presents to the ED with a history of arthralgias, tearing eyes, and a clear urethral discharge. Which of the following statements is correct?

A: Chlamydia can be cultured from joint fluid.
B: Characteristic arthropathy, enthesopathy, refers to synovial inflammation.
C: Urethritis associated with reactive arthritis may be postdysenteric or postvenereal.
D: Most patients develop chronic arthritis.
E: Conjunctivitis is caused by a chlamydial infection.

The correct answer is C: Infectious organisms cannot be cultured from a joint. Chlamydial conjunctivitis may be the inciting infection for reactive arthritis, but conjunctivitis usually is not secondary to the organism. Although recurrences are frequent, development of reactive arthritis occurs in only 15-30% of patients. Synovium is not involved; rather, an inflammatory process occurs at the tendinous insertion in the bone. Venereal and dysenteric disease can precede reactive arthritis.

CME Question 2: An ED physician diagnoses reactive arthritis in a patient with HIV. Which of the following statements regarding treatment is correct?

A: Antibiotics may decrease duration of symptoms.
B: Oral steroids are indicated for joint symptoms.
C: Ciprofloxacin has been shown to improve all symptoms of enterogenic reactive arthritis.
D: Erythromycin ointment is useful for treatment of balanitis circinata and keratoderma blenorrhagica.
E: Cytotoxic agents are useful in patients with HIV.

The correct answer is A: Identification of infectious etiology, especially from the genitourinary tract, for reactive arthritis is important. A prolonged course may decrease recurrences. Nonsteroidal anti-inflammatory agents are the mainstay of therapy for joint symptoms. Ciprofloxacin is useful in all but the joint symptoms in enterogenic reactive arthritis. Skin manifestations should be treated with low-dose topical steroids. Cytotoxic therapy has no role in ED management and would be contraindicated in the patient with HIV.

Pearl Question 1 (T/F): A patient with reactive arthritis is likely to have had nongonococcal venereal disease or dysentery.

The correct answer is True: Nongonococcal venereal disease and infectious diarrhea precipitate reactive arthritis. Human leukocyte antigen (HLA)–B27 contributes to pathogenesis of disease.

Pearl Question 2 (T/F): Asymmetric oligoarthritis, genital ulceration or urethritis, and cervicitis within 1 month are the clinical points needed to make the diagnosis of Reiterlike spondyloarthropathy.

The correct answer is False: Asymmetric oligoarthritis, sausage-shaped fingers or toes, conjunctivitis or iritis, genital ulceration or urethritis, cervicitis, or acute diarrhea within 1 month are clinical points needed to make the diagnosis of Reiterlike spondyloarthropathy.

Pearl Question 3 (T/F): Canaliculitis and corneal ulcerations are eye manifestations of reactive arthritis.

The correct answer is False: Conjunctivitis and iritis are eye manifestations of reactive arthritis.

Pearl Question 4 (T/F): Many agents are likely to be cultured from joint fluid aspirated from a knee in a patient with suspected reactive arthritis.

The correct answer is False: No agents can be cultured from joint fluid aspirated from a knee in a patient with suspected reactive arthritis. Infectious antigens have been detected in synovium.

BIBLIOGRAPHY

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• Cuttica RJ, Scheines EJ, Garay SM, et al: Juvenile onset Reiter's syndrome. A retrospective study of 26 patients. Clin Exp Rheumatol 1992 May-Jun; 10(3): 285-8[Medline].
• Dworkin MS, Shoemaker PC, Goldoft MJ, Kobayashi JM: Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis. Clin Infect Dis 2001 Oct 1; 33(7): 1010-4[Medline].
• Fan PT, Yu DTY: Reiters syndrome. In: Ruddy S, Harris ED Jr, Sledge CB, eds. Kelley's Textbook of Rheumatology. 6th ed. Philadelphia, PA: WB Saunders; 2001:1039-1067.
• Hoogland YT, Alexander EP, Patterson RH, Nashel DJ: Coronary artery stenosis in Reiter's syndrome: a complication of aortitis. J Rheumatol 1994 Apr; 21(4): 757-9[Medline].
• Hughes RA, Keat AC: Reiter's syndrome and reactive arthritis: a current view. Semin Arthritis Rheum 1994 Dec; 24(3): 190-210[Medline].
• Kasper DL, ed: Reactive arthritis. In: Harrison's Online. Part 13. Section 2. Chap 305. McGraw Hill; 2004.
• Kataria RK, Brent LH: Spondyloarthropathies. Am Fam Physician 2004 Jun 15; 69(12): 2853-60[Medline].
• Lu DW, Katz KA: Declining use of the eponym "Reiter's syndrome" in the medical literature, 1998-2003. J Am Acad Dermatol 2005 Oct; 53(4): 720-3[Medline].
• Natarajan UR, Tan TL, Lau R: Reiter's disease following Mycoplasma pneumoniae infection. Int J STD AIDS 2001 May; 12(5): 349-50[Medline].
• Petersel DL, Sigal LH: Reactive arthritis. Infect Dis Clin North Am 2005 Dec; 19(4): 863-83[Medline].
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