A 23 year old female who had delivered a baby 4 months earlier was admitted with a 3 months history of pain in shoulders, back, knees and ankles. The pain was so severe that she had been unable to walk for the same period despite several analgesic treatment in neighbouring clinics. Clinical exam identified severe markedly tender left shoulder, right sacro iliac joint, left hip, left knee and achilles tendon. There was a hyperkeratotic pustular rash, that we later identified as keratoderma blenorrhagica on the soles of her feet. See Picture.

Other systems were normal including the eyes-no conjunctivitis or uveitis was noted.

Laboratory tests for known common causes of polyarthritis were done using reagents manufactured by Human Diagnostics, Wiesbaden, Germany and the results were as follows:

Brucella agglutination tests:	negative.
Anti-streptolysin- O titre (ASOT):	positive (600IU/ml)
RPR and hexagon syphili:	negative
Anti-doublestranded DNA test::	negative
Rheumatoid factors:	negative

 

 

 

 

Because of the nature of presentation of this patient, her age and the laboratory results a presumptive diagnosis of rheumatic fever was made and she was given high dose amoxycillin and aspirin for ten days but there was no improvement. Later the aspirin withdrawn and replaced with high dose prednisolone 30mg b.d but still there was only negligible relief one week later. Consequently a search for another diagnosis was begun. A cervical swab was carried out and it identified gram positiverods and the test for chlamydia trachomatis(Hexagon Chlamydia)was positive.

Therefore our patient was treated 1 gram of Azithromycin and so was her partner. Doxycycline could not be used in this case as she was still breastfeeding. Two weeks later, the young woman was able to walk out of this hospital back to her home!

DISCUSSION

Reiter’s syndrome is a commoner cause of arthritis probably more than previously thought. In many cases it does not present with the complete triad of conjunctivitis, urethritis and oligoarthritis, a presentation which has been termed by some scientists as the “Incomplete Reiter’s Syndrome”. This fact makes it necessary to consider it routinely in all sexually active people with arthritis. Our patient had asymptomatic chlamydial cervicitis. Reiter’s syndrome frequently follows non specific urethritis/ cervicitis or diarrhea due to salmonella ,shigella, yersinia or Campylobacter jejuni. In the chronic forms it can even mimic rheumatoid arthritis. The presence of a positive ASOT in this case was more likely to have been incidental that causal since there was no clinical response to the standard treatment of rheumatic fever.