Epileptic Seizures As a Neurological Complication of Reiter Disease

Epileptic Seizures As A Neurological Complication Of J Am Board Fam Pract: first published as 10.3122/jabfm.8.3.233 on 1 May 1995. Downloaded from Reiter Disease Bernd Wollschlaeger, MD Reiter syndrome is classically characterized as the back pain is an expression of acute sacroiliitis. clinical triad of arthritis, urethritis, and conjunc The arthritis can progress in an additive fashion tivitis. Similar disease entities have been previ to involve the joints of the upper extremities. In ously described by Stoll in 17761 as of postenteric flammation of the bony attachments of tendons origin and by Brodie in 18181 as a postvenereal or fasciae (enthesopathy) is a further characteris syndrome. The German hygienist Hans Reiter tic of Reiter syndrome. Involvement of the digits reported in 19162 a case in which a young lieu is occasionally accompanied by dactylitis (sausage tenant developed purulent urethritis, conjunc digits). The typical extra-articular features of tivitis, arthritis, and iritis after an episode of Reiter syndrome include mucocutaneous (oral bloody diarrhea, and he named the condition ulcerations, keratoderma blennorrhagicum), uro "spirochaetosis arthritica." The term Reiter syn genital (circinate balanitis, cervicitis, vaginitis), drome was formally described by Bauer and and ocular manifestations (conjunctivitis, uveitis, Engelman in 1942,3 and the reports of Paronen4 and keratitis). and Noer5 conclusively associated epidemic dys Rare complications of Reiter syndrome in entery with the onset of Reiter syndrome. clude cardiac conduction abnormalities and aor Young adults are most commonly affected at a tic regurgitation in up to 10 percent of all pa suggested male-female ratio of 5: 1 or 6: 1, and the tients, glomerulonephritis and renal amyloidosis, disease onset peaks during the third decade oflife. serositis, and pulmonary infiltrate. 1 In addition, The increased occurrence of the histocompat unusual neurologic and psychiatric conditions ibility antigen HLA-B27 in patients with Reiter have been described in individual cases. 1,7 syndrome has been known since 1973 6 and is The case presented here suggests the associa found in 75 to 80 percent of all patients. Reiter tion of acute postdysenteric Reiter syndrome and syndrome is preceded by specific gastrointestinal transitory epileptic seizures with electroencepha or genitourinary infections, and there is a distinct lographic changes. http://www.jabfm.org/ geographic variation of the triggering infectious organism. In the United States and United King Case Report dom the posturethritic-venereal origin is the A 19-year-old male soldier was referred to an more common form, with Chlamydia trachomatis army outpatient clinic for evaluation of a I-week or Mycoplasma species as the precipitators of ar history of bloody diarrhea. He had no history of thritis. In other parts of the world Shigella, Salmo gastrointestinal disorder or rheumatologic or on 6 October 2021 by guest. Protected copyright. nella, and Yersinia species have been implicated in neurologic disease. There was no known family the postdysenteric form of the disease. The acute history of mental or neurologic illness or arthri or subacute articular manifestations follow the tis. The patient denied any sexual activity or any triggering infectious episode with a latency pe history of sexually transmitted diseases. For the riod ranging from a few days to 3 weeks. The ar last 4 months he had been undergoing mandatory thropathy is typically a rheumatoid factor-nega basic training in the army and living with other tive asymmetric oligoarthritis involving knees, recruits in army tents. ankles, and feet, and during the acute phase low One week after the onset of diarrhea he de veloped conjunctivitis and oral lesions, and a few days later painful swelling of the right knee and Submitted, revised, 29 December 1994. ankle occurred. There was no urethral discharge, From the Medical Corps, Israel Defense Forces, Central but penile lesions appeared. The dysentery gradu Command, Zrifin, Israel. Address reprint requests to Bernd Wollschlaeger, MD, 7553 Bounty Avenue, N. Bay Village, FL ally subsided during the course of 10 days with 33141-4109. out any antibiotic treatment. Seizures and Reiter Disease 233 The symptoms of peripheral arthropathy per zures. Carbamazepine was prescribed, and no J Am Board Fam Pract: first published as 10.3122/jabfm.8.3.233 on 1 May 1995. Downloaded from sisted for 6 weeks and were accompanied by ten seizures occurred during the I-week hospitaliza derness of the right achilles tendon. tion or the next 16 months of monthly outpatient Two weeks after the onset of diarrhea he com follow-up, even after the discontinuance of the plained of drowsiness and headache that were fol anticonvulsive treatment. His peripheral arthrop lowed by two witnessed episodes of generalized athy was initially treated with ibuprofen, which seizures. He was subsequently admitted to an was subsequently replaced with naproxen for army inpatient facility for further work-up and marked clinical improvement. treatment. A complete remission of Reiter syndrome was On admission a mild bilateral conjunctivitis recorded within 4 months. An EEG was per and erythematous oral mucosal lesions were formed at 10 and 16 months after the first seizure noted. The right knee was swollen, tender, and episode and showed no paroxysmal activity or warm, and the achilles tendon was painful on pal abnormality. pation. Findings of his cardiovascular examina tion were normal, and no heart murmurs were Discussion noted. On the shaft of the penis, distinct large, The clinical diagnosis of Reiter syndrome is often shallow, painless ulcerations were found. No fur difficult because its clinical features are shared by ther cutaneous lesions on the trunk or extremities arthritides associated with enteric infections, in were detected. The neurological and mental flammatory bowel disease, psoriasis, and ankylos status examinations were unremarkable, and no ing spondylitis and because the clinical triad of deficits were found. arthritis, nongonococcal urethritis, and conjunc Laboratory data showed a white cell count of tivitis is observed in only about 30 percent of all 12,000/mm3 with 64 percent segmented neutro patients with Reiter syndrome. The American phils, 25 percent band cells, 8 percent lympho College of Rheumatology (ACR) has therefore cytes, and 3 percent monocytes. Hemoglobin revised the requirements for the diagnosis of Re was 12.4 g/dL and platelets were 216,000/mm3• iter syndromeS to peripheral arthritis of more The screening tests for sexually transmitted than 1 month's duration, occurring in association diseases, including human immunodeficiency with urethritis or cervicitis. These criteria have virus, syphilis, chlamydia, and gonorrhea, were not been universally accepted, because of the sub negative. Rheumatoid factor, serum antinuclear stantial number of patients with postenteric or antibody titer, and anti streptococcal antibody posturethritic arthritides without extra-articular http://www.jabfm.org/ titer were negative. Serum C3 and C4 concentra manifestations, who are often HLA-B27 positive tions were normal, and human leukocyte antigen but failed to meet ACR criteria. In this context (HLA)-B27 was found. A stool culture taken dur the broader concept of reactive arthritides has ing the dysenteric episode of the disease was re been introduced9 to define all clinical entities ported to disclose Shigella flexneri. Findings from in which an inflammatory arthropathy arises at a the urinalysis were normal. An arthrocentesis of site remote from the primary infection. This defi the right knee was performed on admission, and nition is restricted to conditions frequently asso on 6 October 2021 by guest. Protected copyright. 20 mL of turbid fluid was aspirated. The liquid was ciated with HLA-B27 and does not include ar Gram stain negative, and no microorganisms were thritides associated with ulcerative colitis or cultured. The white cell count was 3500/mm3, regional enteritis, rheumatic fever, Lyme arthri consisting predominantly of polymorphonuclear tis, Whipple disease, and postviral arthritides. cells. The arthritis of Reiter syndrome is considered as The results of radiographic studies of the knees one clinical manifestation of reactive arthritis but and ankles were reported as normal. A computed is still distinguishable by its typical extra-articular tomographic brain scan with and without contrast features. showed no pathomorphological changes, and the The postinfectious onset of acute arthritis in cerebrospinal fluid analysis was unremarkable. individuals with the same genetic predisposition The electroencephalogram (EEG) showed two implicated a specific bacteria-host interaction in bifrontal epileptogenic foci, and the convulsions susceptible hosts. Four possible arthritogenic were diagnosed as secondary, tonic-clonic sei- mechanisms have been suggested 10: (1) altered 234 JABFP May-June1995 Vol. 8 No.3 bowel anatomy, (2) altered bowel permeability, DNA probe techniques and, especially in case of J Am Board Fam Pract: first published as 10.3122/jabfm.8.3.233 on 1 May 1995. Downloaded from (3) toxin-mediated synovitis, and (4) autoim- concurrent Chlamydia trachomatis infection, the munity caused by molecular mimicry between exclusion of extra-articular manifestations. HLA-B27 and various enterobacterial cell wall Rheumatic fever and other forms of oligoar- fragments. thritis can be recognized

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