Læknablaðið : fylgirit - 01.10.1980, Blaðsíða 11

5
antigen. Those without this antigen are
generally mild acute cases.
We suggest that in many patients with
gonorrhoea who are treated with penicillin
early and in adequate dosage, the gono-
cocci may survive in the accessory glands
or the oviducts and thereby are able to
induce an aseptic postinfectious or so called
“reactive” arthritis in susceptible patients,
i.e. in HLA-B27 positive individuals; in
fact, 90 per cent of our uro-arthritis patients
carry this antigen.
Acute uro-athritis
Urethritis, conjunctivitis, and polyarthri-
tis consitute the Reiter triad. In more
cases there is often also a fourth compo-
nent, skin and mucosal lesions. It is im-
portant to reali'ze that the conjunctivitis is
absent, in 50 per cent of the cases, so-called
incomplete triad or abortive form of Rei-
ter‘s sjmdrome.
A still greater diagnosic puzzle arise
when the urethritis is also asymptomatic.
This more often occurs in females than in
males.
The pattern of articular mantifestations
is of the postinfectious type: Big joints
mostly in the lower extremities, extra-
articular symptoms as tendinitis, tendoperi-
osteitis; sacro-iliac arthritis. The skin and
mucosal lesions are also characteristic.
Keratodermia blennorrhagica and nail
changes often appear simultaneously. The
nail lesions may be severe but are re-
versible. Enanthema of the mouth and
balanitis are also seen.
Myocarditis is observed in 10 to 15 per
cent, with as a rule only ECG changes.
Laboratory findings
There is a high ESR and abundant leuco-
cytes are often found in the urinary sedi-
ment. Culture of urethral smear may show
Neisseria or Chlamydia. Direct microscopic
examination of smear may show gram-
negative gonococci or inclusion bodies in a
Giemsa prepared slide. The latter are
typical of Chlamydia infection. In gono-
coccal infection the complement fixation
test (GCFT) is reported to be positive in
50 to 80 per cent. In clinical routine Chla-
mydia antibodies may at present be demon-
strated only with the aid of cross-reacting
psittacosis-antigen which is an ihsensitive
complement fixation test. It has recently
been shown that rod shaped inclusions may
be seen electronmicroscopically in synovial
tissue and that chlamydia organisms may
be recovered by culture of such specimens.
Treatment
Antibiotics are giVen according to the
outcome of bacteriologic analysis. In go-
norrhoea penicillin, pivampicillin or amox-
illin. Tetracyclin (0.25g x 4 daily) is given
in cases of non-specific urethritis and in
articular complications.
The Reiter's syndrome induced by Chla-
mydia should be regarded as an infectious
arthritis and aceordingly be treated as
such. Tetracyclin seems to be the drug of
choice. Whether the infection is caused by
Neisseria or Chlamidiae the patient's
sexual partner should be examined and
treated, thus preventing the so-called „ping-
pong disease“.
Systemic steroias are rarely needed. In
the most severe cases, especially those with
pronounced skin lesions, a cure may by
achieved with folic acid antagonist Methot-
rexate (R) which is given in a dose of 25
mg intramuscularly once a week for about
6 weeks.
The prognosis of acute uro-arthritis is
generally speaking good. The disease has
in most cases a selflimiting course — but
relapses are frequent (and it is sometimes
difficult to decide whether these are due
to exogenous or endogenous reinfection).
There is no proof that antibiotic treatment
influences the course of the disease with
respect to severity or duration. It seems,
however, logical to prevent further anti-
genic stimulation from possible gonococci
in the prostate, which may be a reservoir
of these bacteria. Personally I give ampi-
cillin to patients in whom there is bacterio-
logic and immunologic evidence that the
disease is induced by Neisseria gonorr-
hoeae. The hope is to prevent evolution to
chronic uro-arthritis or even pondyliti's.
Chronic uro-arthritis
Regarding the chronic arthritis in con-
nection with urogenital infection I will