REITER’S SYNDROME AND PSORIATIC ARTHRITIS

REITER'S SYNDROME AND PSORIATIC ARTHRITISI
* From the Department of Diagnostic Radiology, The National Institutes of Health, Bethesda, Maryland.
DECEMBER, 1967
THEIR ROENTGEN SPECTRA AND SOME INTERESTING SIMILARITIES
By CARL C. PETERSON, JR., M.D., and MARTIN L. SILBIGER, M.D. BETHESDA, MARYLAND
R EITER’S syndrome and psoriasis may both be manifest in joint pathology.
Ordinarily the diagnosis of these two dis- eases is rather straightforward, clinically and roentgenographicatly. However,in some cases, the clinical findings, the roentgen- ographic findings, or both may coalesce,
causing diagnostic, if not therapeutic, con- fusion. The coexistence of these two dis-
eases, or the evolution ofone into the other, has been mentioned previously by Wein- berger et al.’7 in 1962 and Wright and Reed2’ in 1964. The latter reported 12 cases
in which the two diseases were intimately associated.
In this paper, the roentgen manifesta-
tions of each of these diseases will be set forth and the interesting area of overlap be- tween the two will be considered.
All roentgenograms from 32 cases of
Reiter’s syndrome and 39 cases of psoriatic
arthritis seen at the National Institutes of Health between 1953 and 1962 were studied.
REITER’S SYNDROME
Reiter’s syndrome was named after Hans
Reiter,’4 who reported a case of urethritis, arthritis and conjunctivitis, following an episode of bloody diarrhea in 1916. Urethri- tis, arthritis and conjunctivitis have subse- quently remained as the essential compo-
nents of this syndrome, but some feel that the eye involvement is so often minimal or insignificant that it need not necessarily be present to make the diagnosis.”8”9’2’ Sev-
eral other manifestations are inconsistently associated with this syndrome; these are:
(a) skin involvement (keratodermia blen- norrhagica); (b) nail involvement; (c) bal-
anitis circinata; (d) oral mucosal lesions;
(e) prostatitis; (f) iritis; and (g) diarrhea (as in Reiter’s original case). The skin
lesions are of particular interest because they are considered by most experts to be indistinguishable from pustular psori asis.
Etiologicalty, Rei ter’s syndrome remains an enigma. The latest opinio&6”7”9’2’ favors an infectious origin perhaps with a
hypersensi tivi ty component.2’ Some have postulated a viral etiology, but Weinber-
ger’s group found evidence tending to in- crimi nate pleuropneumoni a-like orga-
nisms.’6 Indiscrete sexual exposure is a very
frequent precursor of symptom atology. Several descriptions of the roentgeno-
graphic manifestations of Reiter’s syn-
drome have appeared in the literature, the most recent in the radiologic literature be-
ing Weldon and Scalettar’s report from Walter Reed General Hospital in Washing-
ton, D. C., in I96I.’ Murray, Oates and Young,’2 and Reynolds and Csonka,’5
authored articles on the subject in 1958,
and Weinberger et al.,’7 Kulka,8 and Wein- berger16 discussed the results of an ex- tremely thorough long-term study of i6 patients in 1962. Our experience with the
disease parallels that of previous authors. In selecting case material for our evalua-
tion, we elected, as have several others in
the past,”8”9’2’ to include cases of venereal arthritis without clear-cut conjunctivitis,
although the majority of our patients did
exhibit eye sYmptoms at some time. No
difference in the roentgenographic features was found between those patients with eye signs and symptoms and those without.
DISTRIBUTION OF LESIONS
As has been the experience of other au-
thors, we found the highest incidence of Reiter’s arthropathy in the joints of the
lower extremities. Involvement of the sac- roiliac joints and the joints of the upper
D ow
nl oa
de d
fr om
w w
w .a
jr on
lin e.
or g
by 2
7. 70
.1 29
.2 0
on 0
3/ 31
/2 3
fr om
I P
ad dr
es s
27 .7
0. 12
9. 20
. C op
yr ig
ht A
R R
S. F
or p
er so
#{149} #{149} pressed b\’ previous authors ill permostitms
Per Cent as a more or less characteristic finding ill Rei ter’s syndrome, we searched our cases
#{149}ver’ carefully for this manifestation. \Ve
32 29 were interested to find that less than one-
- -‘ - fourth of the involved joints (19 of $i)
- - showed periostitis, em tiler of the linear or of
20 the fluffs’, wools’ variety. \Ve found linear
permosteal new bone (Fig. , /1 and B)
53 largely in acute cases (a few weeks’ to a
few months’ history), whereas flu wooi’
periosteal new bone proli teration (Fig. 2,
.1 and B; and ) were not seen unless a long
- history was elicited (this was particularly
true of the catcaneal spurs). Mason et al.,#{176}
in 1959 found a somewllat higiler incidence
of periostitis, particularly about the mat-
,Ankles
Knees
0 iS
2S 22
2 7
\‘oi. ioi, No. Rei ter’s Syndrome and Psoriatic Arthritis 861
29 ‘7 24
frequent (‘Fable i). Knee involvement was
Illost C01illlU)fl in our experience (8o per
cent of all cases), and ankle and foot in-
volvenleilt was the next most common (6o
per cent and 53 per cent, respectivet’). Pos- itive roentgen features were found about
the hands and wrists nearly one-third of the
time, and this is a significant1’ higher in-
cidence than the 14 per cent reported by
\Veldon and Scalettar.’TM Our low incidence
of sacroiliac involvement (24 per cent) is
best explained b the fact that 22 of our 32
patients had a history of less than i year
of symptoms. Other workers have indicated
that the incidence of sacroiliac involvement
in Rei ter’s syndrome increases dramatically
as tile disease becomes more chronic.
Mason and associate&’ reporte(i an mci-
(lence of 8 ier cent in patients whose his-
tory was less than years, and an incidence
of 54 per cent ill patients witil a history
longer than s years. Of 7 patients in our
series with sacroiliac abnormalities (Fig. i),
had long (greater tilan I year) histories.
Only I had a short (2 months) history and
2 were entirely lacking in low back symp-
toilis.
IAIILE I
INVOlVEMENT IN REEFER’S SVNI)ROME
JIG. 1. An anteroposterior roentgenogram of the sa-
croiliac joints in this patient with several \‘ears of
intermittent hack pain shows nearly total oblitera-
tion of the joint spaces hilaterahl v, with extensive
associated juxta-articular sclerosis.
proliferation) were likewise found infre-
quently in our series, undou btedlv because we had relativel- few cases with long his-
tories. Of our 10 chronic cases, however,
or 40 per cent had typical catcaneal spurs
(Fig. 2, .1 and B). Elbows, siloul.iers anti
hips were i nfrequentlv involved, and oiil v
ill patients with histories ill excess of #{231}
years.
se o
nl y;
a ll
ri gh
ts r
es er
ve d
0 0
862 Carl C. Peterson, Jr. and Martin L. Sitbiger l)cE1nER, 1Th7
lI;. 2. (-1 and B) Lateral os calcis views on this patient with long-standing heel pain show unilateral, exuber- ant, irregular, wooly periosteal new bone proliferation resulting in a striking increase in size and density of
the os calcis on one side. Previous authors have considered this appearance essentially pathognomonic of Reiter’s syndrome.
teoli. Interestingly, tllev also indicated that
periostitis is to be found nearly as fre-
(Iuentl)T in rheumatoid arthritis as in Reiter’s syndrome. Patients with psoriatic
arthritis seeiiied to exhibit this feature oc-
casionaltv, altilougil not as frequently as
those with Reiter’s syndrome.
In evaluating a pathologic articulation
exilil)iting periostitis, one should think of
rheum atoid arthritis, Rei ter’s sv ndroni e,
infectious arthritis, and also psoriatic arth-
ri tis. The diflerentiation between these
must and can be made on the basis of other
cli iiicat and roentgenographi c features.
B. Osteoporosis. \Ve also looked carefully
for localized osteoporosis, since some (lis-
agreement seems to have existed in the past
regarding its incidence. Mason et al.,” (Ic-
dined to evaluate their subjects for osteo-
porosis, referring to Keligren and Lawrence
who suggested in 1957 that observer error
could arise in assessing lesser degrees of
osteoporosis.
per cent of all joints involved in our 32 pa-
tients showed defi ni te localized osteoporosis
(Fig. 5, 1 and B), (i.e., involving parts of
2 phalanges or 2 carpal hones on each side
of an involved joint, with alt other 0SSOS
structures appearing normal). The mci-
dence rises to greater than 75 per cent if
only the acute cases are evaluated. As one
would expect, tile well localized zone of
osteoporosis correlates 100 per cent with
the location of clinical involvement (pain
and usually swetlillg and ileat). This ver\’
localized osteoporosis is more like what one
would expect with an infectious arthritis
than with the collagen arthritides. Osteo-
porosis usually is regional aild related, at
least largel’, to disuse in rheunlatoid arth-
ritis. Osteoporosis, either localized or gen-
eralized, is uncommon witil psormatic arth-
ritis.
very nonspecific feature (Fig. 6) was the
most common encountered in our cases,
representing an incidence of 69 per cent
over-alt and greater than $o per cent ill
cases with acute symptoms. The correla-
tion of this finding with local pain, swelling
and heat was very high. However, even in
D ow
nl oa
de d
fr om
w w
w .a
jr on
lin e.
or g
by 2
7. 70
.1 29
.2 0
on 0
3/ 31
/2 3
fr om
I P
ad dr
es s
27 .7
0. 12
9. 20
. C op
yr ig
ht A
R R
S. F
or p
er so
V01.. ioi, No. Reiter’s Syndrome and Psoriatic Arthritis 863
1’ I
11G. 3. (1) .An anteroposterior roentgenogram of the third finger before clinical Reiter’s involvement
appears norm al. (B) An anteroposterior roent-
genogram of the same finger several weeks after
the onset of local pain, warmth and swelling. Both
pure linear (lo er ritht arrow) and somewhat hut-i -appearing (lo er left arrow) periostitis are
apparent along with the local soft tissue swelling (upper arrows) and equivocal joint space narrow-
ing.
11G. . An anteroposterior roentgenogram of the ankle of this patient with a long history of local
symptoms shows exuberant wool j)eriOstitis of the lateral malleolus, astragalus and calcaneus. The ankle joint spaces are intact.
patients with tong histories and clinically
rather quiescent joints, some thickening of
soft tissues was frequent. Mild osteoporosis
and tilickene(l pen artmcular tissues were
usually the only roentgen features about
sites of knee involvement.
D ow
nl oa
de d
fr om
w w
w .a
jr on
lin e.
or g
by 2
7. 70
.1 29
.2 0
on 0
3/ 31
/2 3
fr om
I P
ad dr
es s
27 .7
0. 12
9. 20
. C op
yr ig
ht A
R R
S. F
or p
er so
se o
nl y;
a ll
ri gh
ts r
es er
ve d
864 Carl C. Peterson, Jr. and Martin L. Silbiger DECEMBER, 1967
I
side.
11G. c. (A and B) Oblique roentgenograms of both ankles show no abnormality on the clinically asvlnI)tO-
matic side (A) and local tarsal osteoporosis on the Side manifesting local pain (B). This subcortical atrophy
simulates joint involvement because the cortices appear much less distinct than on the opposite normal
evaluation of tile 8i anatomic areas in-
volved by Reiter’s syndrome in our 32
cases revealed narrowing or destruction of
one or more joints in only i8 of these areas,
or an incidence of 22 pen cent. Many joints
superficially appeared to be narrowed be-
cause of tile local juxta-articular bone
atroph\- on both sides of an involved joint.
Of the i 8 involved areas, 7 were the sacro-
iliac joints. However, of all other joints in-
volved, joint narrowing or destruction was
found in a location other than the hands
an(t feet (including intercarpal and inter-
tarsal joints) onl’ once (narrowing of the
knee joint space). Involvement of tile knees
and ankles was frequent, but the findings
usually were limited to soft tissue swelling,
osteoporosis and occasional peniosti tis. Tile
smaller joints of the tarsus, carpus, ilands
and feet were involved somewhat less fre-
quentlv than tile knees and ankles, but,
wilell involved, showed a much higher in-
cidence of joint narrowing or destruction.
Su rpni singly, roen tgenographm c abnor-
mality of the joint space was as frequent in
our acute cases (Fig. 6), (less than i year-
in most cases, a few weeks to or 6 months)
as in the chronic cases (over i ‘ear-in
most cases, several years). Of alt abnormal
peripheral joints involved in our chronic
cases, 43 per cent showed narrowing or de-
struction of the joint space. A similar eva!-
uation of all of our cases (two-thirds of
which were acute) revealed an incidence of
40 per cent. Tilis would certainly suggest
that, although man\’ peripheral joint ab-
normalities are reversible in acute Reiten’s
s’ndrome, if a peripheral joint space is
going to be irreversibl\ damaged, it is as
tikel’ to happen in the relatively acute case
as in tile chronic case.
Permanent damage to tile joint ill
Rei ten’s syndrome has been underestim ated
some in the past, but our findings tend
to agree with tile experience of\\emnbergen
et al.,’7 who found, in a long term follow-up
study of #{182}6cases, that more tilan 50 pen
cent end up witil permanent joint damage.
E. lendon calczfication-o.cszfication. Re y n-
ol(ls and Csonka reported the occasional
incidence of tendon cat ci fi catmon-ossm flea-
tmon among their 6o patients (a Pellegnini-
Stieda t’pe, around tile knee). We found
tiliS manifestation 7 times, representing an
D ow
nl oa
de d
fr om
w w
w .a
jr on
lin e.
or g
by 2
7. 70
.1 29
.2 0
on 0
3/ 31
/2 3
fr om
I P
ad dr
es s
27 .7
0. 12
9. 20
. C op
yr ig
ht A
R R
S. F
or p
er so
on this patient with a long history of local symp-
tonis shows equivocal narrowing of the knee joint
space and extensive calcification and ossification of
tendinous insertions about the knee.
JIG. (. An oblique view of the index finger on this
patient with a 2 month histor’ of local pain and
swelling shows striking soft tissue swelling, definite
proximal interphalangeal joint narrowing, and minimal j uxta-articular osteoporosis.
\0l.. 101 , No. Reiten’s Sndnome and
iilcidellce of less tilan 10 per cent of all in-
volved joints. the knee was involved 3
tinies (F’ig. 7), the shoulders twice, the el-
bow once and the foot once. This calcifica-
tioll l1l(l, or ossification q)peared to be
Wi tiii Fl on sti rnou iidm ng tendi nous mnsentmons
and was found exclusively in cases with
longstanding disease.
per cent) showed the characteristic woolv
peniosteal new bone and’ on erosion of welt
developed calcaneal spurs (Fig. 2, /1 and B).
All were plantar spurs. This incidence is
low compared with the 30 pen cellt re-
ported b\ others.hllIls However, if we took only at our 10 chronic cases, our incidence
becomes approxim atelv that of previous
authors. G. Para ‘ertebral ossification. Pana yen te-
brat ossification has not been mentioned as
a manifestation of Rei ten’s syndrome alone.
Bvwaters and l)ixon, in 1965, reported 4
cases of progressive para vertebral ossi flea-
ti()n, dmtlenent from ankvtosing spond’litis
and senile ankviosing h’perostosis, in
psoriatic arthritis, and 3 of their cases also
had stigmata of Reiter’s syndrome. \Ve
D ow
nl oa
de d
fr om
w w
w .a
jr on
lin e.
or g
by 2
7. 70
.1 29
.2 0
on 0
3/ 31
/2 3
fr om
I P
ad dr
es s
27 .7
0. 12
9. 20
. C op
yr ig
ht A
R R
S. F
or p
er so
I,,
0 , .-
866 Carl C. Peterson, Jr. and Martin L. Silbigen DECEMBER, 1967
FIG. 8. (A) .A lateral roentgenogram of the cervical spine shows diskogenic degenerative disease only. (B) .A
lateral view of the same spine less than i year later. In the interim the patient developed severe Reiter’s
arthropathy, which later seemed to evolve into pSoriatic arthritis. Now a heavy anterior cloak of bone is
noted (arrows). This patient had normal sacroiliac joints and no evidence of anklosing spondylitis in the
thoracolumbar spine.
in which similar progressive panavertebral
ossification was present, 2 in the cervical
anterior prevertebral region (Fig. 8, 4 and
B), and one in the lumbar region laterally.
In 2 of these 3 cases, Rei ten’s sndronle ap-
peared to evolve into or coexist with pson_
iasis.
specific entity has been stressed in the Ii ten-
ature.”2’2#{176}It is stated that psoriatics with
arthritis, who are seronegative for rheu-
matoid factor, either exhibit changes of
rheumatoid arthritis or a distinct arthrop_
athy characteristically involving the dis-.
tal interphalangeal (D.I.P.) joints. It may be associated with bony proliferation at the
base of tile great toe, while causing various
degrees of destructioll of mans’ of tile other
joint surfaces, as well as joint fusion.1’7’2#{176}
In many was’s, our findings parallel those
earlier described. However, we have had
some difficulty ill distinguishing psoniatic
arthritis from tile arthritis of Reiter’s syn-
drome and, indeed, even in separating tile
“rheumatoid” and ‘‘non-rheumatoid type
marized below.
27 patients, 5 (i8 pen cent) of whom had
erosive changes of the apoph-seal joints
and 4 (i6 per cent) of whom had abnormal
atlantoaxial separation (Fig. 9). Those pa-
tients with abnormal mobility of the atlan-
D ow
nl oa
de d
fr om
w w
w .a
jr on
lin e.
or g
by 2
7. 70
.1 29
.2 0
on 0
3/ 31
/2 3
fr om
I P
ad dr
es s
27 .7
0. 12
9. 20
. C op
yr ig
ht A
R R
S. F
or p
er so
3
11G. 10. .An anteroposterior view of the ankle with dense periostitis of the medial malleolus.
.‘ a
I
11G. . A lateral view of the cervical sj)ine in flexion
showing abnormal atlantoaxial separation as well as subluxation of C4 on C.
\oi.. ioi, No. Rei ten’s Syndrome and Psoriatic Arthritis $67
toaxial joint all had roentgen evidence of
svstenlic rheuniatoid artllnitis. Erosion at
the apoph ‘seal joi ilts associated occasion-
ally with dense paravertebral ligamentous
calcification has been pnevmousl’ noted.’
Articulan erosions were seen ill of 28
(i $ pt cent) lumbar spines reviewed. (One case of associated allk\’tosiilg spondvlitis
was observed.)
Arthritic changes in the sacroiliac jOiiltS
were seen in 10 of 28 (36 per cent) cases, a
similar incidence llavmng been pnevmousl’
noted.2’6’2 Erosion of the greater and lessen
femonal trochantens bilaterally was seen in
one case.
rheumatoid arthritic changes Ill tile knee
with joint space narrowing, articulan Je-
struction, and juxta-articular osteoporosis.
lendinous and-on penitendmnous calcifica-
tion was observed in 3 of 30 (io per cent)
cases. Peniostitis was seen in 2 ( pen cent)
pa tie 11ts.
seen in $ of 27 (:3o per cent) cases, with
pen tendi nous calcification or ossification
ill 4 (is per cent). 1)ense peniostitis was also seen in patients (Fig. io).
Changes of rheumatoid artllnmtis with nO
illvotvefllent of tile D.I.P. joints of tile feet
were present in 9 of 32 (28 per cent) pa-
FIG. 11. .An anteroposterior view of the toes with
bony proliferation along the phalangeal shafts and
arthritis of the proximal interphalangeal joint of
the great toe.
se o
nl y;
a ll
ri gh
ts r
es er
ve d
11G. 1 2. An anteroposterior roentgenogram of the hand shows arthritic disease of the ulna, carpal, Iietacarpophalangeal and interphalangeal joints.
Note 1). 1.P. joint widening.
86$ Carl C. Peterson, Jr. and Martin L. Sitbiger R , l9(7
tients. Proximal interphalangeal joint eno-
smon of the great toe associated with D.I.P.
joint erosion of the remaining digits was
present in…