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…