Atiya Mahboob, Zafar Iqbal, Farrukh Iqbal, Shandana Tarique.
Painful Joints With Scaly Rash - A Case Report.
Proceeding Shaikh Zayed Postgrad Med Inst Jan ;14(2):103-8.

We present an uncommon case of Reiter`s syndrome. The patient presented with pain in joints and scaly skin lesions. Presence of skin lesions helped in reaching the diagnosis.

A 56 years old man was admitted in medical ward through Dermatology Out Patient Department, at Sheikh Zayed Hospital in February 2000. He presented with complaints of pain in the neck, right knee and left ankle joint which was accompanied by skin lesions on various parts of body for last two months. He also complained of an increase in frequency of micturition and watering from eyes. Pain in joints was continuous, aggravated by movement and relieved partially by simple analgesics. There was no history of trauma to limbs. Initially he could perform his routine work but due to increasing in intensity of pain his activity was gradually limited. These joints became red and swollen. At the same time he developed skin lesions on medial side of feet, front of legs, right side of lower abdomen including external genitalia and right arm. These lesions were multiple, itchy, red, raised, varying from half to one centimeter in size, round to oval in shape with watery discharge and crust formation. The patient developed polyuria with an urge to micturate after every 12 hours. Urine was pale in color and was about half a cup in quantity. At the end of stream he experienced extreme burning sensation in urethra. There was no history of passage of pus, blood, gravel particles or froth in urine. He had no complaint of increased intake of water or abdominal pain. He also complained of bilateral ocular watery discharge that remained through out the day and got worsened on exposure to light. He had no pain, purulent discharge, redness or gritty sensation in his eyes. His vision was not affected. He had low-grade intermittent fever during this period, chills accompanied it but there was no evening rise or night sweats.

On systemic review, patient gave history of cough with occasional white expectoration. There was no history of shortness of breath, wheeze, palpitation or chest pain. He had no history of nausea, vomiting, heartburn, altered bowel habits, weakness of any part of body, loss of sensation, photosensitivity, oral ulceration or bleeding from any part of the body. He had occasional mild pain in joints of lower limbs for the last 14 years. There was no past history of diarrhea, any major urinary complaint, polyuria, polydypsia or surgical operation. Personal and family history was unremarkable.

At the time of examination, patient was conscious and fully oriented in time and space. He was unable to sit or stand due to pain in his various joints. He was pale and having temperature of 100°F. Examination of locomotor system revealed swelling of left ankle and right knee joints. These were red, tender and mildly warm. Active and passive movements were limited. No deformity of feet, toes, hands or fingers were noted. Movements of neck in all directions were limited. Tenderness was present in lower cervical region. Rest of spine was normal. Dermatological examination showed multiple round to oval papulonodular lesions of half to one centimeter in size on feet, shins, lower abdomen and right arm. These were red, crusted having collarette of scales at periphery surrounded by erythematous halo. Crusted vesiculopustular lesions were present on scrotum, shaft of penis and around external urethra coalescing to form polycylic and circinate pattern. Palatal mucosa was red in color with no ulceration. Dorsum of tongue was normal. There was bilateral pterygium formation and excessive watery discharge in both eyes. Early lenticular changes were noted on slit lamp examination. No signs of uveitis were present. Fundi were normal. Rest of the systemic examination was insignificant.

A provisional diagnosis of Reiter`s syndrome was made. His haemoglobin was 9.7 gm/dl with normal peripheral picture. Total count was 6.6x10e2/mm3 with 82% polymorphs. Platelets were 432,000/mm2. His ESR was 120mm in first hour. Urine examination showed 20-25 pus cells per high field. His renal function tests, serum electrolytes, uric acid, CPK, rheumatoid factor, antinuclear antibodies, anti-double stranded antibodies, VDRL and HIV were negative. Stool complete examination was normal. Repeated urine and blood cultures showed no growth. Biopsy of skin lesion showed psoriatic pattern with subcorneal pustule formation. X-ray of left foot and ankle joint revealed presence of spurs at insertion of plantar fascia and tendoachillis. X-ray spine showed syndesmophyte formation and squaring of vertebral bodies.

Patient was given analgesics, steroids preparation for skin lesions and oral tetracycline. Initially he responded to treatment but after two weeks his condition became static and after 4 weeks injection methotrexate was added for his joint complaint.

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