BRIEF COMMUNICATION

Reiter's Syndrome in Eskimos

Reiter's Syndrome is a disease that is un- common in males. The exact frequency is unknown. However, it has been estimated to occur in about 4 per 100,000 Navy Per- sonnel (1). The following case histories de- scribe the first two cases of Reiter's Syn- drome to be reported in Eskimos. Some background of the health care delivery sys- tem in Southwest Alaska is indicated. There are approximately 9,500 Eskimos in South- western Alaska, living in 52 villages. There are eight practicing physicians who are re- sponsible for the entire health care delivery system in Southwest Alaska, and work out of the Indian Health Service Hospital in Bethel. In remote villages, patients first pre- sent themselves to the Native Village Health Aid who reports on her patients daily to the hospital physician via radio. A physician visits each village once or twice a year and a Public Health Nurse visits three to four times a year.

CASE REPORTS Case 1. PP is a 23-year-old married Eskimo male

from Alakamuk. Alaska, located on the South mouth of the Yukon River, 15 air miles from Bethel. Three weeks prior to admission on March 11. 1973, the patient reported to the Village Health Aid with a 4-day history of urethral discharge. Both he and his wife denied extramarital inter- course. They were reported to the physician and treated with 4.8 million units of procaine penicillin. Two days later, the patient noted pain and redness in his left eye and was treated for conjunctivitis with metamyd eye drops by the Village Health Aid. One week later, the patient noted onset of pain and swelling in his right knee and right ankle, which progressed over 2 weeks, causing him to

report to the Health Aid who referred him to the Bethel Hospital

Physical examination revealed: temperature, 100.7"F; blood pressure 116/60 mm Hg; pulse 88. His chest was clear. There was no lymphadeno- pathy, no heart murmur or rub, the liver and spleen were not felt. He had a warm, tender, swol- len right knee with fluid; his ligaments were intact. His right ankle was also warm, tender and swollen. The rest of his joints were normal, and no mum- cutaneous lesions were present.

His admitting laboratory data showed: hemato- crit 35, leukocyte count 10,400, with 80 segmented cells, 19 lymphocytes, 1 eosinophil, normal platelets and a sedimentation rate of 50 mm/hr (Wester- gren); analysis of urine showed: specific gravity 1.029, pH 6, negative glucose, blood and acetone, trace protein, 15-25 white blood cells per high power field and a few bacteria. Chest x-ray showed hilar prominence, but PPD was negative. EKG showed PR interval of .20 with a rate of 100. No other abnormalities were seen. BUN was 12 mg/100 ml creatinine 0.8 mg/100 ml; uric acid, 1.4 mg/100 ml; VDRL negative, and AS0 titer, 200 Todd Units.

Hospital course. After hospitalization, the right knee was aspirated of 50 ml of straw-colored fluid. There were 20,000 red blood cells, 10,000 leukocytes. 70% polymorphonuclear leukocyte and 30% lym- phocytes. Gram stain and culture were negative (Thayer-Martin). Fluid was negative for uric acid crystals and rheumatoid factor. Joint fluid comple- ment was 128. X-rays of the right knee and ankle showed soft tissue swelling with no other abnormal- ity. Urethral and urine cultures were negative.

The patient was initially started on 3 million units of aqueous penicillin, intravenously, every 6 hours, and aspirin 600 mg every 4 hours. For the next 2 weeks, the patients spiked temperatures to 101-102°F daily. Blood cultures were negative. Three EKGs showed continued prolonged PR inter- vals with nonspecific ST/T changes. Daily auscul- tation of the heart failed to reveal any murmur or rubs. Repeat urinalyses, gram stains and cul- tures were negative. The hematocrit fell from 35 to 31; sedimentation rate ranged from 33 to 60

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MCMAHN AND ARMSTRONG

mm/hr. Two LE preps were negative. A reticulo- cyte count was 2.7, uncorrected: Coombs tests were negative. Smears of peripheral blood showed nor- mocytic-normochronic red cells, serum iron was 31, TIBC 251 with 15% saturation. Three tests for antinuclear antibody were negative. Serum was negative, as was rheumatoid factor (Latex). Two repeat chest x-rays showed no change.

After 9 days of intravenous penicillin produced no improvement, the antibiotic was stopped. Sali- cylates were started at 16-20 tablets of sodium salicylate daily. Whirlpool, hot pack and range-of- motion exercises were initiated with only modest improvement. On the fourteenth hospital day, the right knee was again aspirated of 80 ml of straw- colored fluid with 23,400 leukocytes, 95% polymor- phonuclear leukocytes, 25% lymphocytes and 9,900 erythrocytes. Cultures of synovial fluid, including AFB cultures were negative. After the aspiration, 10 mg of Depo Medral were injected into the right knee and the patient was started on phenylbuta- zone, 100 mg 4 times daily. Over the next few days, the swelling and tenderness in the right knee and ankle decreased. Repeat x-rays of the right knee and right ankle were again negative.

On discharge, after 26 days in hospitalization, there still remained some swelling and tenderness in the right knee and ankle. Since discharge, the patient has continued to have pain and swelling in the right knee and ankle but refused to return to the hospital for follow-up because, according to the Health Aid, he is afraid he’ll be rehospitalized. Case 4. MP was a 19-year-old male from Napa-

skiuk, 6 miles down river from Bethel. He pre- sented to Bethel Hospital on December 13, 1972 with a 3-week history of urethral discharge and a 3-week history of swollen ankles. He denied any eye symptoms.

On physical examination his temperature was 99.8”F. Eyes, chest and heart were normal. He had a milky urethral discharge ahd swelling o v a the ateral malleoli of both ankles. Laboratory studies revealed a hematocrit of 39; sedimentation rate, 50 mm/hr: leukocytes, 7,400; blood glucose was 111 mg/IOO mI. uric acid, and 100-150 leukocytes per high power field. Chest x-ray revealed right hilar calcification.

Hospital course. The right ankle was aspirated and yielded a small amount of cloudy, yellow fluid with a poor mucin clot. The leukocyte count was

89,400 with 99% polymorphonuclear leukocytes and 1% lymphocytes. Synovial fluid glucose was 90 mg/ 100 ml (serum glucose was 111). Rheumatoid factor was present in the synovial fluid but absent in the serum, while urethral and synovial fluid cultures were negative.

The patient was treated with 12 million units of aqueous penicillin intravenously for 7 days. On the fourth hospital day, his urethral discharge disap- peared and his ankle swelling decreased. He was discharged on the ninth hospital day, with minimal ankle swelling and pain. The patient’s joint pain gradually disappeared and he was well until August 31, 1973 when he presented to Bethel Hospital with a 5-day history of urethral discharge and a 3-day history of bilateral conjunctivitis. He was treated with 1 g of Probenecid and 4.8 million units of procaine penicillin. Ten days later he returned with a 1-week history of a swollen left ankle. He still had a urethral discharge, but the conjunctivitis was gone. Urethral and conjunctival cultures were negative for gonococcus. On physical examination, he was found to have a classic circi- nate ballanitis. He was started on 12 aspirin tablets daily. He returned 1 week later with decreased swelling in his left ankle but a swollen, tender left knee. Aspiration of the knee revealed bloody fluid, with 1.2 million RBCs, 2250 WBCs, 99% polymor- phonuclear lymphocytes. 1% lymphocytes. Serum and synovial fluid Latex fixation were negative, as was synovial fluid culture. He was started on phenylbutazone and one week later had swelling in both the left knee and ankle. He was seen October 23, 1973 in Arthritic Clinic and still had a 1+ effusion of the left knee and pain in the left ankle. He was, at that time, started on indometha- cin and quadricep exercises.

BRIAN MCMAHN, MD US Public Health Semice Hospital

Bethel, Alaska MICHAEL B. ARMSTRONG, MD

Anchorage Medical Q Surgical Clinic

718 K Street Anchorage, Alaska 99501

REFERENCE 1. Noer HR: An “Experimental” Epidemic of

Reiter’s Syndrome. JAMA 197:117, 1966

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