Polyarthritic, symmetric arthropathy in reactive arthritis

Reactive arthritis (ReA) is an immune mediated disease, clinically associated with oligoarthritis of the lower limbs and sometimes with urethritis and conjunctivitis. In our case, a 24-year-old male presented with severe mutilating arthritis involving both upper and lower extremities in contrast to conventional Reiter's syndrome which presents with asymmetric oligoarthritis. He had multiple well-defined, irregular, erythematous, hyperkeratotic, scaly and itchy plaques, not easily distinguishable from pustular psoriasis. The patient also gave history of circinate balanitis and urethritis. He was started on methotrexate (7.5 mg/week, later escalated to 15 mg/week with 15 mg/day folinic acid supplementation) to which he responded. But when he stopped it on his own, the symptoms recurred. Hence, methotrexate was restarted, but still the patient suffers from fixed flexion deformities in affected joints. Histopathological examination of skin lesions is also suggestive of ReA. Thus, this case report suggests that diagnosis of Reiter's should be considered in symmetrical, mutilating polyarthritis patients with typical skin lesions.