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In the Clinic |

Chlamydia and Gonorrhea

Kimberly Workowski, MD
Ann Intern Med. 2013;158(3):ITC2-1. doi:10.7326/0003-4819-158-3-201302050-01002
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Reiter Syndrome
Posted on February 20, 2013
Victor Sloan
Robert Wood Johnson Medical School
Conflict of Interest: None Declared

To the editor:

Regarding the most recent In the clinic (5 February 2013), the editors should know that the term "Reiter syndrome" is out of date. Wallace and Weisman asked in 2000 "Should a war criminal be rewarded with eponymous distinction?" (1) They note that others described the syndrome several hundred years prior to Reiter. Panush et al (2) noted in 2003 that Hans Reiter was a Nazi war criminal. As President of the Reich Health Office knew about euthanasia and murder, and designed an “experiment” conducted at Buchenwald. They remind us that "medicine is a moral enterprise", and propose that there is "no acceptable rationale to preserve any professional memory of Reiter…except as a symbol of what our societal values obligate us to reject."

Ephraim Engleman first suggested the use of the term "Reiter’s syndrome" in 1942. In 2007, he, along with others, retracted that suggestion (3). Rheumatology journal editors in 2003 agreed to no longer use the term in the literature, substituting “reactive arthritis.” (4).

Given this well-known history, as well as the trend away from the use of eponyms, it is shameful that in 2013 Annals continues to recognize Hans Reiter with the use of the term Reiter syndrome.

1. Wallace DJ, Weisman M. Should a war criminal be rewarded with eponymous distinction?: the double life of Hans Reiter (1881-1969). J Clin Rheumatol 2000 Feb; 6(1): 49-54.

2. Panush RS, Paraschiv D, Dorff RE. The Tainted Legacy of Hans Reiter. Semin Arthritis Rheum 2003 Feb; 32(4): 231-6.

3. Panush RS, Wallace DJ, Dorff EN, Engleman EP. Retraction of the suggestion to use the term “Reiter’s syndrome” sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum 2007 Feb; 56(2): 693-4.

4. Panush RS, editor. Year book of rheumatology, arthritis and musculoskeletal disease. Philadelphia: Mosby: 2004, p 331-4.

Editor's Response
Posted on February 20, 2013
The Editors
Annals of Internal Medicine
Conflict of Interest: None Declared

We thank Dr. Sloan for pointing out this important issue regarding the appropriate term for reactive arthritis. We agree and regret the error. A correction has been made.

The Editors

A late complication of Gonococcal infections: urethral stricture
Posted on April 25, 2013
Fabrizio Dal Moro, MD, FEBU
University of Padova
Conflict of Interest: None Declared

I would like to congratulate Workowski (1) on his paper on Chlamydia and Gonorrhea, in which he describes not only the screening and the diagnostic tools available for an early detection, but also the therapeutic guidelines. As emphasized by Workowski, appropriate treatment, and prompt management of sex partners are mandatory for an effective prevention strategy: many studies have shown that about 30% of cases are positive at rescreening and, in more than 60% of these, repeat infections occur (originating from re-exposure to an untreated or inadequately treated partner) (2).

In my opinion, recommendations for follow-up cultures or tests of cure are essential in order to demonstrate possible recurring infections or re-infection, thus not only improving health in the individual patient as well as in the community, but also minimizing any late complications related to infection. Focusing the attention on the urological manifestations of these infections in men, I would like to stress some points: first, many infections (and re-infections!) of the urethra are asymptomatic, making the diagnosis of failure of treatment very difficult.

Then, one of the most frequent and dramatic late complications of male urethritis is inflammatory stricture of the urethra, which usually starts with meatal stenosis, later progressively involving the anterior and posterior urethra and often requiring long-term management. Optical endoscopic urethrotomy, as described by Sachse in 1974, is still the initial treatment for the majority of men. Unfortunately, this treatment alone is associated with a significantly high recurrence rate, which may reach 50% (3). Given the expanding number of endoscopic techniques available, the choice of the best surgical option is often difficult and management of recurrent stenoses is a complex dilemma for urologists (4). Surgical urethral reconstruction has become an increasingly specialized urologic procedure and many urologists have limited experience of performing more complicated repairs, due to the cost and invasiveness of some treatments (e.g., urethroplasty with buccal mucosa grafts).

 In conclusion, we may say that proper medical management of male urethral gonococcal infection is essential, in view of the possible late complications of untreated urethritis; in case of failure of treatment, the patient should be referred to a specialist in sexually transmitted diseases, in order to avoid late complications, such as urethral stricture.

References

1. Workowski K. Chlamydia and Gonorrhea. Annals Intern Med. 2013;158:ITC2-1.

2. Kissinger PJ, Reilly K, Taylor SN, Leichliter JS, Rosenthal S, Martin DH. Early repeat Chlamydia trachomatis and Neisseria gonorrhoeae infections among heterosexual men. Sex Transm Dis 2009;36:498-500.

3. Meeks JJ, Erickson BA, Granieri MA, Gonzalez CM. Stricture recurrence after urethroplasty: a systematic review. J Urol. 2009;182:1266–70.

4. Wong SS, Aboumarzouk OM, Narahari R, O'Riordan A, Pickard R. Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men. Cochrane Database Syst Rev. 2012;12:CD006934.

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