Prostatitis, Arthritis, Low Back Pain, and Other Inflammatory Symptoms

John J. Cush, MD

Disclosures

September 25, 2000

Question

A 51-year-old man presented with prostatitis, urethritis, balanitis, oligoarthritis, low back pain, mucositis, rash, fever, photophobia, and conjunctivitis. A short course of prednisone worsened the urologic symptoms and caused scrotal redness. The patient has been receiving multiple antibiotics for more than 6 months, but he was mostly untreated with high-dose antibiotics for the first 6 months of the illness (he is now 1 year into this syndrome). He is receiving levofloxacin and azithromycin for suspected Mycoplasma prostatitis; prostate symptoms have improved somewhat since starting this therapy. Urethral swab for chlamydia/gonococcus was negative at the time of the first episode of urethritis. The patient has now failed to respond adequately to rofecoxib, indomethacin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) at maximal appropriate dosing. He may be allergic to sulfonamides and therefore is not a candidate for azulfidine.

I am considering hydroxychloroquine sulfate and continuing the antibiotics for several months. He is moderately affected with undulating constitutional symptoms and musculoskeletal pain.

Is this man's syndrome driven by continuing prostatis, and should antibiotics be continued? Is serum Mycoplasma by polymerase chain reaction useful for assessing the need for antibiotics?

Response from John J. Cush, MD

Such a patient meets criteria for Reiter's syndrome -- the triad of arthritis, urethritis, and conjunctivitis. Other symptoms attributable to Reiter's syndrome include low back pain (especially if associated with prominent morning lower back stiffness), balanitis, oral ulcers, oligoarthritis, and fever. Truncal rash and photophobia are not typical of Reiter's syndrome. However, a palmar or plantar eruption called keratoderma blenorrhagicum is typical of Reiter's syndrome. This patient also meets the Amor criteria for a seronegative spondyloarthropathy. If this patient has Reiter's syndrome (spondyloarthropathy), there is a high likelihood he will be HLA-B27-positive; this should be tested.

The differential diagnosis may also include Wegener's granulomatosis (low back pain, prostatitis, rash, fever) or Behçet's syndrome. There is no diagnostic test for Behçet's, but Wegener's granulomatosis may be associated with a positive C-antineurotrophil cytoplasmic antibody (C-ANCA) test. Treatment of the prostatitis is wise at this point. It may have been helpful to test for chlamydia by sending urethral swabs for analysis by DNA probes. Three months of therapy with minocycline or lymecline is suggested by the literature. Use of "floxins" and other antibiotics has not been adequeately tested.

After an initial trial of the NSAIDs listed, you may also try 75 mg of diclofenac twice or three times daily or 100 mg of diclofenac extended release once or twice daily (watching for gastrointestinal symptoms, heme, and liver toxicity). If this proves ineffective, treatment options include either 1000 to 1500 mg of sulfasalazine twice daily[1] or 10 to 15 mg of methotrexate once a week (with 1 mg of folate every day) and/or a tumor necrosis factor inhibitor (etanercept or infliximab). I would not assume he is sulfa-allergic and, if concerned, he should be referred to an allergist for testing or desensitization. Hydroxychloroquine is not effective in such patients.

This patient represents a highly complex case in whom routine measures have been ineffective. Further testing and treatment with the assistance of a rheumatologist is likely to be helpful and cost-effective.

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