Series Editor: Herbert L. Fred, MD
Prepared by Jon M. Sweet, MD, Assistant Professor of Clinical Internal Medicine, University of Virginia, Carilion Health System, Roanoke, Va

A 43-year-old man complained of foot, ankle, knee, wrist, and back pain, along with a rash involving his hands, feet, and groin. He had untreated HIV infection with a CD4+ cell count of 264 x 106/L (264/µL) and HIV RNA of more than 200,000 copies/mL. He had escalated his injection drug use to help alleviate his leg and back pain. Physical examination showed hyperkeratosis of the soles and palms (Figures 1, 2) consistent with keratoderma blennorrhagica; an arcuate, sharply demarcated, painless erythematous eruption on the glans characteristic of balanitis circinata; and facial seborrhea. The ankles, knees, and wrists exhibited minimal swelling and restricted range of motion. No conjunctival or urethral discharge was evident. Laboratory studies were unremarkable.

Points to remember: Reiter’s syndrome was the first rheumatic disease associated with HIV infection. Keratoderma blen­norrhagica and balanitis circinata are diagnostic of this reactive oligoarticular spondyloarthropathy, which develops in genetically susceptible (HLA-B27–positive) persons after gastrointestinal or genitourinary infections. Keratoderma blennorrhagica begins as sterile vesicopustules, which coalesce into keratotic plaques. The lesions are clinically and histologically indistinguishable from pustular psoriasis. Severe Reiter’s syndrome or psoriasis should prompt evaluation for HIV infection.

Diagnosis: HIV infection–associated spon­dyloarthropathy (ie, Reiter’s syndrome).