reactive arthritis or fiessinger - leroy disease is a genetically determined disease characterized by the triad of urethritis or cervicitis , conjunctivitis , and arthritis , which closely follows lower urogenital or enteric infection .
mucocutaneous findings such as circinate balanitis ( 3040% ) , keratoderma blenorrhagicum ( 15% ) , oral ulcers ( 17% ) and dystrophy of nails ( 2030% ) are also associated with reactive arthritis . our case presented with circinate balanitis as the only initial clinical finding , which otherwise is the most common finding associated with reactive arthritis , but is rarely seen as a preceding finding .
a 22-year - old married male presented with asymptomatic superficial lesions present over the glans and under surface of prepuce since 1-year .
he was treated elsewhere with oral antibiotics and topical antifungal preparations assuming it to be an infection , but without any relief .
patient also had mild lower back pain with morning stiffness and left knee joint pain since 6 months .
examination revealed multiple well - defined superficial erosions of size 0.52.5 cm , round to oval in shape with irregular margins , which coalesced at places to form circinate pattern over the glans and under surface of prepuce [ figures 1 and 2 ] . from the above findings ,
circinate lesions present over glans before treatment lesions present on under surface of prepuce before treatment laboratory investigations showed mildly raised total leukocyte count 11,700/mm ( normal 400011000 ) .
viral markers such as hepatitis b surface antigen , antihepatitis c antibodies , human immune deficiency virus ( hiv ) antigen , and venereal disease research laboratory tests were nonreactive .
c - reactive protein ( crp ) ( 7.31 mg / dl , normal < 0.6 mg / dl ) and human leukocyte antigen ( hla ) b-27 were positive .
radiologically magnetic resonance imaging lumbosacral spine and sacroiliac joints showed straightening of the lumbar spine and right sided sacroiliitis .
histopathology of lesions from the glans showed parakaratosis containing neutrophils forming intracorneal and superficial epidermal pustules resembling spongiform pustules .
various psoriasiform changes seen on histopathological examination based on the above clinical and histopathological findings , diagnosis of reactive arthritis was made .
patient was treated for circinate balanitis with pimecrolimus 1% cream twice daily for 3 weeks .
lesions cleared completely , and no recurrence was seen subsequently [ figures 4 and 5 ] . patient was referred to rheumatologist for management of arthritis .
post - treatment complete resolution of lesions from glans post - treatment complete resolution of lesions from under surface of prepuce
reactive arthritis was first described by hans conrad julius reiter , a german physician during thefirst world war in 1916 . in the same year
, fiessinger and leroy published similar finding as  oculo - urethro - synovial syndrome . 
although it is a disease of young males with hla - b27 associated with 80% of cases , other hla types that are linked with hla - b27 and other age groups are not excluded .
caucasians are the most commonly affected , probably because of higher prevalence of hla - b27 in this population group .
it occurs in response to enteric infections such as salmonella , shigella , yersinia , campylobacter or urethral infection from chlamydia trachomatis .
it has been proposed that damaged exogenous pathogen - associated molecular patterns , derived from microbes , can disseminate upwards via the pelvic and spinal lymphatic pathways and activate toll - like receptors ( tlrs ) .
their activation triggers signaling pathways that result in the expression of immune response genes and cytokine production .
however , recent human data suggest that tlr-2 , not tlr-4 , is important in determining reactive arthritis susceptibility after salmonella infection
other rare factors , which can induce the disease are immunotherapy with bacillus calmette - gurin and interferon  , or following hepatitis b vaccination .
one of the various treatment modalities tried for mucosal lesions include use of topical steroids like hydrocortisone or triamcinolone .
a combination of keratolytic agents likes 10% salicylic acid ointment with hydrocortisone 2.5% cream , and oral aspirin has also been reported to clear circinate balanitis .
topical 0.1% tacrolimus or pimecrolimus 1% cream has been used in refractory case with variable success [ table 1 ] .
various studies showing topical calcineurin inhibitors as treatment modalities for balanitis the diagnosis in our patient rested on a constellation of signs and symptoms suggestive of reactive arthritis which included diarrhea , arthritis and circinate balanitis .
however , the above mentioned clinical findings along with hla - b27 and crp positivity favored diagnosis of reactive arthritis .
the interesting finding in our patient was the presence of circinate balanitis as the preceding feature , which has been rarely reported to the best of our knowledge .
this case is being reported for its rarity in which circinate balanitis is the only presenting feature of reiter 's disease , which was successfully treated with topical 1% pimecrolimus cream .
however , further clinical trials and research is needed to study underlying mechanism of action of topical pimecrolimus in its management .
 circinate balanitis , although a common manifestation of reactive arthritis , is usually an associated finding present along with the triad of arthritis , conjunctivitis , and urethritis . 
 it is rarely seen as the only preceding manifestation of reactive arthritis . 
 we hereby report a case of circinate balanitis as alone preceding presentation of reactive arthritis that was successfully treated with topical pimecrolimus 1% cream . 