A 20-year-old man presented to our outpatient with a history of diarrhoea since the last 40 days. Stools were 3–4 times/day, watery and not containing mucous or blood. Patient had arthritis involving hips, knees and shoulders intermittently for 6 years which flared up again after his recent episodes of diarrhoea. He also observed skin lesions that were first noted on the scalp about 5 years ago and were now present on trunk, abdomen, thighs and soles since the last 3 months. Patient had recently also noted that he had puffiness around his eyes and swollen feet. He did not have any diagnosis or specific treatment in the past.
On physical examination, he appeared cachectic and had perorbital puffiness and pedal oedema. He had fixed flexion deformities in both knees (figure 1), along with restricted motion and swelling in both hips and right shoulder. He had skin lesions which were multiple, discrete to confluent well-defined scaly plaques with heaped up crusting present on the trunk and limbs (figures 2–4). There were well-defined glazed erythematous patches present on the glans penis and prepuce in a circinate pattern (figure 5). Slit lamp examination of the eyes was normal.
 | Figure 1 Fixed flexion deformities of both knees. |
 | Figure 2 Keratoderma blenorrhagicum. |
 | Figure 4 Skin lesion on limb. |
 | Figure 5 Circinate balanitis. |
 | Figure 3 Skin lesion on trunk. |
His investigations revealed hypoalbuminemia (serum albumin 1.5 g/dl) 4+ albuminuria and 5–6 pus cells. USG abdomen showed enlarged kidneys and cystitis. On skin biopsy, histopathological findings were consistent with spongiform pustule of Reiter's disease (figures 6 and and7).7). Renal biopsy revealed positive congo red stain confirming amyloid involvement of kidney (figure 8). Patient was offered antibiotics imidazoles and quinolones in standard doses as well as antisecretory agents like racecadotril for diarrhoea. Non-steroidal anti-inflammatory drugs, methotrexate and physiotherapy for arthritis and symptomatic treatment for skin lesions. He gradually started improving. His skin lesions started regressing, his diarrhoea subsided and his joint pains started decreasing.
 | Figure 6 Acanthosis and elongation of rete ridges and diminution of granular layer. |
 | Figure 7 Spongioform pustule beneath the para keratotic cornified layer. |
 | Figure 8 Renal biopsy suggestive of amyloidosis. |