A 26-year-old woman comes to the office due to fever, malaise, and joint pain. A week ago, the patient had pain in the small joints of her right hand, which improved spontaneously but was quickly followed by pain in the right ankle and left wrist. She has no prior medical problems and takes no medications. Temperature is 38 C (100.4 F), blood pressure is 124/82 mm Hg, and pulse is 90/min. The extremity joints are not erythematous or swollen, but tenderness is present along the tendons of the left wrist and right ankle. Several small, nontender pustules are seen on the extremities. There is no other rash. Blood culture in a selective growth medium consisting of chocolate agar and multiple antibiotics yields the causative pathogen. Which of the following strategies would most likely have prevented this patient's current condition?

Question

A 26-year-old woman comes to the office due to fever, malaise, and joint pain.  A week ago, the patient had pain in the small joints of her right hand, which improved spontaneously but was quickly followed by pain in the right ankle and left wrist.  She has no prior medical problems and takes no medications.  Temperature is 38 C (100.4 F), blood pressure is 124/82 mm Hg, and pulse is 90/min.  The extremity joints are not erythematous or swollen, but tenderness is present along the tendons of the left wrist and right ankle.  Several small, nontender pustules are seen on the extremities.  There is no other rash.  Blood culture in a selective growth medium consisting of chocolate agar and multiple antibiotics yields the causative pathogen.  Which of the following strategies would most likely have prevented this patient's current condition?

Quizplus · Accepted Answer

Disseminated gonococcal infection occurs when Neisseria gonorrhoeae spreads from the genitourinary tract to the bloodstream. It typically presents with the triad of polyarthralgia, tenosynovitis, and dermatitis (painless pustules on the extremities) or purulent arthritis. The diagnosis is confirmed when the organism is isolated on Thayer-Martin media, chocolate agar infused with antibiotics. N gonorrhoeae is spread primarily via infected genital secretions during sexual contact. Therefore, most cases can be prevented by the consistent use of condoms, which act as a mucosal barrier between sexual partners. Patients with genitourinary N gonorrhoeae infections may have purulent cervicitis or urethritis, but many are asymptomatic. Asymptomatic infection increases the risk of spread to deeper tissues (eg, disseminated gonococcal infection, pelvic inflammatory disease) because of treatment delay. (Choice A) Lyme disease is a tick-borne illness caused by the spirochete Borrelia burgdorferi. Early localized Lyme disease can be associated with arthralgias, myalgias, fever, and erythema migrans (a migrating, erythematous, bull's-eye rash). However, it is not associated with tendonitis/pustules, and spirochetes cannot be cultured on Thayer-Martin media. (Choice B) N gonorrhoeae undergoes dramatic antigenic variation of its surface molecules, which prevents the formation of protective antibodies against future infection. Therefore, recurrent infection is common and vaccinations are ineffective. (Choice C) The roundworm Trichinella can be transmitted via undercooked pork. It invades the skeletal muscle and causes severe muscle pain, swelling, and tenderness. Periorbital edema and eosinophilia are often important diagnostic clues. Diagnosis is made by serology; culture on Thayer-Martin media is not performed. (Choice E) Dengue fever, also called breakbone fever, is a mosquito-borne viral infection associated with fever, severe myalgias, arthralgias, and macular rash. Hemorrhagic complications can occur. The diagnosis is usually made clinically; Thayer-Martin media would not yield an organism (as it is a viral pathogen). Educational objective: Neisseria gonorrhoeae is spread sexually by genitourinary secretions and can be prevented by the consistent use of condoms. Genitourinary infections are often asymptomatic, which increases the risk of spread through the bloodstream, leading to disseminated gonococcal infection. Patients with disseminated disease typically present with the triad of polyarthralgia, tenosynovitis, and dermatitis or purulent arthritis.

A 26-Year-Old Woman Comes to the Office Due to Fever