A 24-year-old woman comes to the physician with joint pain and malaise for the past 2 weeks. She had pain in her right wrist and elbow initially, but now it involves primarily the right knee. Yesterday, she noted a red bump on her finger. She lives in Connecticut. The patient has no medical problems and takes no medications. She does not use tobacco, alcohol, or illicit drugs. She lives alone and has had a boyfriend for the past 2 years. Her last menstrual period was 2 weeks ago. Her mother suffers from hypertension and arthritis.
The patient's temperature is 38.1° C (100.6° F), blood pressure is 105/85 mm Hg, and pulse is 99/min. Physical examination shows no neck masses or lymphadenopathy. There are no cardiac murmurs. The spleen is not enlarged. The right knee is warm and slightly swollen without erythema. Range of motion is unrestricted. There is a pustule on the right index finger but otherwise there are no skin rashes.
Which of the following is the best next step in management of this patient?

Question

A 24-year-old woman comes to the physician with joint pain and malaise for the past 2 weeks.  She had pain in her right wrist and elbow initially, but now it involves primarily the right knee.  Yesterday, she noted a red bump on her finger.  She lives in Connecticut.  The patient has no medical problems and takes no medications.  She does not use tobacco, alcohol, or illicit drugs.  She lives alone and has had a boyfriend for the past 2 years.  Her last menstrual period was 2 weeks ago.  Her mother suffers from hypertension and arthritis.
The patient's temperature is 38.1° C (100.6° F), blood pressure is 105/85 mm Hg, and pulse is 99/min.  Physical examination shows no neck masses or lymphadenopathy.  There are no cardiac murmurs.  The spleen is not enlarged.  The right knee is warm and slightly swollen without erythema.  Range of motion is unrestricted.  There is a pustule on the right index finger but otherwise there are no skin rashes.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_985d_bc46_853d_4315264638bc_MD0002_00 This patient's presentation of fever, arthralgias, and pustular skin lesion suggests disseminated gonococcal infection (DGI). Suspected DGI may present as purulent arthritis without skin lesions or a triad of migratory asymmetric polyarthralgias, tenosynovitis, and painless pustular skin lesions with fever. Most patients do not recall recent genitourinary infection, and women are more commonly affected. Purulent arthritis usually affects knees, ankles, and wrist joints. Diagnosis requires drainage of purulent arthritis with synovial fluid analysis. Synovial fluid may show up to 50,000 cells/mm³, but many patients have < 10,000 cells/mm³. Blood cultures (2 sets) are more likely to be positive in patients with the classic triad but can be negative. As a result, isolation of the Gram-negative diplococcus from mucosal sites (eg, pharyngeal, rectal, urethral, or cervical swabs) is preferred for diagnosis and is positive in up to 50% of patients. Treatment involves parenteral ceftriaxone, which can be switched to oral cefixime when symptoms improve. Total duration of therapy is usually 7-14 days (longer for septic arthritis). Concomitant treatment for chlamydia with azithromycin or doxycycline is also recommended, as is treatment of sexual partners. In addition, all patients should be tested for HIV and syphilis. Patients with recurrent DGI should be evaluated for terminal complement deficiencies. (Choices B & C) Doxycycline is recommended empirically in patients with suspected Lyme disease. Lyme disease rash has characteristic central clearing (erythema migrans). Arthritis is also a late manifestation of Lyme disease, and antibodies to Borrelia burgdorferi are negative in early localized disease. (Choice D) Parvovirus can cause peripheral edema, symmetric small joint arthritis, and aplastic anemia. It is most commonly seen in patients with sickle cell disease and those exposed to multiple children (eg, day care workers). However, it does not typically cause a pustular rash. (Choice E) Rheumatoid arthritis is associated with subcutaneous nodules instead of the pustular lesions seen in this patient. Educational objective: Asymmetric migratory joint pain and pustular lesions are characteristic of disseminated gonococcal infection. Diagnosis involves blood cultures, synovial fluid analysis (if purulent arthritis is present), and mucosal (eg, pharyngeal, rectal, urethral, or cervical) cultures. Treatment is ceftriaxone for 7-14 days and concomitant treatment of chlamydia with azithromycin or doxycycline. __________ References: Gonococcal arthritis (disseminated gonococcal infection). (http://www.ncbi.nlm.nih.gov/pubmed/16297736)

A 24-Year-Old Woman Comes to the Physician with Joint Pain