A 24-year-old woman comes to the clinic due to 4 days of skin rash and pain in her wrists, ankles, and elbows. She also has had a fever but no headache, nausea, or vomiting. The patient has no significant past medical history and does not take medications. She recently went on a weekend vacation with her new boyfriend. The patient has an intrauterine device and does not use condoms. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.5 C (101.3 F) and pulse is 98/min. The oropharynx is clear, and there is no thrush or lymphadenopathy. Abdominal and pelvic examinations are normal. The patient has pain along the tendon sheaths with active and passive hand movement. The skin rash is shown in the image below. Which of the following is the most likely cause of her symptoms?

Question

A 24-year-old woman comes to the clinic due to 4 days of skin rash and pain in her wrists, ankles, and elbows.  She also has had a fever but no headache, nausea, or vomiting.  The patient has no significant past medical history and does not take medications.  She recently went on a weekend vacation with her new boyfriend.  The patient has an intrauterine device and does not use condoms.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.5 C (101.3 F) and pulse is 98/min.  The oropharynx is clear, and there is no thrush or lymphadenopathy.  Abdominal and pelvic examinations are normal.  The patient has pain along the tendon sheaths with active and passive hand movement.  The skin rash is shown in the image below.  Which of the following is the most likely cause of her symptoms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d50a_1f2f_bc81_1382d9fa68c4_MD0003_00 This patient went on vacation with a new boyfriend and subsequently developed manifestations suggestive of disseminated gonococcal infection (DGI), which typically presents with purulent monoarthritis or the following triad: Polyarthralgia: Migrating asymmetric small and large joint pain Tenosynovitis: Pain along multiple flexor tendon sheaths and with passive range of motion; most common in the wrists, fingers, ankles, and toes Dermatitis: Usually 2-10 pustular/vesiculopustular lesions on the distal extremities that may be confused with pimples or furuncles Fever and chills are also frequently present. Although patients typically have culture-positive urogenital disease, frank symptoms of gonococcal urethritis (eg, dysuria, purulence) are often absent. Definitive diagnosis requires culture of blood and synovial fluid (when effusion is present) and nucleic acid amplification testing of mucosal sites (eg, urethra, anus). Treatment with intravenous ceftriaxone is usually curative, but joint drainage is recommended for those with purulent arthritis. Screening for other sexually transmitted infections (eg, Chlamydia trachomatis) should be performed because coinfections are common. (Choice A) Acute HIV infection often causes fever, arthralgias, and rash. However, the rash is typically maculopapular and involves the upper thorax, neck, and face. Many patients also have sore throat, lymphadenopathy, and/or mucocutaneous ulcers. (Choice B) Acute rheumatic is associated with migratory arthritis of the large joints and rash. However, the rash is raised, ring-shaped lesions over the trunk and extremities (erythema marginatum) or subcutaneous nodules. In addition, pharyngitis typically precedes other symptoms by 2-4 weeks. (Choice D) Late Lyme disease often causes monoarticular arthritis, and early Lyme disease can cause rash. However, the rash is a target-like, spreading annular lesion (erythema migrans); pustular lesions and tenosynovitis would be atypical. erythema migrans (Choice E) Meningococcemia typically presents with acute-onset petechial rash, high fever, headache, nausea/vomiting, stiff neck, and photophobia that progress within hours to septic shock and death. This patient with 4 days of symptoms is unlikely to have meningococcemia; in addition, tenosynovitis and a pustular rash would be atypical. (Choice F) Primary syphilis typically causes a painless, ulcerative lesion with heaped-up borders (chancre). Secondary syphilis causes a diffuse, symmetric macular or papular rash that involves the palms and soles. A few pustular lesions and tenosynovitis would be atypical. chancre Educational objective: Disseminated gonococcal infection causes monoarticular purulent arthritis or the triad of polyarthralgia, tenosynovitis, and vesiculopustular skin lesions. Although many patients have positive genitourinary cultures, symptoms of gonococcal urethritis (eg, dysuria, purulence) are often absent.

A 24-Year-Old Woman Comes to the Clinic Due to 4