A 27-year-old man comes to the physician with pain in his left knee, ankle, and lower back over the last week. His back feels stiff in the morning and improves with activity. Three months ago, he was treated for chlamydia proctitis with azithromycin and ceftriaxone. He also had painless sores on his glans penis, but tests for syphilis were negative at that time. On examination, he still has multiple shallow ulcers on the glans penis. The patient reports no change in appearance of the ulcers over the 3-month period. There is no urethral discharge or inguinal lymphadenopathy. The left knee and ankle joints are swollen and nontender. No redness or warmth is noted. Laboratory results are as follows: Synovial fluid aspirated from the knee shows a white blood cell count of 4,000/mm³ with 80% neutrophils. Gram stain is negative and no pathogen is isolated on fluid culture.
Which of the following is the best next step in management of this patient?

Question

A 27-year-old man comes to the physician with pain in his left knee, ankle, and lower back over the last week. His back feels stiff in the morning and improves with activity. Three months ago, he was treated for chlamydia proctitis with azithromycin and ceftriaxone. He also had painless sores on his glans penis, but tests for syphilis were negative at that time. On examination, he still has multiple shallow ulcers on the glans penis. The patient reports no change in appearance of the ulcers over the 3-month period. There is no urethral discharge or inguinal lymphadenopathy. The left knee and ankle joints are swollen and nontender. No redness or warmth is noted. Laboratory results are as follows:

Synovial fluid aspirated from the knee shows a white blood cell count of 4,000/mm³ with 80% neutrophils. Gram stain is negative and no pathogen is isolated on fluid culture.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0bf_1056_8f63_27d10ba46a89_MD0005_00 Recent-onset asymmetric oligoarthritis that is inflammatory (elevated white blood cell count) yet sterile (culture negative) in a patient with a recent history of chlamydia infection is suggestive of reactive arthritis (ReA). Sacroiliac joints may also be involved. Extraarticular symptoms such as urethritis, uveitis, circinate balanitis, and keratoderma blennorrhagicum may be present. ReA usually develops within 1-4 weeks of the inciting infection. Therefore, new symptoms suspicious for ReA in a patient with history of chlamydia should prompt repeat testing for infection even in the absence of obvious symptoms. The nucleic acid amplification test (NAAT) for chlamydia is usually performed on urine samples. Rectal screening is recommended for men who have sex with men or in patients with a history of chlamydia proctitis. Circinate balanitis (painless, shallow ulcers of the glans penis) is an extraarticular manifestation of ReA occurs in 20%-40% of patients. In some patients, it may be the only initial symptom. Circinate balanitis appears within weeks of the primary infection. It may persist for several months before spontaneous resolution, as seen in this patient. By contrast, the painless lesions of lymphogranuloma venereum (LGV) resolve within a few days, and those of syphilis resolve within 3-6 weeks. In addition, this patient does not have lymphadenopathy present in the secondary stages of syphilis and LGV. Therefore, dark field microscopy for syphilitic chancre is not necessary (Choice C). Similarly, NAAT of the penile ulcers, which can be performed to diagnosed LGV (caused by L1, L2, and L3 serovars of Chlamydia trachomatis), is not indicated (Choice B). Circinate balanitis may be treated with topical steroids. (Choice A) Antinuclear antibodies are a nonspecific indicator of autoimmune disease. They are not found in patients with ReA. (Choice E) Herpes simplex virus can be diagnosed with viral cultures or with polymerase chain reaction-based assays. Herpetic lesions are painful, usually vesicular, and resolve within a few weeks. Tender lymphadenopathy may also be present. Educational objective: Reactive arthritis (ReA) may develop within 1-4 weeks of chlamydia infection. Circinate balanitis is an extraarticular manifestation of ReA that is painless, resolves after several months, and is not associated with inguinal lymphadenopathy. New-onset ReA in patients with a history of chlamydia infection should prompt repeat testing for chlamydia, even in those who are otherwise asymptomatic. References: Chlamydia-induced reactive arthritis: hidden in plain sight? (http://www.ncbi.nlm.nih.gov/pubmed/22100286) Successful use of dapsone for the management of circinate balanitis. (http://www.ncbi.nlm.nih.gov/pubmed/24635073)

A 27-Year-Old Man Comes to the Physician with Pain in His