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.
The suspected pathogen is detected in this patient. Which of the following is the most appropriate therapeutic regimen?

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.
The suspected pathogen is detected in this patient. Which of the following is the most appropriate therapeutic regimen?

Quizplus · Accepted Answer

Explanation: This patient most likely has reactive arthritis (ReA) from the recurrent chlamydia infection. In studies, chlamydia DNA has been isolated from synovial fluid of affected patients. Because persistent chlamydia infection may lead to chronic (>6 months) ReA, an active infection (symptomatic or asymptomatic) requires treatment with antibiotics. Self-limited gastrointestinal infections do not warrant antibiotic therapy. Antibiotic use in itself does not provide rapid relief of arthritic symptoms, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen or indomethacin, are indicated (Choice A). (Choices C, D and E) Exercise is useful in preserving joint mobility when lumbosacral joints are affected. In peripheral arthritis, rest and icing of the affected joint are recommended. Persistent arthritic symptoms, despite adequate NSAID therapy, may require intraarticular glucocorticoids, systemic glucocorticoids, and disease-modifying antirheumatic drugs such as sulfasalazine or methotrexate in a step-wise manner. Educational objective: Active chlamydia infection should be treated in patients with reactive arthritis. Symptomatic treatment with nonsteroidal anti-inflammatory drugs is also indicated. References: Chlamydia and chronic arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/21864020) Treatment of reactive arthritis: a practical guide. (http://www.ncbi.nlm.nih.gov/pubmed/18034510) Seronegative arthritis in South Asia: an up-to-date review. (http://www.ncbi.nlm.nih.gov/pubmed/24515283)

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