A 46-year-old woman comes to the office for follow-up of rheumatoid arthritis. The patient was diagnosed 2 years ago and started on treatment with prednisone and methotrexate; she had a good initial response to treatment, and the oral glucocorticoid was gradually tapered. However, her symptoms have progressively worsened over the last several months, despite increases in the methotrexate dose. The patient continues to have hand stiffness and pain lasting 2-3 hours every morning and increasing knee and ankle pain. She takes frequent doses of acetaminophen and ibuprofen but her symptoms still significantly restrict her daily activities. Medical history is otherwise unremarkable. The patient does not use tobacco, alcohol, or illicit drugs. Physical examination shows symmetric swelling and tenderness of the proximal small hand joints, wrists, and knees. Blood cell count shows mild normochromic, normocytic anemia with normal leukocyte and platelet counts. Erythrocyte sedimentation rate is 55 mm/hr. Hand x-ray reveals periarticular osteopenia and mild joint erosions. The new treatment is initiated and the patient's symptoms gradually improve. Six months later, she returns to the office with 12 hours of right knee pain. The patient has had no trauma and says, "This pain is more severe than prior arthritis flare-ups." Temperature is 38.3 C (101 F), blood pressure is 130/80 mm Hg, pulse is 82/min, and respirations are 14/min. Right knee examination demonstrates a moderate effusion, warmth, and tenderness. Range of motion is decreased due to pain. Which of the following is the best next step in management of this patient's condition?

Question

A 46-year-old woman comes to the office for follow-up of rheumatoid arthritis.  The patient was diagnosed 2 years ago and started on treatment with prednisone and methotrexate; she had a good initial response to treatment, and the oral glucocorticoid was gradually tapered.  However, her symptoms have progressively worsened over the last several months, despite increases in the methotrexate dose.  The patient continues to have hand stiffness and pain lasting 2-3 hours every morning and increasing knee and ankle pain.  She takes frequent doses of acetaminophen and ibuprofen but her symptoms still significantly restrict her daily activities.  Medical history is otherwise unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.  Physical examination shows symmetric swelling and tenderness of the proximal small hand joints, wrists, and knees.  Blood cell count shows mild normochromic, normocytic anemia with normal leukocyte and platelet counts.  Erythrocyte sedimentation rate is 55 mm/hr.  Hand x-ray reveals periarticular osteopenia and mild joint erosions. The new treatment is initiated and the patient's symptoms gradually improve.  Six months later, she returns to the office with 12 hours of right knee pain.  The patient has had no trauma and says, "This pain is more severe than prior arthritis flare-ups."  Temperature is 38.3 C (101 F), blood pressure is 130/80 mm Hg, pulse is 82/min, and respirations are 14/min.  Right knee examination demonstrates a moderate effusion, warmth, and tenderness.  Range of motion is decreased due to pain.  Which of the following is the best next step in management of this patient's condition?

Quizplus · Accepted Answer

Explanation: Septic arthritis should be considered in patients with rheumatoid arthritis who develop acute monoarthritis, especially those on immunosuppressive therapy or when systemic signs of infection (eg, fever) are also present. Expedited joint aspiration is recommended and fluid should be sent for cell count, Gram stain, and culture. Blood cultures are positive in approximately 50% of patients and should be obtained along with synovial fluid studies prior to antibiotic therapy. Treatment of septic arthritis requires prompt administration of intravenous antibiotics to lessen the likelihood of joint destruction (Choice D). (Choice A) Short courses of glucocorticoids are appropriate for flare-ups of rheumatoid arthritis symptoms. Such flares are typically polyarticular. This patient's acute, severe monoarthritis is more consistent with septic arthritis. (Choice B) MRI for evaluation of septic arthritis is primarily used in joints that are not easily accessible with arthrocentesis (eg, lumbar facet joints, sternoclavicular joints). However, routine use can delay proper diagnosis, and this patient should proceed directly to joint aspiration. (Choice E) Joint replacement is primarily considered for chronic management of late-stage arthritis that limits patient activity. This patient's acute symptoms require immediate action to control infection. Educational objective: Septic arthritis should be considered in patients with rheumatoid arthritis who develop acute monoarthritis, especially in patients on immunosuppressive therapy or when it is accompanied by systemic signs of infection (eg, fever). Expedited joint aspiration is recommended, and fluid should be sent for cell count, Gram stain, and culture.

A 46-Year-Old Woman Comes to the Office for Follow-Up of Rheumatoid