A 36-year-old woman comes to the emergency department due to 12 hours of malaise and fever with chills. The patient also has pain in multiple joints. Her menstrual period started 3 days ago, and she is using 4-6 tampons per day. The patient uses intravenous heroin and sometimes has sex in exchange for a dose of the drug. Temperature is 39.3 C (102.7 F), blood pressure is 122/81 mm Hg, pulse is 104/min, and respirations are 14/min. Examination shows several pustules on the chest and extensor surfaces of the forearms. The palms and soles are unaffected. Joint examination shows no redness or swelling, but the right wrist and right ankle are tender on palpation. Heart sounds are normal. Funduscopy and oropharyngeal examination are normal. There is no cervical, axillary, or inguinal lymphadenopathy. Three sets of blood cultures are negative. Based on these findings, which of the following is the most likely diagnosis in this patient?

Question

A 36-year-old woman comes to the emergency department due to 12 hours of malaise and fever with chills.  The patient also has pain in multiple joints.  Her menstrual period started 3 days ago, and she is using 4-6 tampons per day.  The patient uses intravenous heroin and sometimes has sex in exchange for a dose of the drug.  Temperature is 39.3 C (102.7 F), blood pressure is 122/81 mm Hg, pulse is 104/min, and respirations are 14/min.  Examination shows several pustules on the chest and extensor surfaces of the forearms.  The palms and soles are unaffected.  Joint examination shows no redness or swelling, but the right wrist and right ankle are tender on palpation.  Heart sounds are normal.  Funduscopy and oropharyngeal examination are normal.  There is no cervical, axillary, or inguinal lymphadenopathy.  Three sets of blood cultures are negative.  Based on these findings, which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d1b1_cd13_bc81_d5adc4c9c3d8_MD0003_00 This patient who engages in high-risk sexual behavior has symptoms of disseminated gonococcal infection (DGI), which typically presents with purulent monoarthritis or the following triad: Polyarthralgia: Asymmetric pain in multiple distal and proximal joints. Examination usually shows pain with movement and palpation, but multiarticular joint swelling, erythema, and warmth are uncommon. Pustular rash: Most patients have 2-10 transient pustular or vesiculopustular lesions on the distal extremities; trunk lesions can also occur. The palms and soles may or may not be affected. Tenosynovitis: Pain over the flexor tendons of multiple distal joints (eg, wrists, ankles, fingers, toes) and/or pain with passive range of motion of the joint. Systemic signs of infection (eg, fever, chills, malaise) frequently occur. Although testing often reveals signs of urogenital (eg, dysuria, purulent discharge) infection, many patients have no urogenital symptoms. The diagnosis of DGI requires culture of blood and synovial fluid (when joint swelling is present) and nucleic acid amplification testing (NAAT) of urogenital sites. Because Neisseria gonorrhoeae grows fastidiously, blood and synovial fluid cultures are frequently negative (fewer than one-third of patients had positive blood cultures in one study); therefore, the diagnosis is usually established by NAAT of urogenital sites. (Choice B) Infective endocarditis is common in intravenous drug users and frequently presents with fever, arthritis, and pustular rash. However, the absence of murmur and positive blood cultures makes this less likely; in addition, this patient has only 3 of the minor Duke criteria. Duke criteria (Choice C) Parvovirus B19 is associated with fever, rash, and arthritis. However, the rash is usually on the malar surface. This patient's pustular lesions are not consistent with parvovirus infection. (Choice D) Secondary syphilis can present with fever and rash. However, the rash is usually generalized, symmetric, and maculopapular and typically occurs on the trunk, extremities, palms, and soles. A few pustular lesions would be atypical. Most patients with secondary syphilis have palpable lymphadenopathy. (Choice E) Toxic shock syndrome caused by Staphylococcus aureus is associated with prolonged tampon use. It often presents with fever and rash. However, the rash is usually diffuse, "sunburn-like," and includes the palms and soles; in addition, many patients develop rapid onset of hypotension and multiorgan dysfunction. Educational objective: Disseminated gonococcal infection causes purulent monarthritis or the triad of tenosynovitis, polyarthralgia, and pustular lesions. Blood, synovial, and skin cultures are often negative due to the fastidious nature of Neisseria gonorrhoeae, but urogenital mucosa testing (eg, nucleic acid amplification) is typically positive even in the absence of urogenital symptoms. References: Gonococcal arthritis (disseminated gonococcal infection). (http://www.ncbi.nlm.nih.gov/pubmed/16297736)

A 36-Year-Old Woman Comes to the Emergency Department Due to 12