A 16-year-old girl is brought to the office due to pain in multiple joints. The pain has primarily been in her left knee and hip, right shoulder, and both wrist and hand joints. The patient says the pain seemed to be in one joint and would improve after a day or 2 before moving to a different joint. She also notes that she had 2 days of fever and malaise a week ago, but these have since resolved. Physical examination shows tenderness and pain on movement of the bilateral wrists and left fingers. There is mild swelling and tenderness of the left knee with no erythema. Several 3- to 4-mm, nontender pustules with a surrounding erythematous rim are present on the left lower extremity. Left knee arthrocentesis yields clear synovial fluid with a leukocyte count of 30,000/mm³. Synovial fluid culture is negative. Which of the following historical factors is most likely associated with this patient's presentation?

Question

Quizplus · Accepted Answer

11ec25c8_d2c7_3432_bc81_9bb72e0db824_MD0003_00 This patient likely has disseminated gonococcal infection (DGI), which usually presents with either purulent monarthritis or the triad of pustular rash, migrating arthralgia, and tenosynovitis. Although it is unclear why disseminated Neisseria gonorrhoeae infection causes 2 distinct systemic syndromes, a minority of patients with DGI have overlapping manifestations; this is particularly common when the condition is untreated for long periods (as is likely in this patient with symptoms >1 week). N gonorrhoeae is transmitted by unprotected sexual intercourse. It typically causes infectious urethritis (eg, purulent discharge, dysuria), but asymptomatic infections are common, particularly in women. Untreated urogenital infection can spread through the blood, leading to DGI in 0.5%-3% of cases. Patients with suspected DGI who have joint effusion require synovial fluid sampling. In contrast to most other forms of bacterial arthritis, DGI is marked by synovial fluid leukocyte count <50,000/mm³. In addition, synovial fluid culture is usually negative because N gonorrhoeae is a fastidious intracellular organism that does not grow well on standard media. As such, DGI is generally diagnosed presumptively based on clinical symptoms and a positive urogenital nucleic acid amplification test (urogenital assays are usually positive even when no urogenital symptoms are present). Treatment with intravenous ceftriaxone is curative in most cases. (Choice A) Unimmunized children age ˂5 are at risk for septic arthritis from Haemophilus influenzae type b and Streptococcus pneumoniae. However, these rarely cause septic arthritis in older children and adolescents, even amongst unimmunized patients. (Choice B) Transient synovitis is a self-limited, reactive arthritis that often follows upper respiratory tract infections. It typically occurs in younger children (age ≤10) and does not cause a pustular rash. (Choice C) Skin abrasions can lead to hematogenous dissemination of Staphylococcus aureus or Streptococcus pyogenes, the most common causes of septic arthritis. However, patients usually have high fever and a markedly elevated synovial fluid leukocyte count (>50,000/mm³); in addition, synovial fluid culture is usually positive. (Choice D) Tick bites are associated with Lyme disease, which can cause rash early after transmission and large-joint monarthritis months or years later. The rash of Lyme disease is an target-shaped, spreading lesion (erythema migrans), not pustular lesions. Arthritis and rash rarely occur together. Educational objective: Neisseria gonorrhoeae is contracted via unprotected sexual intercourse. Although it usually causes symptomatic urogenital disease, a minority of patients develop disseminated gonococcal infection, which typically presents with either purulent monarthritis or pustular rash, tenosynovitis, and migrating arthralgia. Overlapping symptoms occasionally occur. References: Cutaneous manifestations of disseminated gonococcemia. (http://www.ncbi.nlm.nih.gov/pubmed/28329470) Disseminated gonococcal infection. (http://www.ncbi.nlm.nih.gov/pubmed/30995376)

A 16-Year-Old Girl Is Brought to the Office Due to Pain