A 27-year-old woman comes to the emergency department due to several days of aching pain in her right ankle, left wrist, and hand joints. She has also had subjective fever and malaise. The patient took acetaminophen and ibuprofen, which provided some pain relief. She takes no other medications and has no chronic medical problems. The patient smokes a pack of cigarettes daily and drinks 1 or 2 glasses of wine most days. She smokes marijuana occasionally but does not use intravenous drugs. She has been sexually active with 2 partners over the last 6 months and uses condoms inconsistently. The patient works in a retail shop in Massachusetts and has not traveled recently. She has no known allergies. Temperature is 38.1 C (100.6 F), blood pressure is 122/65 mm Hg, pulse is 95/min, and respirations are 16/min. The left hand joints are mildly swollen, and passive extension of the fingers elicits pain. There is tenderness of the left wrist and right ankle with no joint effusion. Skin examination reveals scattered pustules over the patient's distal extremities. The remainder of the physical examination shows no abnormalities.
Which of the following is most likely to yield the diagnosis?

Question

A 27-year-old woman comes to the emergency department due to several days of aching pain in her right ankle, left wrist, and hand joints.  She has also had subjective fever and malaise.  The patient took acetaminophen and ibuprofen, which provided some pain relief.  She takes no other medications and has no chronic medical problems.  The patient smokes a pack of cigarettes daily and drinks 1 or 2 glasses of wine most days.  She smokes marijuana occasionally but does not use intravenous drugs.  She has been sexually active with 2 partners over the last 6 months and uses condoms inconsistently.  The patient works in a retail shop in Massachusetts and has not traveled recently.  She has no known allergies.  Temperature is 38.1 C (100.6 F), blood pressure is 122/65 mm Hg, pulse is 95/min, and respirations are 16/min.  The left hand joints are mildly swollen, and passive extension of the fingers elicits pain.  There is tenderness of the left wrist and right ankle with no joint effusion.  Skin examination reveals scattered pustules over the patient's distal extremities.  The remainder of the physical examination shows no abnormalities. 
Which of the following is most likely to yield the diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c16f_9ac8_8f63_9f0237765e95_MD0005_00 This young patient with a history of inconsistent condom use likely has disseminated gonococcal infection (DGI), which typically presents with purulent monarthritis or the following triad: Polyarthralgia: Migrating, asymmetric joint pain in the small and large joints; examination often shows pain, but signs of arthritis (eg, swelling, erythema, warmth) are usually absent. Tenosynovitis: Pain with passive extension and/or tenderness over the flexor sheaths of multiple tendons; the distal extremities are most often affected. Dermatitis: a few (eg, 2-10) painless pustules on the distal extremities or thorax. Fever and malaise also commonly occur. Although mucosal testing for urogenital gonococcus is usually positive, many patients with DGI have no manifestations (eg, dysuria, discharge) of urogenital infection. Diagnostic evaluation requires blood cultures and synovial fluid sampling (if there is an accessible joint effusion), but these tests have low diagnostic sensitivity because Neisseria gonorrhoeae grows fastidiously. Most patients are diagnosed presumptively when nucleic acid amplification testing (NAAT) of a urogenital specimen is positive for N gonorrhoeae. Testing for other sexually transmitted infections (eg, HIV, Chlamydia) should also be performed. (Choice A) Anti-Borrelia burgdorferi antibodies can be used to diagnose early disseminated or late Lyme disease. Early Lyme disease can present with rash (erythema migrans), fever, and arthralgias; however, it is not associated with pustular lesions. Late Lyme disease often causes arthritis; it typically affects a single large joint (eg, knee) and is not associated with rash. (Choice B) Cultures of skin lesions are not typically performed in patients with suspected DGI because diagnostic sensitivity is low. NAAT of a sample from the urogenital mucosa is far more likely to provide proof of infection. (Choice D) Parvovirus B19 is often asymptomatic in adults but can cause fever, arthritis/arthralgia, and a reticulated or lace-like rash. A pustular rash would be atypical. (Choice E) Herpes simplex virus (HSV) can be diagnosed by viral PCR. HSV can cause fever, but skin lesions are typically painful, vesicular, and located on the genitals or oral mucosa. Educational objective: Disseminated gonococcal infection typically presents with purulent monarthritis or the triad of polyarthralgia, tenosynovitis, and dermatitis (pustular lesions on the distal extremities). Diagnosis is typically made presumptively by nucleic acid amplification testing of a urogenital sample.

A 27-Year-Old Woman Comes to the Emergency Department Due to Several