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RheumatologyMain31-40Q1A28~year-oldwomancomestothephysicianwithpaininherleftkneejoint.Shehadmilddiscomfortandpaininherrightwrist4daysagoandleftanklepain2daysago.Shehasnorecentrespiratoryillness,diarrhea,orurinarysymptoms.Shehasnovaginaldischarge.Thepatienthasnopreviousmedicalproblemsandtakesnomedications.Shedrinkshalfapintofvodkadailybutdoesnotuseintravenousdrugs.Sheissingleandsexuallyactive.Herlastmenstrualperiodwasaweekago.Temperatureis38.5℃(101.3℉),bloodpressureis120/80mmHg;pulseis93/min;andrespirationsare15/min.Examinationofthekneeshowswarmth,tenderness,decreasedrangeofmotion,andaneffusion.Moskinlesionsarepresentandherpelvicexaminationisunremarkable.Synovialfluidanalysisshowsawhitebloodcel!countof50,000/mm³.Whichofthefollowingisthemostlikelycauseofhersymptoms?A.AcuteHIVinfectionB.AcuterheumaticfeverC.Crystal-inducedarthritisD.GonococcalsepticarthritisE.InfectiveendocarditisF.Mon-gonococcalsepticarthritisG.ReactivearthritisA1Correctanswer:DThefever,kneepain,andwhitebloodcell(WBC)countof50,000/mm³onsynovialfluidanalysisstronglysuggestsepticarthritis.Septicarthritisinayoung,sexuallyactiveindividualismostoftencausedbyNeisseriagonorrhoeae(75%ofcases).Gonococcalsepticarthritismaypresentwithasymmetricpolyarthralgias(mostoftenassociatedwithtenosynovitisandskinrash)oranisolatedpurulentmono-oroligoarthritis,insomepatients,asymmetricpolyarthralgiasmayprecedepurulentmonoarthritis.Roughly75%ofcasesaresilent,meaningthattheprecedinggenitourinaryorpharyngealinfectiongoesunnoticed.Forthispatient,migratoryasymmetricpolyarthralgiasoftherightwristandleftankleprecededpurulentmonoarthritisoftheleftknee.Althoughskinrashandtenosynovitisarenotpresentinthispatient,purulentarthritisinasexuallyactiveindividualisgonococcalarthritisuntilprovenotherwise.Synovialfluidwhitebloodcel!countisabout50,000/mm³(slightlylowerthanothersepticarthritides).Gramstainofthesynovialfluid(positivein25%ofcases),bloodcultures(positivein20%-50%ofcases),andgenital/pharyngealmucosa!nucleicacidamplificationtests(positiveIn90%ofcases)areusedtoconfirmthediagnosis.Treatmentisceftriaxoneorcefotaxime.(ChoiceA)SymptomsofacuteHIVinfectiontendtopresent2-4weeksafterexposuretothevirus.Thesymptomsarenonspecificandincludefever,arthraSgias,sorethroat,lymphadenopathy,mucocutaneouslesions,diarrhea,andweightloss.(ChoiceB)Acuterheumaticfevergenerallyoccurs2-4weeksafterpharyngitiscausedbyGroupAStreptococcus.Symptomsofacuterheumaticfeverincludemigratoryarthritisofthelargejoints,erythemamarginatumrash,subcutaneousnodules,carditis,andSydenhamchorea.(ChoiceC)Crystal-inducedarthritisoftenpresentswithawarm,painful,swollenjointaccompaniedbylow-gradefever.Synovia!fluidanalysisshowsaWBCcountof5,000-80,000/mm³andcharacteristiccrystalsunderpolarizedlight.(ChoiceG)ReactivearthritismaybecausedbygenitourinaryinfectionwithChlamydiatrachomatisorbycertaingastrointestinalinfections.Itpresentswithatriadofarthritis,,conjunctivitis,andurethritis.Educationalobjective:Neisseriagonorrhoeaeisthemostcommoncauseofsepticarthritisinyoung,sexuallyactivepatients.Gonococcalsepticarthritismaypresentwithasymmetricpolyarthralgias(oftenassociatedwithtenosynovitisandskinrash)orasanisolatedpurulentmono-orpolyarthritis.DiagnosismaybeconfirmedbyGramstainofthesynovialfluid,bloodcultures,andgenital/pharyngealmucosalnucleicacidamplificationtests.Q2A24~year-oldwomancomestothephysiciancomplainingofaskinrashandpaininherwrists;anklesandelbowsoverthepast4days.Shehasalsohadafeverandsweats,butdeniesheadache,nauseaorvomiting.Shehasnosignificantpastmedicalhistoryanddoesnottakeanymedications.Sherecentlytookavacationwithhernewboyfriend.Shedeniesanyprevioussexuallytransmitteddiseasesbutacknowledgeshavingunprotectedsexwithhernewboyfriend.Shedoesnotusetobacco,alcoholorillicitdrugs.HertemperatureIs33.5°C(101.3°F)andherpulseis98/min.Heroropharynxisclearandthereisnothrushorlymphadenopathy.Herabdomenisbenignandthepelvicexaminationiswithinnormallimits.Shehaspainalongthetendonsheathswithactiveandpassivehandmovement.Aphotoofherskinrashisshownbelow.Whichofthefollowingisthemostlikelycauseofhersymptoms?A.LymediseaseB.SyphilisC.GonococcemiaD.MeningococcemiaE.AcuteHIVinfectionF.AcuterheumaticfeverA2Correctanswer:CThispatienthastheclassictriadofpolyarthralgia,tenosynovitis,andpainlessvesiculopustularskinlesionsfordisseminatedgonococcalinfection.Hercomplaintsofwrist,elbowandanklepainareconsistentwithgonococcalpolyarthralgias,andherpainelicitedalongthetendonsheathssuggeststenosynovitis.Thelesionsshowninthephotographaretypicalvesiculopustularlesionsofdisseminatedgonococcalinfection;theytendtonumberfromtwototenandmaybedismissedasfurunclesorpimples.Feversandchillsmaybepresent.Ahistoryofrecentunprotectedsexwithanewpartnerisfrequentlyassociatedwithdisseminatedgonococcalinfection,whilesymptomsofsymptomaticvenerealdiseasearemostoftenabsent.(ChoiceA)ArthritisandrashareassociatedwithLymedisease.Therash(erythemamigrans)ofLymediseaseoccursearlyoninillness,whilearthritis,typicallymonoarticularkneepain,doesnotoccuruntilmonthslater.Erythemamigransoccursatthesi