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Difficulty: EasyRheumatology and Immunology

A 26-year-old man comes to the office due to a 5-day history of right knee swelling and pain. He also reports a mild burning sensation during urination and bilateral eye redness that started around the same time. He has no significant past medical history and takes no medications. Three weeks ago, he had a 4-day episode of abdominal cramps and watery diarrhea that resolved without medical treatment. His temperature is 37.6°C (99.7°F), blood pressure is 120/80 mm Hg, and pulse is 82/min. Physical examination reveals bilateral conjunctival injection. The right knee is swollen, warm, and tender to palpation with a moderate effusion. Arthrocentesis is performed. Synovial fluid analysis shows a leukocyte count of 24,000/mm³ with a negative Gram stain and no crystals. Which of the following is the most appropriate initial management for this patient's condition?

  1. A
    Intravenous ceftriaxone
  2. B
    Oral methotrexate
  3. C
    Oral allopurinol
  4. Oral ibuprofenAnswer
  5. E
    Intra-articular glucocorticoid injection

Answer

The correct answer is oral ibuprofen, as nonsteroidal anti-inflammatory drugs are the preferred first-line treatment for reactive arthritis.
This patient's presentation of asymmetric oligoarthritis, conjunctivitis, and urethritis following a recent gastrointestinal illness is the classic triad of reactive arthritis. Reactive arthritis is a seronegative spondyloarthropathy that typically develops 1 to 4 weeks after a gastrointestinal (e.g., Salmonella, Shigella, Campylobacter) or genitourinary (e.g., Chlamydia) infection. Synovial fluid analysis characteristically reveals an inflammatory effusion (often 2,000 to 50,000 leukocytes/mm³) with a negative Gram stain and no crystals, confirming a sterile inflammatory process. The initial and most effective treatment for the acute joint inflammation in reactive arthritis is a nonsteroidal anti-inflammatory drug (NSAID), such as oral ibuprofen.

Step-by-Step Solution

1
Identify the patient's clinical syndrome based on the history and physical examination.
The combination of asymmetric oligoarthritis, conjunctivitis, and urethritis following a recent diarrheal illness is classic for reactive arthritis.
To establish the underlying diagnosis before determining the appropriate treatment.
2
Evaluate the synovial fluid analysis results.
The synovial fluid shows an inflammatory leukocyte count (24,000/mm³) but is sterile (negative Gram stain) and free of crystals.
To safely rule out septic arthritis and crystal arthropathies, which require entirely different management.
3
Select the most appropriate initial therapy for the diagnosed condition.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are selected.
NSAIDs are the first-line symptomatic treatment for the immune-mediated joint inflammation seen in reactive arthritis.

Key Concept

The classic presentation of reactive arthritis (arthritis, urethritis, and conjunctivitis following a gastrointestinal or genitourinary infection) and its initial management with nonsteroidal anti-inflammatory drugs.
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Topics

Rheumatology and Immunology

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