Question

Difficulty: MediumRheumatology and Immunology

A 2828-year-old male is seen at the university health clinic for right knee pain and swelling that began 33 days ago. He also reports a mild burning sensation when urinating and bilateral eye redness. Four weeks ago, he experienced an episode of severe, watery diarrhea that resolved without medical intervention after several days. His temperature is 37.3∘C37.3^\circ\text{C} (99.1∘F99.1^\circ\text{F}), blood pressure is 122/78 mmHg122/78\text{ mmHg}, and pulse is 84/min84/\text{min}. Physical examination reveals a warm, swollen, and tender right knee with a palpable effusion. There is exquisite tenderness upon palpation of the left posterior heel at the calcaneal insertion. The conjunctivae are injected bilaterally. Arthrocentesis of the right knee yields synovial fluid with a leukocyte count of 22,000/mm322,000/\text{mm}^3 and no organisms on Gram stain. Which of the following is the most appropriate next step in management for this patient?

  1. A
    Intramuscular ceftriaxone and oral doxycycline
  2. B
    Transthoracic echocardiography
  3. Oral naproxenAnswer
  4. D
    Human leukocyte antigen B27 typing
  5. E
    Diagnostic arthroscopy with joint lavage

Answer

The most appropriate next step is initiating therapy with a nonsteroidal anti-inflammatory drug, such as oral naproxen.
The correct answer provides the standard first-line treatment for reactive arthritis. This patient presents with the classic triad of arthritis, conjunctivitis, and urethritis following a gastrointestinal infection (likely Campylobacter, Salmonella, Shigella, or Yersinia). He also has enthesitis (Achilles tendon tenderness), a hallmark of seronegative spondyloarthropathies. The synovial fluid analysis reveals an inflammatory but sterile effusion (leukocyte count of 22,000/mm322,000/\text{mm}^3 and no organisms). Because the joint inflammation is immune-mediated rather than directly infectious, nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen or ibuprofen are the primary treatment.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and history.
The patient exhibits asymmetric oligoarthritis (right knee), enthesitis (Achilles tenderness), conjunctivitis, and urethritis following a recent diarrheal illness.
Identifying the classic triad (arthritis, conjunctivitis, urethritis) and prior inciting infection establishes the diagnosis.
2
Interpret the synovial fluid analysis.
The leukocyte count is 22,000/mm322,000/\text{mm}^3 with a negative Gram stain.
This confirms an inflammatory, sterile effusion rather than a purulent septic arthritis (which typically presents with >50,000/mm3>50,000/\text{mm}^3 leukocytes).
3
Determine the appropriate therapeutic intervention.
Select a nonsteroidal anti-inflammatory drug (NSAID).
Because reactive arthritis is an immune-mediated sterile inflammation, NSAIDs are the standard first-line symptomatic treatment.

Key Concept

Reactive arthritis is a seronegative spondyloarthropathy presenting with asymmetric oligoarthritis, enthesitis, and extra-articular symptoms (conjunctivitis, urethritis) following a gastrointestinal or genitourinary infection. The joint inflammation is sterile and treated first-line with NSAIDs.
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