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Difficulty: MediumRheumatology and Immunology

A 28-year-old man comes to the physician because of a 5-day history of right knee swelling, left heel pain, and redness in both eyes. He reports no recent trauma. Four weeks ago, he had a diarrheal illness that resolved spontaneously after 33 days. His temperature is 37.2∘C37.2^{\circ}\text{C} (99.0∘F99.0^{\circ}\text{F}), blood pressure is 122/78122/78 mmHg, and pulse is 84/min. Physical examination shows a moderately effused, warm, and tender right knee. There is marked tenderness to palpation at the insertion of the left Achilles tendon. 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 (75%75\% neutrophils). Gram stain of the fluid shows no organisms, and polarized light microscopy reveals no crystals. Which of the following is the most appropriate initial pharmacotherapy for this patient's current symptoms?

  1. A
    Intravenous cefotaxime
  2. B
    Oral ciprofloxacin
  3. C
    Oral febuxostat
  4. Oral indomethacinAnswer
  5. E
    Oral sulfasalazine

Answer

The most appropriate initial pharmacotherapy is a nonsteroidal anti-inflammatory drug (NSAID) such as oral indomethacin.
The clinical picture of acute asymmetric oligoarthritis, enthesitis (Achilles tenderness), and conjunctivitis following a gastrointestinal infection is highly characteristic of reactive arthritis. Synovial fluid analysis typically shows an inflammatory pattern (leukocytes between 2,0002,000 and 50,000/mm350,000/\text{mm}^3) but is sterile, with no crystals or organisms. The initial management of choice for the joint inflammation in reactive arthritis is systemic nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin. These agents provide rapid relief of symptoms while the condition naturally resolves in most patients.

Step-by-Step Solution

1
Analyze the patient's history and clinical presentation.
The patient exhibits asymmetric oligoarthritis (right knee), enthesitis (left Achilles tendon), and conjunctivitis following a recent diarrheal illness.
Identifying the classic clinical triad and linking it to a preceding gastrointestinal infection establishes the clinical syndrome of reactive arthritis.
2
Evaluate the synovial fluid analysis results.
The fluid shows 22,00022,000 leukocytes/mm3\text{mm}^3 with negative Gram stain and no crystals.
This inflammatory but sterile profile confidently rules out septic arthritis (which typically has >50,000>50,000 WBCs/mm3\text{mm}^3 and positive cultures) and crystal arthropathies like gout.
3
Determine the most appropriate initial therapy for the diagnosed condition.
Systemic NSAIDs are selected as the first-line treatment.
Reactive arthritis is initially managed with symptomatic anti-inflammatory therapy to reduce joint pain and swelling.

Key Concept

Diagnosis and initial management of reactive arthritis.
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Topics

Rheumatology and Immunology

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