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A 26-year-old white male presented with polyarthralgias, and severe heel pain. He discloses that he had a sexual intercourse with prostitute; since then he started having urethral discharge. On examination all his digits are diffusely swollen and appears like œsausage digits. Gram stain of the urethral discharge and joint aspiration is negative for organisms. Which of the following is the most appropriate next step in the management of this patient?
A. Treatment with corticosteroids
B. Treatment with NSAIDs
C. Treatment with ceftriaxone IM one dose
D. Draw blood cultures
E. Treatment with methotrexate
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The correct answer is B
This patient is most likely suffering from arthritis reactive to genitourinary infection by Chlamydia. Reactive arthritis is a form of seronegative spondyloarthropathy. This patient also has evidence of enthesopathy that has caused heel pain and sausage digits in this patient. Enthesopathy is quite specific for spondyloarthropathy.
The treatment of choice for reactive arthritis or Reiter™s syndrome is with NSAIDs. Tetracycline may be added to them if the disease is due to genitourinary infection with Chlamydia and this will result in early resolution of symptoms due to anti-chlamydial and anti-inflammatory activity of tetracycline. Patients who are refractory to the above treatment may benefit from sulfasalazine, infliximab and methotrexate.
Treatment with IM ceftriaxone is indicated when there is gonococcal infection that is a gram-negative diplococcus. Gonococcal infection is not a cause of reactive arthritis. In cases of gonococcal infection, gram stain of the urethral discharge will shows gram-negative diplococcus.
Blood cultures are not the appropriate choice in this setting since this is not a septic process.
