the most appropriate next step - pursuit

[ArchivalUser]

pursuit:

I am not sure for how long we should be waiting the correct answer, but please don't make it so long.

Thanks

[ArchivalUser]

yes E&B are correct answers

[ArchivalUser]

Sorry for the delay.

The correct answer is E.

This patient has a monoarticular arthritis with a very high white cell count in the arthrocentesis strongly suggestive of a septic arthritis. Since the gram stain is unrevealing in this case (which you should be aware can happen) as to the specific organism, broad-spectrum antibiotics to cover the two most likely organisms is appropriate. This includes therapy for gonococcus (ceftriaxone) as well as nafcillin for Staphylococcus aureus septic arthritis.

Either ceftriaxone or nafcillin alone (choices A and D) would be insufficient.

Since the polarizing microscopy is negative, there is no indication for colchicine (choice B).

Indomethicin (choice C) may be an adjunctive therapy but is not the appropriate therapy in a patient with this many white blood cells in the joint fluid, consistent with a septic arthritis.


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.

[ArchivalUser]

pursuit -

In the second question; if it was single hot joint (monoarthritis), would it be still reactive arthritis, or septic artheritis? In other words, can reactive artheritis present with single hot joint, or usually poly?

Thanks

[ArchivalUser]

pursuit -

In the second question; if it was single hot joint (monoarthritis), would it be still reactive arthritis, or septic artheritis? In other words, can reactive artheritis present with single hot joint, or usually poly?

Thanks

[ArchivalUser]

How specific are sausage digits for psoriatic arthritis?

[ArchivalUser]

I am convinced that the first question's answer is 'E' for inital step to cover septic arthritis by broad spectrum.
For the second question : polyarthralgia + severely tender heel ( tendonitis ) + sausage digits, I think more specific for Psoriatic Arthritis, which the answer would still be 'B" NSAIDs.

[ArchivalUser]

Reiter's syndrome is triad of arthritis, conjunctivits, urethritis... pt can't see, can't pee, can't climb a tree !