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Old 09-21-2012
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Arrow Gyrus Daily Questions; Internal Medicine #16

A 45-year-old woman presents to the emergency room for evaluation of fatigue, fever, and acute onset of joint pain and swelling of the right knee, left ankle, and right second toe. She reports that she was ill with a diarrheal illness about 2 weeks ago. She did not seek evaluation as the symptoms resolved spontaneously over 48 h. She did lose about 2.3 kg, which she has been unable to regain. Three days ago, she developed a feeling of malaise with fevers and pain in her right second toe. Additional joints have become inflamed over the ensuing 72 h. She denies any prior similar episodes. She is not currently sexually active and estimates her last sexual activity to be 8 months prior to presentation. She has a history of seasonal rhinitis, but is taking no medications currently. On examination, she is febrile at 38.4°C. Her left eye has evidence of conjunctival injection. There is a superficial ulcer on the inside of her lower lip that is not painful. The right knee is warm to touch with an effusion. Passive movement results in pain. The left ankle is similarly warm and painful. The right second great toe has the appearance of a “sausage digit.” There is also pain with palpation at the tendinous insertion of both Achilles tendons. There are no genital ulcers or discharge. No rash is present. Arthrocentesis is performed and is consistent with inflammatory arthritis without crystals or organisms seen on Gram stain. Cervical probes for Neisseria gonorrhoeae and Chlamydia trachomatis are negative. Reactive arthritis following Campylobacter infection is suspected with positive serum antibodies to C. jejuni. Which of the following statements is true regarding this diagnosis?

A. Chronic joint symptoms affect 15% of individuals, and recurrences of the acute syndrome may occur.
B. Presence of HLA-B27 antigen predicts individuals who are likely to have a better prognosis.
C. Reactive arthritis is self-limited and should be expected to resolve spontaneously over the next 2 weeks.
D. The causative organism has no effect on long-term outcomes following an initial episode of reactive arthritis
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Old 09-21-2012
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D. The causative organism has no effect on long-term outcomes following an initial episode of reactive arthritis

Man it took hell lot of time to read this. Reminded me of my graduation exam questions.... ;-)




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D

Once you have it you have it, regardless of the trigger
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Old 09-22-2012
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The answer is A. Chronic joint symptoms affect 15% of individuals, and recurrences of the acute syndrome may occur.

Reactive arthritis is an acute inflammatory arthritis that occurs in the context of an infection elsewhere in the body.

The most common causes of reactive arthritis are diarrhea and urethritis. Individuals with reactive arthritis typically present with asymmetric polyarthritis with associated fever, fatigue, and weight loss.

Most often these symptoms begin 1–4 weeks after an antecedent illness. The arthritis usually begins with a single joint affected, but additional joints become inflamed over the next 1–2 weeks. The arthritis is painful with frequent effusions present. The most commonly affected joints are those of the lower extremities.

Dactylitis presenting as a “sausage digit” with diffuse swelling of a single toe or finger may occur. Pain at tendinous insertion, known as enthesitis, is also a feature of reactive arthritis.

Extraarticular manifestations of reactive arthritis include urethritis, prostatitis, uveitis, and oral ulcers. In rare instances, life-threatening systemic manifestations can occur including cardiac conduction defects, aortic insufficiency, pulmonary infiltrates, and central nervous system disease. The arthritis typically persists for 3–5 months and can be present for up to a year. Fifteen percent of individuals will develop chronic joint symptoms, and relapses with recurrence of acute arthritis may occur. Risk factors for a worse outcome include presence of HLA-B27 antigen and epidemic shigellosis
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