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Old 09-21-2012
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Arrow Gyrus Daily Questions; Internal Medicine #17

A 26-year-old man presents with severe bilateral pain in his hands, ankles, knees, and elbows. He is recovering from a sore throat and has had recent fevers to 38.9°C. Social history is notable for recent unprotected receptive oral intercourse with a man ~1 week ago. Physical examination reveals a well-developed man in moderate discomfort. He is afebrile. His pharynx is erythematous with pustular exudates on his tonsils. He has tender anterior cervical lymphadenopathy. His cardiac examination is notable for a normal S1 and S2 and a soft ejection murmur. His lungs are clear. Abdomen is benign with no organomegaly. He has no rash, and genital examination is normal. His bilateral proximal interphalangeal joints, metacarpophalangeal joints, wrists, ankles, and metatarsophalangeal joints are red, warm, and boggy with tenderness noted with both passive and active movement. A complete metabolic panel and complete blood count are all within normal limits. His erythrocyte sedimentation rate is 85 mm/h and C-reactive protein is 11 mg/dL. What is the most likely diagnosis?


A. Acute HIV infection
B. Acute rheumatic fever
C. Lyme disease
D. Neisseria gonorrhoeae infection
E. Poststreptococcal reactive arthritis
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gonococcal arthritis
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Ya it would be infective arthritis
D. Neisseria gonorrhea infection.



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I think D....
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C-reactive protein is 11 mg/dL ?
Don't have a clue about the answer.
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Quote:
Originally Posted by Novobiocin View Post
C-reactive protein is 11 mg/dL ?
Don't have a clue about the answer.
Sir, when there is no clue about the answer, just remember God and pick one choice....Dont leave the question unattempted as u just did .
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The answer is E.
E. Poststreptococcal reactive arthritis

This patient has a small-joint, symmetric polyarthritis in the setting of a very recent sore throat.

A. Although acute HIV commonly presents with a sore throat, other common features, such as rash, are missing. Moreover, the incubation period between this patient’s high-risk sexual encounter and clinical syndrome would be too short for acute HIV infection. Certainly, this patient should be screened for HIV infection.

The patient meets clinical criteria for group A Streptococcus throat infection
given his recent fever, pustular exudates on examination, tender cervical lymph nodes, and lack of cough. His syndrome is consistent with a reactive arthritis, given the symmetric small-joint involvement and very short incubation period. Acute rheumatic fever is also seen with streptococcal throat infections but is very uncommon in the developed world. One would expect to see a latency period ranging between 1 and 5 weeks between resolution of sore throat and arthritis; asymmetric large-joint involvement; and possibly evidence of carditis, chorea, erythema marginatum, or subcutaneous nodules to suspect a diagnosis of acute rheumatic fever.

Gonococcal infection can cause pharyngitis but is more commonly associated with single large-joint infection or enthesopathy, but not small-joint polyarthritis. Lyme disease is a clinical diagnosis contingent upon tick exposure, a classic target lesion rash, and, if present, a migratory large-joint arthritis
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