Photo Rounds

Conjunctivitis and oral inflammation

A 42-year-old woman presented to her family physician (FP) with fever (102.6° F), chills, and generalized pain in her joints, abdomen, and pelvis. Her symptoms developed gradually over the prior 48 to 72 hours. The patient had bilateral conjunctival injection and oral mucosal inflammation; her abdomen was diffusely tender, with no distension or organomegaly. She did not have any rash. Pelvic examination revealed normal mucosa with thin white cervical discharge and cervical motion tenderness. The patient said she’d not been sexually active for 3 weeks and had no abnormal vaginal discharge, pharyngitis, or eye pain. The patient said she took an occasional acetaminophen and denied illicit drug use.

What’s your diagnosis?


 

This patient was diagnosed with reactive arthritis, based on her clinical syndrome of conjunctivitis, arthralgias, mucositis, and cervicitis. The widespread distribution of symptoms in this syndrome may be due to activation of the immune system by a viral or bacterial agent. In this case, a complete blood count revealed a white blood cell count of 17,000/mcL (with a left shift of 6% bands). An endocervical DNA probe was positive for Chlamydia trachomatis.

Interestingly, a test for the human leukocyte antigen HLA-B27 came back negative. This did not, however, change the diagnosis. Only 85% of patients with reactive arthritis are positive for HLA-B27, and the test results are frequently negative in African Americans.

Because many sexually transmitted diseases occur concurrently—or are transmitted together—the patient was also tested for human immunodeficiency virus, syphilis, and hepatitis B and C. All of these tests were negative.

The patient was hospitalized and given an injection of ceftriaxone 250 mg, as well as oral azithromycin 1 g for chlamydia (and possible gonorrhea). She also received nonsteroidal anti-inflammatory drugs for pain control. She responded rapidly to therapy as evidenced by decreased arthralgias, normalization of temperature and white blood cell count, and decreased abdominal pain. The patient was discharged after her third day in the hospital with instructions to take doxycycline twice daily, and to finish the 14-day course.

Historical note: “Reiter’s syndrome” is no longer the preferred term for reactive arthritis, as Dr. Reiter was affiliated with the Nazi Party and performed unethical experimentation on human subjects.

Photo courtesy of Joseph Mazziotta, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chumley H, Shedd A, Reddy S, et al. Reactive arthritis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 910-914; Mazziotta JM, Ahmed N. Conjunctivitis and cervicitis. J Fam Pract. 2004;53:121-123.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

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