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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{YD}} (Reviewed by {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|Prompt=A 27 year old man, previously healthy, presents to the physician's office for recurrent left knee pain. The patient explains that he has recently recovered from a urethral infection 2 weeks ago that required antibiotics without identifying the bacteria. He reports his knee pain does not involve his right knee, and is moderately relieved with naproxen use. Work-up is remarkable elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) and a strong increase in HLA-B27. What is the most likely additional finding during physical examination of this patient?  
|Prompt=A 27-year-old man with no past medical history presents to the physician's office for recurrent left knee pain. The patient explains that he has recently received antibiotics to treat a urethral infection 2 weeks ago. He reports his current knee pain does not involve his right knee and is moderately relieved with administration of naproxen. Work-up is remarkable for elevated concentration of C-reactive protein (CRP) and a markedly elevated HLA-B27 surface antigen. Which of the following findings on physical examination is most associated with this patient's condition?
|Explanation=The patient is presenting with reactive arthritis (ReA), formerly known as Reiter's syndrome. ReA is an autoimmune inflammatory arthritis that typically follows a gastrointestinal or a urethral infection. Chlamydia infections are strongly associated with ReA, in addition to other bacterial infections, such as Salmonella, Shigella, and Campylobacter.  
|Explanation=Reactive arthritis (ReA or Reiter's syndrome) is an autoimmune inflammatory arthritis. Infection with either ''Chlamydia'', ''Salmonella'', ''Shigella'', or ''Campylobacter'' is strongly associated with the development of ReA. ReA typically manifests with mono-inflammatory, non-migratory, arthritic pain 2 to 4 weeks following a gastrointestinal or a urethral infection. Laboratroy findings are usually unremarkable except for elevated concentrations of acute phase reactants, such as CRP and ESR. ReA is a subtype of seronegative spondyloarthropathies (arthritis with negative RF) that is associated with HLA-B27 class I surface antigen. The classic triad of ReA manifestations is conjunctivitis, urethritis, and arthritis [Mnemonic: Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)]. The diagnosis of ReA is clinical, and treatment includes NSAIDs for symptomatic relief in most of the cases until the pain self-resolves. However, rare refractory cases might require either intra-articular, systemic steroids, or disease-modifying antirheumatic drugs (DMARDs).<br>
 
Common HLA subtypes and their associated diseases are shown in the table below.<br>
The typical presentation of ReA is mono-inflammatory non-migratory arthritic pain that follows a gastrointestinal or a urethral infection by 2-4 weeks. Laboratroy findings are usually unremarkable except for elevation of acute phase reactants, such as CRP and ESR. ReA is associated with HLA-B27, along with other conditions (i.e.  psoriatric arthritis, ankylosing spondylitis, and inflammatory bowel disease), all of which are called seronegative spondyloarthropathies because they patients have negative serological levels of  rheumatoid factor (RF).  
[[Image:HLA subtypes and associated diseases.jpg|600px]]
 
|AnswerA=Conjunctival redness
The classic triad of ReA is: Conjunctivitis, urethritis, and arthritis. [Mnemonic: Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)]
|AnswerAExp=Manifestations of reactive arthritis are summarized by the classic triad of conjunctivitis, urethritis, and arthritis.
 
|AnswerB=Systolic ejection murmur
The diagnosis of ReA is mainly clinical. Treatment of the arthritis in ReA includes NSAIDs for symptomatic relief in most of the cases until the pain self-resolves. However, rare refractory cases might require intra-articular or rarely systemic steroids, or even disease-modifying antirheumatic drugs (DMARDs)
|AnswerBExp=Aortic stenosis is not common among patients with reactive arthritis. However, ankylosing spondylitis, also a seronegative spondyloarthropathy, is associated with aortic regurgitation.
 
|AnswerC=Facial rash that spares the nasolabial folds
Educational Objective:
|AnswerCExp=Malar rash is characteristic of systemic lupus erythematosus.
Reactive arthritis has a classic triad of conjunctivitis, urethritis, and arthritis.
|AnswerD=Violaceous eruption on the upper eyelids
 
|AnswerDExp=Heliotrope rash is characteristic of dermatomyositis.
Reference:
|AnswerE=Excoriated papules on the dorsum of the hands
Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. 2009; 44(4):309-15.
|AnswerEExp=Skin excoriation is not associated with reactive arthritis.
|AnswerA=Conjunctivitis
|EducationalObjectives=Reactive arthritis (ReA or Reiter's syndrome) is an autoimmune inflammatory arthritis. Infection with either ''Chlamydia'', ''Salmonella'', ''Shigella'', or ''Campylobacter'' is strongly associated with the development of ReA. ReA typically manifests with mono-inflammatory, non-migratory, arthritic pain 2 to 4 weeks following a gastrointestinal or a urethral infection. Reactive arthritis manifestations are the triad of conjunctivitis, urethritis, and arthritis.
|AnswerAExp=Reactive arthritis has a classic triad: conjunctivitis, urethritis, and arthritis.  
|References=Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. 2009;44(4):309-15.<br>
|AnswerB=Aortic stenosis
First Aid 2014 page 426
|AnswerBExp=Aortic stenosis is not commonly seen in patients with reactive arthritis. Patients with ankylosing spondylitis, another disease associated with HLA-B27, have high rates of aortic regurgitation.
|AnswerC=Malar rash
|AnswerCExp=Malar rash is common in systemic lupus erythematosus.
|AnswerD=Heliotrope rash
|AnswerDExp=Heliotrope rash is commonly seen in patients with dermatomyositis.
|AnswerE=Excoriation of skin
|AnswerEExp=Skin excoriation is not associate with reactive arthritis.
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=reactive, arthritis, knee, pain, urethritis, chlamydia, chlamydial, infection, conjunctivitis, spondyloarthropathy, spondyloarthropathies, arthritis, HLA-B27, seronegative,  
|WBRKeyword=Reactive arthritis, Seronegative spondyloarthropathies, HLA-B27, HLA subtypes, Conjunctival redness, Conjunctivitis, Urethritis, Arthritis, Autoimmune, Inflammatory arthritis,  
|Approved=No
|Approved=Yes
}}
}}

Revision as of 20:36, 6 March 2015

 
Author [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Musculoskeletal/Rheumatology
Prompt [[Prompt::A 27-year-old man with no past medical history presents to the physician's office for recurrent left knee pain. The patient explains that he has recently received antibiotics to treat a urethral infection 2 weeks ago. He reports his current knee pain does not involve his right knee and is moderately relieved with administration of naproxen. Work-up is remarkable for elevated concentration of C-reactive protein (CRP) and a markedly elevated HLA-B27 surface antigen. Which of the following findings on physical examination is most associated with this patient's condition?]]
Answer A AnswerA::Conjunctival redness
Answer A Explanation AnswerAExp::Manifestations of reactive arthritis are summarized by the classic triad of conjunctivitis, urethritis, and arthritis.
Answer B AnswerB::Systolic ejection murmur
Answer B Explanation AnswerBExp::Aortic stenosis is not common among patients with reactive arthritis. However, ankylosing spondylitis, also a seronegative spondyloarthropathy, is associated with aortic regurgitation.
Answer C AnswerC::Facial rash that spares the nasolabial folds
Answer C Explanation AnswerCExp::Malar rash is characteristic of systemic lupus erythematosus.
Answer D AnswerD::Violaceous eruption on the upper eyelids
Answer D Explanation AnswerDExp::Heliotrope rash is characteristic of dermatomyositis.
Answer E AnswerE::Excoriated papules on the dorsum of the hands
Answer E Explanation AnswerEExp::Skin excoriation is not associated with reactive arthritis.
Right Answer RightAnswer::A
Explanation [[Explanation::Reactive arthritis (ReA or Reiter's syndrome) is an autoimmune inflammatory arthritis. Infection with either Chlamydia, Salmonella, Shigella, or Campylobacter is strongly associated with the development of ReA. ReA typically manifests with mono-inflammatory, non-migratory, arthritic pain 2 to 4 weeks following a gastrointestinal or a urethral infection. Laboratroy findings are usually unremarkable except for elevated concentrations of acute phase reactants, such as CRP and ESR. ReA is a subtype of seronegative spondyloarthropathies (arthritis with negative RF) that is associated with HLA-B27 class I surface antigen. The classic triad of ReA manifestations is conjunctivitis, urethritis, and arthritis [Mnemonic: Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)]. The diagnosis of ReA is clinical, and treatment includes NSAIDs for symptomatic relief in most of the cases until the pain self-resolves. However, rare refractory cases might require either intra-articular, systemic steroids, or disease-modifying antirheumatic drugs (DMARDs).

Common HLA subtypes and their associated diseases are shown in the table below.

Educational Objective: Reactive arthritis (ReA or Reiter's syndrome) is an autoimmune inflammatory arthritis. Infection with either Chlamydia, Salmonella, Shigella, or Campylobacter is strongly associated with the development of ReA. ReA typically manifests with mono-inflammatory, non-migratory, arthritic pain 2 to 4 weeks following a gastrointestinal or a urethral infection. Reactive arthritis manifestations are the triad of conjunctivitis, urethritis, and arthritis.
References: Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. 2009;44(4):309-15.
First Aid 2014 page 426]]

Approved Approved::Yes
Keyword WBRKeyword::Reactive arthritis, WBRKeyword::Seronegative spondyloarthropathies, WBRKeyword::HLA-B27, WBRKeyword::HLA subtypes, WBRKeyword::Conjunctival redness, WBRKeyword::Conjunctivitis, WBRKeyword::Urethritis, WBRKeyword::Arthritis, WBRKeyword::Autoimmune, WBRKeyword::Inflammatory arthritis
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