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Internal Medicine

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A 34-year-old woman with a history of three weeks of swelling and tenderness over the dorsum of the left hand, pain, redness, and swelling in her right ankle, intermittent pain in shoulder and knee joints, and a rash on her lower extremities. Here are the key points and findings:

Patient History:

  • Unhoused: Staying in shelters and homes of acquaintances in downtown Los Angeles.

  • Substance Use: Smokes one pack of cigarettes daily, consumes four to six alcoholic beverages daily, occasionally smokes marijuana, and occasionally smokes methamphetamine. No injection drug use.

  • Sexual History: Several intimate partners in the past year.

Physical Examination:

  • Temperature: 37.8°C (100.0°F)

  • Stable Vital Signs

  • Physical Findings:

  • Tenderness, swelling, edema, and erythema of the dorsum of the left hand, with pain on extension of the third and fourth digits.

  • Right ankle swelling, edema, erythema, and tenderness.

  • Mildly tender shoulder and knee joints without swelling, erythema, or warmth.

  • Pustular rash on the lower extremities.

Laboratory Studies:

  • Leukocyte Count: 13,500/µL (elevated; normal range 4000–11,000/µL)

  • Segmented Neutrophils: 89% (elevated; normal range 50%–70%)

  • Erythrocyte Sedimentation Rate: 125 mm/hr (elevated; normal range 0–20 mm/hr)

  • Serum C-Reactive Protein: 32 mg/dL (elevated; normal ≤0.8 mg/dL)

  • HIV Antigen/Antibody: Negative

  • Treponema Pallidum Antibodies: Negative

  • Blood Cultures: Negative at 48 hours

Which of the following is most likely cause of the infection?

  • Bartonella quintana

  • Neiserria gonorrhoaea

  • Rickettsia typhi

  • Staphylococcus aureus

Mazen Kherallah
Mazen Kherallah
3 days ago

Key Points:

  • Clinical Presentation: Swelling and tenderness in multiple joints, rash on lower extremities, and elevated inflammatory markers.

  • Risk Factors: Multiple sexual partners and substance use.

  • Laboratory Findings: Elevated leukocyte count, neutrophilia, elevated ESR, and CRP.

Neisseria gonorrhoeae is known to cause disseminated infections, presenting with symptoms such as tenosynovitis, dermatitis, and polyarthralgia, which matches the patient's symptoms.

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