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[21.11 E. The patient described best (its the picture of disseminated gonococcal infection. She has the rash, which typically is located on extensor surfaces of distal extremities. Pain on passive flexion of her wrist indicates likely tenosynovitis of that area. The fluid is inflammatory, but gonococci are typically not seen on Gram stain. Ceftriaxone is the usual treatment of choice for gonococcal infection. Nafcillin would be useful for staphylococcal arthritis and would be the more likely choice if she were older, had some chronic joint disease such as rheumatoid arthritis, or were immunocompromised. Gonococcal arthritis is the most common cause of infectious arthritis in patients younger than 40 years. Indomethacin or colchicine would be useful if she had a crystalline arthritis, but that is unlikely in this clinical picture. Intraarticular prednisone is contraindicated while infectious arthritis is a possibility.

121.21 I). Synovial fluid cultures usually are sterile in gonococcal arthritis (in fact, the arthritis is more likely caused by immune complex deposition than by actual joint infection), and blood cultures are positive <50% of the time. Diagnosis is more often made by finding gonococcal infection in a more typical site, such as urethra, cervix, or pharynx.

[21.3] C. Corticosteroids should not be used until infection is ruled out. The inflammatory arthritis as shown by Gram stain of the joint aspirate is suspicious for infection, even with no organisms seen on Gram stain. Also, the presence of a few crystals does not eliminate an infection.

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