USMLE Step 1 Question 315

Question:

A 23-year-old man presents to your office with a five day history of unremitting fever and right wrist pain. He denies a history of illicit drug use. Vitals are as follows: HR 118, BP 135/90, RR 20, T 101.9F. The patient is noticeably anxious. On physical exam, his right wrist and left elbow are both painful to palpation. No needle marks are visible. Small papular, non-pruritic lesions are noted on his back. Which of the following is the likely event that introduced the pathogen for this patient’s presentation?

Correct Answer: E.  Unprotected sexual contact

This patient is presenting with likely gonococcal arthritis given his young age, polyarticular symptoms, fever and rash. It is likewise probable that he was infected during unprotected sexual contact with an individual exhibiting genital gonorrhea. Our patient was unable to contain the organism locally, either due to a failure in his own immunity or the increased virulence of the gonococcal strain, and he presented with the arthritic form.

Airborne droplets can create an osteomyelitis-type picture in the case of TB-induced Pott’s disease of the vertebrae, particularly in indigent populations in developing countries. However our patient fits none of the risk factors or symptoms for TB. Fecal-oral transmission may create osteomyelitis in the case of Salmonella, but this is particular in patients who are already afflicted with sickle cell disease. Needle sticks and operative injury may introduce myriad organisms that can cause septic arthritis (i.e. Staph aureus, Pseudomonas aeruginosa), but our patient has no history of this type of introduction.