A few months ago, our office received an urgent call from an anxious primary care provider (PCP) asking to speak with our clinic director. In his office, he had an 18-year-old female (JW) crying in pain.
A college freshman, JW said she had been experiencing severe right ankle pain and swelling for approximately 3 weeks before going to see her PCP. She was unaware of any specific injury that triggered the pain.
JW was initially evaluated at the university health clinic and discharged with a diagnosis of a sprained ankle after an X-ray revealed no fractures, only minor soft tissue swelling. JW was instructed to rest, ice the ankle regularly, and take ibuprofen to blunt the pain.
Two weeks later, the pain had gotten significantly worse, JW could not bear weight on her right leg, and the ankle had become very swollen, red, and warm. Sensing this was much more than a sprained ankle, JW reached out to her parents for help. Her parents immediately made an appointment with JW’s PCP and picked up their daughter from college.
During JW’s appointment with her PCP, she was examined and asked again about any specific injury to the ankle. X-rays were repeated, again revealing no obvious fracture or acute injury. Feeling there was something unusual going on, JW’s PCP called our office before deciding upon any treatment. The primary concern he relayed to us was that he thought JW might have a septic joint.
Our team instructed JW and her parents to come right over (the beauty of having nurse practitioners in our rheumatology office to take urgent calls). When JW arrived, she was being pushed in a wheelchair by her parents. She could not bear any weight on the right ankle without experiencing excruciating pain.
Upon examination, JW’s foot and ankle were very red, warm to the touch, and exquisitely painful on exam. A thorough history revealed no significant injuries, and no family or personal history of autoimmune disorders. The remainder of our exam was normal—no skin abnormalities or fever.
So in summary, we had an 18-year-old with a sudden onset of monoarthritic joint pain and swelling with no recent illness or infections who denied any sexual activity. This was just not adding up. I planned on ordering some labs, but I could just sense that there was something I was missing.
I asked JW’s parents to step out into our waiting room so I could get her in a gown to do a full exam, feeling that I needed to talk to her alone. Once her parents left the room, I again asked JW about any sexual activity. Sure enough, once we were alone, she admitted that she had been sexually active with her current boyfriend but did not want her parents to know. I asked if she thought she could have contracted a sexually transmitted disease. She said she didn’t think so (she had only been with her boyfriend), but admitted she didn’t know about his past relationships. I told her we would do some testing and began treatment to get her ankle feeling better as quickly as possible.
Once we were able to rule out a septic joint, we started JW on prednisone. Laboratory results revealed she had chlamydia, which was the clue we needed to unravel this mystery.
Chlamydia affects people of all ages, but is most common in young women and is frequently asymptomatic. For this case, the important link is that chlamydia is a common case of reactive arthritis, an inflammatory arthritis that develops after certain infections of the gastrointestinal or genitourinary tracts. Symptoms of reactive arthritis are commonly acute, affect <4 joints (commonly in the lower extremities), and occur within several weeks of the initial infection. It is classified as one of the spondyloarthropathies. C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) are frequently elevated in patients with reactive arthritis. HLA-B27 positivity is seen in up to 50% of patients.1
Reactive arthritis is typically self-limiting, lasting from 3-5 months, though it can become chronic. Patients with HLA-B27 positivity, family history of spondyloarthropathies, and chronic bowel inflammation will typically fair worse than others.1
After we received back JW’s lab report, we notified her PCP of the positive chlamydia result and allowed him to initiate treatment, which would typically involve either doxycycline or azithromycin. JW responded well and has not had any further inflammation. She continues to do well in college.
AUTHOR PROFILE:
Linda Grinnell-Merrick, MS, NP-BC, is a board-certified nurse practitioner at the University of Rochester Medical Center in Rochester, NY, and the incoming President of the Rheumatology Nurses Society.
Reference
1. Centers for Disease Control and Prevention. Chlamydia – CDC Fact Sheet (Detailed). Available at www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm. Accessed April 6, 2017.