Intended for healthcare professionals

Endgames Case Review

A limp with an unusual cause

BMJ 2015; 350 doi: (Published 21 April 2015) Cite this as: BMJ 2015;350:h1985
  1. Rebecca Metcalfe, specialty trainee, genitourinary medicine1,
  2. Michael Reed, specialty trainee, rheumatology2,
  3. Andrew Winter, consultant, genitourinary medicine1
  1. 1Sandyford Sexual Health Service, Glasgow G3 7NB, UK
  2. 2Department of Rheumatology, Glasgow Royal Infirmary, Glasgow
  1. Correspondence to: R Metcalfe rebeccametcalfe{at}

A 41 year old Ghanaian man resident in the United Kingdom presented with a five hour history of pain and swelling of the right ankle, left wrist, and right middle finger. He felt generally unwell but had no other specific symptoms on systemic inquiry. He had just returned from a two week visit to Ghana. There was no medical history of note, he was taking no regular drugs, and he had no known drug allergies. The appropriate travel prophylaxis had been adhered to. He had had unprotected intercourse with a new female partner about 10 days ago.

On examination, his temperature was 37.8°C. There was evidence of synovitis (joint swelling, redness, tenderness, and reduced range of movement) of the right ankle, left wrist, and the proximal interphalangeal joint of the middle finger of his right hand. Initial investigations confirmed that his neutrophil count, C reactive protein concentration, and erythrocyte sedimentation rate were raised. Radiographs of the affected joints showed soft tissue swelling but were otherwise normal.

The pain did not ease with oral non-steroidal anti-inflammatory drugs and he was admitted to hospital.


  • 1. What is the differential diagnosis?

  • 2. What is the most likely diagnosis and why?

  • 3. What further investigations are necessary?

  • 4. What are the treatment options?


1. What is the differential diagnosis?


The main differential diagnosis is between polyarticular septic arthritis and reactive arthritis. Other possibilities include seronegative inflammatory arthritis, connective tissue disorder, and polyarticular gout.


Septic arthritis may be polyarticular, although this is less common than monoarticular septic presentations. Polyarticular septic arthritis is caused by the haematogenous spread of organisms to affected joints. Most cases are caused by Staphylococcus aureus or Streptococcus spp. Less common causes are Gram negative organisms such as Escherichia coli and Neisseria gonorrhoeae.1 2 Risk factors for septic arthritis include local factors such as pre-existing joint …

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