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Septic arthritis in rheumatoid arthritis — SCE Acute Medicine MCQ

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HardAcute Rheumatological EmergenciesSeptic arthritis in rheumatoid arthritisSCE Acute Medicine

A 66-year-old man with rheumatoid arthritis on methotrexate presents with an acutely swollen painful knee and fever. Knee aspirate shows turbid fluid with 88,000 white cells/mm3, predominantly neutrophils; Gram stain is pending and crystals are not seen. What is the most appropriate next step in management?

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Correct answer: E — Start intravenous antibiotics after aspiration and involve orthopaedics urgently

A hot swollen joint with fever and highly inflammatory synovial fluid is septic arthritis until proven otherwise, especially in immunosuppression. Antibiotics should follow diagnostic aspiration but not await culture. Steroid injection into a potentially infected joint is unsafe. The pearl is that crystal disease and infection can coexist, so clinical suspicion still matters even if crystals are present.

Reference: BSR septic arthritis guidance, BNF