A 28-year-old white male presented to his outpatient rheumatologist with monoarticular left knee pain, erythema, warmth, significant swelling, and immobility due to pain. He had a history of recurrent episodes of refractory inflammatory arthritis mostly affecting the knees. The current episode began about 1 week prior to presentation and consisted of swelling in the left knee with difficulty bearing weight and ambulating. Similar symptoms had recurred for the previous 3 months. No other joints were painful. He denied fever or chills. He also noted a diffuse maculopapular and pustular rash over his back, chest, hands, and trunk that started about 2 weeks prior and was painful and pruritic. He had some slight chronic bilateral eye pain near his baseline without associated visual loss and slight photophobia.His recent history was significant for recurrent inflammatory arthritis in the right (contralateral) knee with large effusions refractory to medical therapy requiring 2 synovectomies. The most recent synovectomy on the right knee was performed 1 year prior, and this successfully controlled his effusion and pain in this knee. He had been maintained on methotrexate 25 mg subcutaneously weekly, but had several flares in the left knee in the 3 months prior to the current presentation requiring high-dose systemic glucocorticoids and intraarticular corticosteroids. Multiple prior therapies were ineffective or not tolerated (detailed below in Past medical history). Recurrent episodes in the left knee consisted of large effusions, reduced range of motion, and inability to bear weight. In these 3 months, he had a total of 6 aspirations (synovial white blood cell counts ranging from 17.2 to 98.2 x 10 3 cells/mm 3 ) with multiple corticosteroid injections of the left knee, and none of which revealed crystals on microscopy or organisms on Gram stain or culture.The patient was hospitalized about 3 weeks prior to the current presentation for left knee pain. During this hospitalization, 70 ml of cloudy synovial fluid were aspirated. Synovial fluid analysis at that time showed 17.3 x 10 3 white blood cells/mm 3 (normal 4.4-11 x 10 3 cells/mm 3 ), 74% neutrophils, 21% monocytes, 5% lymphocytes, no crystals, and no organisms on Gram stain. Cultures were without growth. At that time, triamcinolone 80 mg with lidocaine was injected into the left knee. He was discharged and a few days later received 1 dose of methylprednisolone 1 gram intravenously and infliximab infusion at 3 mg/kg as an outpatient.
Past medical historyThe patient's medical history was notable for history of uveitis and iritis since the age of 2 years and reported polyarticular juvenile idiopathic arthritis (JIA) since the age of 5 years, mostly involving both knees. He was negative for antinuclear antibody, rheumatoid factor (RF), HLA-B27, and anti-cyclic citrullinated peptide antibodies. The inflammatory arthritis in his knees was refractory to many diseasemodifying antirheumatic drugs (DMARDs), biologic DMARDs, and other systemic immunosuppressants, including gl...