The ACR Image Competition 2021 Results, Part 2: People’s Choice

People’s Choice: Keratoderma Blennorrhagica

Submitted by Kunal Chandwar, MD, MBBS, King George’s Medical University, Lucknow, India, the photo depicts extensive keratoderma blennorrhagica in a patient with reactive arthritis.

Spondyloarthropathies

An 18-year-old man presented with psoriasiform plaque-like lesions that began on the limbs and progressed to involve his entire body (including his face) over a month. He had a painless ulcer near the urethral meatus and glans penis associated with severe debilitating axial and peripheral polyarthritis. He had had unprotected sex and recently developed a urethral discharge.

Given his severe keratoderma blennorrhagica and circinate balanitis and history suggesting a urinary tract infection, a diagnosis of reactive arthritis was made.

Investigations suggested anemia, leukocytosis and thrombocytosis with elevated inflammatory markers. An HIV test was negative; tests for other sexually transmitted diseases and blood cultures were also negative.

The patient received pulse methylprednisolone followed by 0.5 mg/kg of prednisolone, which was tapered rapidly, non-steroidal anti-inflammatory drugs and methotrexate, with doxycycline to treat suspected urethritis, and responded well, with almost complete clearance of skin lesions and improvement in his arthritis.