[Quiz] Rash on soles after travelling


A 22-year-old man presented with acute pain and swelling of his left knee 4 weeks after a
holiday in Spain.
On examination, his temperature was 38.1°C and he had a rash on the soles of his feet.
His right foot is shown

What is the most likely diagnosis?

A gonococcal arthritis
B HIV seroconversion illness
C psoriatic arthritis
D reactive arthritis
E syphilis


Answer Key: D
This is about a picture demonstrating keratoderma blennorrhagica on the sole of the right foot.  In
addition to the rash, this person also has a history of travel about four weeks ago, fever
with an acute phase reaction, and a large joint monoarthritis.  Reactive arthritis is the most likely
diagnosis.  The rash and the monoarthritis may well be related to psoriatic arthritis. However, psoriatic
arthritis is not usually associated with a temperature or such a CRP response.  We are not given any
information about balanitis or urethritis, but gonococcal arthritis is unlikely. It is usually a migratory
polyarthritis.  Syphilis is not usually associated with arthritis, and involvement of the palms and soles is a
feature of secondary syphilis.  While gonococcal and psoriatic arthritis are both plausible distractors,
reactive arthritis is the most likely diagnosis here.

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