Differential diagnosis

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A. Septic arthritis. Appropriate cultures of synovial fluid, and of all potential portals of entry, should be performed to exclude septic arthritis. The most common diagnosis to exclude in a young patient is gonococcal arthritis. RS and disseminated gonococcal infection may both involve tenosynovitis, urethritis, conjunctivitis, and dermatitis.

B. Colitic arthropathy. Arthritis following diarrhea may represent the rheumatic complication of either Crohn's disease or ulcerative colitis, and gastrointestinal endoscopy and radiology may be required to exclude this possibility. Arthritis may be the presenting manifestation of inflammatory bowel disease and may precede bowel complaints for some period of time.

C. Psoriatic arthritis. Skin rash coincident with arthritis may represent psoriatic arthritis rather than RS, and indeed the histopathologic findings of psoriasis and keratoderma are similar. Coexisting urethritis and conjunctivitis, or antecedent diarrhea, would favor a diagnosis of RS. Pitting of the nails occurs in both conditions, but the nail dystrophy of psoriatic arthritis is generally more severe.

D. Rheumatoid arthritis. If chronic polyarthritis suggests rheumatoid arthritis, the presence of asymmetry and sacroiliitis and negativity for rheumatoid factor would favor RS. The extraarticular features of rheumatoid arthritis are distinct from those of RS.

E. Human immunodeficiency virus (HIV) infection. There are indications from some series that RS may occur with higher frequency and severity in patients with HIV infection. The frequency of this clinical overlap is not known. Patients in a high-risk category should be screened for HIV serology. There may be a unique arthropathy associated with HIV, but this is not fully resolved. In some patients, the episode of Rs occurs long before clinically overt acquired immune deficiency syndrome (AIDS). This is an important consideration when any immunosuppressive therapy is being considered.

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