A 42-year-old white homosexual man presented to our clinic in April, 2008, with a 12-day history of right knee and back pain, conjunctivitis, and proctitis. 10 days earlier, after a normal radiograph, an arthrocentesis of his right knee had been done; 40 mL of clear synovial fluid was aspirated and corticosteroids were injected locally. There was no history of recent injury, febrile illness, or rheumatological conditions. He reported anonymous unprotected receptive anal sex 1 month earlier. Since 2000, he had had three episodes of uncomplicated urethritis, secondary syphilis, HIV, and an episode of primary syphilis (rapid plasma reagin [RPR] 1/32 in August, 2007). He had been taking antiretrovirals since October, 2007, with a CD4 count of 300 per uL (31%) and undetectable viral load in March, 2008. On examination, his right knee was cool, swollen, and painful, and he had a right non-purulent conjunctivitis. Proctoscopy showed a hyperaemic mucosa with superficial ulcers and a mucopurulent exudate (figure A); gram stain showed more than 40 leucocytes per high-power field (magnification xl000) without diplococci. Making a presumptive diagnosis of lymphogranuloma venereum and sexually acquired reactive arthritis (SARA), we gave our patient 100 mg doxycycline twice daily for 21 days and non-steroidal anti-inflammatory drugs (NSAIDs).
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