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Key Features

Essentials of Diagnosis

  • Prodromal migratory polyarthralgias

  • Tenosynovitis most common sign

  • Purulent monarthritis in 50%

  • Characteristic skin lesions

  • Most common in young women during menses or pregnancy

  • Symptoms of urethritis frequently absent

  • Dramatic response to antibiotics

General Considerations

  • Usually occurs in otherwise healthy individuals

  • Most common cause of infectious arthritis in large urban areas

  • Recurrent disseminated gonococcal infection occurs when there is a congenital deficiency of a terminal complement component (C5, C6, C7, or C8)

Demographics

  • Two to three times more common in women than in men and is especially common during menses and pregnancy

  • Gonococcal arthritis is also common in men who have sex with men

  • Rare after age 40

Clinical Findings

Symptoms and Signs

  • One to 4 days of migratory polyarthralgias involving the wrist, knee, ankle, or elbow

  • Thereafter, two patterns emerge

    • 60% of patients characterized by tenosynovitis (most often affecting wrists, fingers, ankles, or toes)

    • 40% of patients characterized by purulent monarthritis (most frequently involving the knee, wrist, ankle or elbow)

  • Less than half of patients have fever

  • Less than one-fourth have genitourinary symptoms

  • Most patients will have asymptomatic but highly characteristic skin lesions: two to ten small necrotic pustules distributed over the extremities, especially the palms and soles

Differential Diagnosis

  • Reactive arthritis (previously known as Reiter syndrome)

    • Can produce acute monarthritis, urethritis, and fever in a young person

    • However, it is distinguished by negative cultures and failure to respond to antibiotics

  • Lyme disease involving the knee

    • Less acute

    • Does not show positive cultures

    • May be preceded by known tick exposure and characteristic rash

  • Infective endocarditis with septic arthritis

  • Nongonococcal septic arthritis

  • Gout or pseudogout

  • Rheumatic fever

  • Sarcoidosis

  • Meningococcemia

  • Early hepatitis B infection

    • Associated with circulating immune-complexes that can cause a rash and polyarthralgias

    • The rash in hepatitis B infection is urticarial in contrast to disseminated gonococcal infection

Diagnosis

Laboratory Tests

  • Synovial fluid

    • White blood cell count usually ranges from 30,000 to 60,000 cells/mcL

    • Gram stain is positive in one-fourth of cases and culture in less than half

  • Positive blood cultures uncommon

  • Urethral, throat, cervical, and rectal cultures should be done in all patients, since they are often positive in the absence of local symptoms

  • The peripheral blood leukocyte count averages 10,000 cells/mcL and is elevated in less than one-third of patients

  • Urinary nucleic acid amplification tests have excellent sensitivity and specificity for the detection of Neisseria gonorrhoeae in genitourinary sites

Imaging Studies

  • Radiographs are usually normal or show only soft tissue swelling

Treatment

Medications

  • Approximately 25% of patients have absolute or relative resistance to penicillin

  • Initial treatment

    • Azithromycin, 1 g orally as a ...

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