Arthritis, Gonococcal

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

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 the 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: 2–10 small necrotic pustules distributed over the extremities, especially the palms and soles

Differential Diagnosis

• Reactive arthritis

  • 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

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

Medications

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

• Initial treatment

  • Azithromycin, 1 g orally as a single dose, and a third-generation cephalosporin:

    • Ceftriaxone, 1 g intravenously daily (or every 12 hours if concomitant meningitis or endocarditis is suspected)

    • Cefotaxime, 1 g intravenously every 8 hours

    • Ceftizoxime, 1 g intravenously every 8 hours

  • Azithromycin enhances eradication of gonorrhea and covers potential coinfection with Chlamydia

  • To mitigate against the increasing prevalence of resistant strains of gonococci, step-down treatment from parenteral to oral antibiotics is no longer recommended in the absence of culture results documenting sensitivity to the oral antibiotic being selected

• Once improvement has been achieved for 24–48 hours, patients must receive ceftriaxone 250 mg intramuscularly every 24 hours to complete a 7- to 14-day course

Therapeutic Procedures

• Generally responds dramatically in 24–48 hours after initiation of antibiotics; drainage of infected joints is required infrequently

Prognosis

• Complete recovery is the rule

When to Refer

• When diagnosis is in doubt

• Report to the public health department for tracing contacts

When to Admit

• While outpatient treatment has been recommended in the past, the rapid rise in gonococci resistant to penicillin makes initial inpatient treatment advisable

• Patients in whom gonococcal arthritis is suspected should be admitted to the hospital to

• Confirm the diagnosis

• Exclude endocarditis

• Start treatment