Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 20-36: Gonococcal Arthritis + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + Reference Download Section PDF Listen +++ + +Birrell JM et al. Characteristics and impact of disseminated gonococcal infection in the "Top End" of Australia. Am J Trop Med Hyg. 2019 Oct;101(4):753–60. [PubMed: 31392956]