Arthritis, Gonococcal

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 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

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

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