Key Clinical Updates in Gonococcal Arthritis
The treatment of disseminated gonorrhea is ceftriaxone. Once susceptibility testing has been obtained, 24–48 hours after clinical improvement the antibiotic regimen can be changed to an oral agent to complete a 7-day course.
ESSENTIALS OF DIAGNOSIS
Prodromal migratory polyarthralgias.
Tenosynovitis is the most common sign.
Purulent monoarthritis in 50%.
Characteristic skin lesions.
Most common in young women during menses or pregnancy.
Symptoms of urethritis frequently absent.
Dramatic response to antibiotics.
In contrast to nongonococcal bacterial arthritis, gonococcal arthritis usually occurs in otherwise healthy individuals. Host factors, however, influence the expression of the disease: gonococcal arthritis is two to three times more common in women than in men, is especially common during menses and pregnancy, and is rare after age 40. Gonococcal arthritis is also common in men who have sex with men, whose high incidence of asymptomatic gonococcal pharyngitis and proctitis predisposes them to disseminated gonococcal infection. Some of the signs of disseminated gonococcal infection may result from an immunologic reaction to nonviable fragments of the organism's cell wall. Recurrent disseminated gonococcal infection should prompt testing of the patient’s CH50 level to evaluate for a congenital deficiency of a terminal complement component (C5, C6, C7, or C8).
One to 4 days of migratory polyarthralgias involving the wrist, knee, ankle, or elbow are common at the outset. Thereafter, two patterns emerge. The first pattern is characterized by tenosynovitis that most often affects the wrists, fingers, ankles, or toes and is seen in 60% of patients. The second pattern is purulent monoarthritis that most frequently involves the knee, wrist, ankle, or elbow and is seen in 40% of patients. Less than half of patients have fever, and less than one-fourth have any genitourinary symptoms. Most patients will have asymptomatic, but highly characteristic, skin lesions that usually consist of 2 to 10 small necrotic pustules distributed over the extremities, especially the palms and soles.
The peripheral blood leukocyte count averages about 10,000 cells/mcL (10 × 109/L) and is elevated in less than one-third of patients. The synovial fluid WBC count usually ranges from 30,000 to 60,000 cells/mcL (30–60 × 109/L). The synovial fluid Gram stain is positive in one-fourth of cases and culture in less than half. Positive blood cultures are uncommon. Urethral, throat, cervical, and rectal cultures should be done in all patients, and are often positive in the absence of local symptoms. Culturing Neisseria gonorrhoeae is facilitated by rapid transport to the microbiology laboratory, inoculation on appropriate media, and incubation in carbon dioxide. Urinary nucleic acid amplification tests have excellent sensitivity and specificity for the detection of Neisseria gonorrhoeae in genitourinary sites.