- Discussion:
- most common form of septic arthritis in young adults;
- women are affected two to four times as often as men;
- disseminated infection may occur more frequently in women because gonorrhea in women is often asymptomatic,
allowing for dissemination before symptoms occur;
-
sub species characteristics:
- strains of Neisseria gonorrhoeae that disseminate and cause arthritis seem to belong to subgroup with
a unique membrane protein I and to have a transparent appearance of the colonies on culture more
frequently than strains that do not disseminate;
-
diff dx:
- most common infectious diseases associated w/ new onset of purpuric lesions and fever include bacteremias
caused by gram-neg organisms, especially neisseria species, in addition to rickettsial illnesses;
- other causes include listeria monocytogenes and
staph, esp when
endocarditis is present;
- rash is a prominent characteristic of diseases caused by rickettsia except for Q fever;
- rocky mountain spotted fever is most common rickettsial disease in the United States;
-
Reiter's syndrome:
- less common in women;
- presents with the triad of urethritis, conjunctivitis, and axial arthritis;
- onset is subacute, without fever;
- hyperkeratotic skin lesions in palms and soles are typical;
- Clinical Presentation:
- migratory arthritis often precedes gonococcal monoarthritis;
- most common initial manifestation of disseminated gonococcal infection is a migratory polyarthralgia;
- polyarthritis is present in approximately 50 % of patients;
- fever, dermatitis, and tenosynovitis are the most common features on initial exam, with each present in 2/3 of patients;
- only about 30-40 % of pts with disseminated GC infection present w/ classic hot, swollen, purulent joint;
- skin lesions:
- are usually small papules located on trunk or extremities, palms, and soles and then turn into pustules
on broad erythematous bases and necrotic centers;
- rash typically occurs below the neck but spares the scalp, face, and mouth;
- pts may be unaware of dermatitis, and new skin lesions may appear even during the first 24 to 48 hours of ATB therapy;
- Culture:
- culture samples can be obtained from blood, synovial fluid, skin lesions, endocervix, urethra, rectum, and pharynx;
- when culturing the GU tract, rectum, and pharynx, a Thayer-Martin or modified New York media (contains antibiotics) is used;
- joint effusions associated with disseminated gonococcal infection are
often sterile & may involve immune or hypersensitivity mechanisms
- n. gonorrhoeae is found in < 50 % of purulent joints and in < 20 %
of blood cultures from pts w/ disseminated gonococcal infection;
- n. gonorrhoeae and H. influenzae grow best when inoculated on chocolate agar and incubated in 5-10 % carbon dioxide;
- n. gonorrhoeae is recovered in < 50 % of purulent joints in pts w/ suspected disseminated gonococcal
infection, even w/ careful microbiologic techniques;
- Synovial Fluid Exam: in GC: (see:
synovial fluid analysis in septic arthritis)
- synovial-fluid leukocyte count may be less elevated than in patients w/ NG bacterial arthritis, but mean
count is > 50,000 cells /cc;
- in disseminated gonococcal infection, assoc polyarthritis & dermatitis are often sterile and
may be related to immunologic mechanisms;
- gram's stain smears are positive in approx 75 % of pts w/
staph infections & 50 %
of those w/
gram-negative bacilli, but in less than 25 % of pts w/ gonococcal arthritis;
- Treatment:
- in past strains which cause disseminated arthritis have been more sensitive to
penicillin than
have isolates obtained from patients with localized disease;
- the emergence of more penicillinase-producing organisms has led to the use of cephalosporins as standard therapy;
- alternatives to penicillin include
ceftriaxone or
ceftizoxime (IV agents) or
erythromycin or
doxyclyline (PO agents);
- treatment for presumptive C. trachomatis:
- consider treating these patients for concomitant C. trachomatis infection;
- doxycycline 100 mg PO bid for 4 weeks (or erythromycin in pregnant women);
- response to therapy is usually rapid & complete; this form of septic arthritis is much less destructive than
staphylococcal arthritis;
- arthritis, fever, & dermatitis generally are markedly improved after just 24 to 48 hours of antibiotic therapy;
- in most cases, open drainage is unnecessary;
Gonococcal infections.
Dallabeta G, Hook EW III: Infect Dis Clin North Am 1:25, 1987
Infectious Arthritis: GONOCOCCAL ARTHRITIS. Elena Cucurull MD and Luis R. Espinoza MD
Rheumatic Diseases Clinics of North America Vol 24 No 2 May 1998
