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Neiserria Gonnorhea

- 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
    - 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
         - n. gonorrhoeae is found in < 50% of purulent joints and in < 20% of blood cultures from pts w/ disseminated gonococcal
         - 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
    - 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 1987;1:25. 

Gonococcal arthritis.