Gonococcal Arthritis


Article Author:
Raymund Li


Article Editor:
Jason Hatcher


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/25/2018 9:07:54 PM

Introduction

Gonococcal arthritis is a bacterial arthritis that results from the bacteremic spread of Neisseria gonorrhoeae, a sexually transmitted pathogen. It is a clinical manifestation of disseminated gonococcal infection. It comprises two major clinical forms: localized septic arthritis and arthritis-dermatitis syndrome.[1][2][3]

Etiology

Neisseria gonorrhoeae, a gram-negative diplococcus, is the etiologic pathogen in gonococcal arthritis. It is usually transmitted sexually and is an important cause of bacterial arthritis in sexually active adolescents. However, it may also be acquired perinatally during childbirth and may cause gonococcal infection in newborns.[4][5]

Epidemiology

Approximately 0.5% to 3% of patients who are infected with N. gonorrhoeae develop disseminated gonococcal infection (DGI). There is a paucity of recent epidemiologic data that looks into the incidence of DGI in patients with arthritis, but historical data in the 1980s show that N. gonorrhoeae were associated with up to 14% of patients who have arthritis. Gonococcal arthritis is more commonly seen in young healthy individuals although it may occur in any age group.[6][7][8]

Pathophysiology

Host risk factors that are associated with disseminated gonococcal infection (DGI) include complement deficiencies, menstruation, pregnancy, history of pelvic surgery, and intrauterine devices (IUD). Specific strains of N. gonorrhoeae have virulence factors that have been associated with dissemination. These include strains containing a specific outer membrane called the porin 1A serotype that promotes resistance, diminished host inflammatory response, and host cell invasion and strains that require specific substrates for growth. It is also hypothesized that the pathogenesis of DGI may be partly immune-mediated. This is supported by the fact that the pathogen is frequently not isolated from both the synovial fluid and blood of patients with clinical manifestations of dissemination.[9]

History and Physical

Disseminated gonococcal infection (DGI) usually comprises two major clinical syndromes: the arthritis-dermatitis syndrome and localized purulent arthritis without associated skin lesions. There are, however, patients who present with symptoms that overlap between these two classic presentations. Although localized infection of the genitourinary tract, rectum, or pharynx by N. gonorrhoeae is a prerequisite for dissemination, patients with clinical manifestations of DGI often do not manifest symptoms of localized gonococcal infection.

  • Arthritis-dermatitis syndrome: This is a form of DGI that usually comprises a triad of manifestations which include tenosynovitis, dermatitis, and polyarthralgia. It is also often associated with constitutional symptoms such as fever, chills, and body malaise. Approximately 60% developed fever in one study in women with DGI. Tenosynovitis is a unique finding in gonococcal arthritis and is usually not seen in other forms of septic arthritis. It is demonstrated by tenderness along the flexor sheath and pain on a passive extension during a physical examination. It usually affects multiple tendons, more commonly the fingers, wrists, toes, and ankles. Polyarthralgia is typically asymmetric and may affect both large and small joints. Skin lesions occur in up to 75% of cases and are frequently seen in the trunk and extremities and usually spares the face. Although a large variety of skin lesions have been observed, DGI is most commonly associated with pustular or vesicular lesions. Other skin manifestations that occur less frequently include macules, papules, bullae, or nodules. Skin lesions are characteristically transient and may disappear after several days even without treatment.
  • Localized septic arthritis: This syndrome usually present as a monoarthritis or asymmetric oligo- or polyarthritis with pain and swelling of one or more joints. Most patients do not present with systemic symptoms such as fever or chills. Joints that are commonly affected include knees, ankles, wrist, and elbow.

Evaluation

A high clinical suspicion is necessary for patients who present with joint pain or swelling that is concerning for septic arthritis especially in those who are sexually active and younger than 40 years old and in certain at-risk populations such as in men who have sex with men (MSM). A thorough history and physical examination including an emphasis on sexual history are needed in patients with suspected gonococcal arthritis. Menstrual history and pregnancy need to be assessed in premenopausal patients. Skin and joint examination may provide information that heightens clinical suspicion especially in patients who present with the typical triad of tenosynovitis, arthralgia, and skin lesions.[1][4][10]

Definitive diagnosis of disseminated gonococcal infection (DGI) or gonococcal arthritis is made through the identification of the etiologic pathogen in a specimen taken from a non-mucosal site (such as blood, synovial fluid, or skin lesions). Microbiologic tests, however, are not always positive and in such cases, diagnosis is made clinically. A clinical diagnosis may be supported by evidence of N. gonorrhoeae infection from specimens obtained from mucosal sites. Screening for other sexually transmitted illnesses such as HIV, syphilis, and chlamydia is often recommended since these frequently co-exist with gonococcal infection.

Two sets of blood cultures should be obtained, and a positive result helps distinguish gonococcal arthritis from other pathogens that cause septic arthritis. Positive blood cultures, however, are only positive in less than 1/3 of cases and is more frequently seen in patients who present with arthritis-dermatitis syndrome. Specimens from mucosal sites should also be obtained and are frequently helpful in patients who have a high clinical suspicion of DGI but who have sterile synovial fluid or blood specimens. Nucleic acid amplification testing (NAAT) of either urine specimens in both men and women or vaginal swabs in women is preferred, if available. The culture of a urogenital specimen is an alternative.

In patients who demonstrate joint swelling and effusion, arthrocentesis and synovial fluid analysis should be performed. Typically, a synovial fluid analysis will show white blood cell (WBC) count of 50,000 cells/mm3 or more; although, a cell count below 10,000 cells/mm3 is not uncommon. This may be associated with reduced glucose concentration and elevated LDH level but these findings are non-diagnostic and of limited value. In patients who present with localized purulent arthritis, N. gonorrhoeae will be isolated in only about 50% (range of 25% to 75%) of synovial fluid specimens. This is even less in patients who present with the arthritis-dermatitis syndrome. NAAT of synovial fluid is more sensitive (greater than 75%) than culture and should be performed if available.

Obtaining skin lesion specimens is usually not done because of the difficulty of sampling and its very poor yield. The culture of skin lesions is often negative. NAAT of skin specimens may be slightly more sensitive, but this is not widely available.

Treatment / Management

Initial management in the inpatient setting is recommended for patients with a presumptive diagnosis of disseminated gonococcal infection (DGI) or gonococcal arthritis. Ceftriaxone as a parenteral therapy, either given intravenously or intramuscularly, is the preferred initial antibiotic of choice. Intravenous administration of 1 gm every 24 hours is usually preferred in patients presenting with purulent arthritis. A single dose of 1 gram of azithromycin by mouth is usually added to cover potential coinfection with C. trachomatis. Alternative antimicrobial agents include third-generation cephalosporin such as cefotaxime and ceftizoxime, which are given as 1 gm every 8 hours. A dose of 100 mg of doxycycline twice a day for 7 days is an alternative to azithromycin.[11][12][13]

Widespread resistance to oral cephalosporins such as cefixime has been documented. Oral cephalosporins are therefore not recommended as initial therapy. Although not always possible, the microbiologic diagnosis should be attempted, and antimicrobial susceptibility testing should be performed to guide antibiotic therapy. After 1 to 2 days of clinical improvement with ceftriaxone as parenteral therapy, a seven-day course of antibiotics may be completed with daily intramuscular ceftriaxone given at 250 mg daily. Patients with septic arthritis or those who are immunocompromised or slower to respond to treatment may require a longer course of therapy (7 to 14 days). De-escalation to oral antibiotic therapy (such as cefixime, fluoroquinolones, or penicillin) may be done only in patients who do not have septic arthritis and only if culture and susceptibility results are available. However, not all laboratories are capable of performing N. gonorrhoeae culture and sensitivity testing. In cases wherein the microbiologic diagnosis is not established, the course of therapy should be completed with a parenteral cephalosporin.

Partners of patients diagnosed with DGI within 2 months should be contacted and treated whenever possible. Patients with recurrent DGI or gonococcal arthritis will require further evaluation for complement deficiency.

Patients with a history of beta-lactam allergy are often able to tolerate ceftriaxone. Due to the absence of effective alternative parenteral agents, patients who have a history of IgE mediated hypersensitivity reaction to beta-lactams may undergo either skin testing or graded challenge testing. Patients who test positive for these tests should undergo desensitization. Those with a history of severe, non-IgE mediated reaction will require consultation with an Infectious Disease specialist.

Patients presenting with localized purulent arthritis should undergo joint drainage, either arthroscopically or through repeated joint aspirations until there is evidence of response such as the resolution of fever, leukocytosis, joint pain, and effusions. Open surgical drainage may be necessary if aspiration is not adequate.

Differential Diagnosis

  • Septic arthritis: Acute purulent arthritis due to other bacteria may present similarly. They may be distinguished from gonococcal arthritis through microbiologic identification from synovial fluid culture.
  • Poststreptococcal arthritis: Acute rheumatic arthritis may present with both polyarthritis and rash. The rash, however, is transient and is typically not vesicular or pustular.
  • Crystal arthropathy: This may also present as mono- or oligo-arthritis and may be distinguished through synovial fluid analysis.
  • Other inflammatory arthritis: Rheumatoid arthritis, reactive arthritis, and psoriatic arthritis may be mistaken for gonococcal arthritis, but these disease entities are usually associated with other clinical or radiologic manifestations not seen in disseminated gonococcal infection.
  • Several other infections such as Lyme disease, infective endocarditis, and certain viruses may also present with some form of joint involvement.

Prognosis

Disseminated gonococcal arthritis has an excellent prognosis if appropriate therapy is given. Rare complications such as meningitis, perihepatitis, osteomyelitis, and endocarditis may occur if treatment is delayed or inadequate. 

Complications

  • Meningitis
  • Joint Damage
  • Perihepatitis
  • Endocarditis
  • Osteomyelitis

Postoperative and Rehabilitation Care

After the patient has completed treatment, re-evaluation is necessary. Patients also need to be screened for other sexually transmitted infections in 3-6 months. More important, the partners need to be contacted and treated.

Consultations

  • Orthopedic surgeon
  • Infectious disease

 

Enhancing Healthcare Team Outcomes

Gonococcal arthritis is ideally managed with an interprofessional team of healthcare professionals. While the acute joint problem is managed by a physician, many patients may require a short program in physical therapy to regain their joint mobility and muscle strength. The nurse should educate the patient on sexually transmitted infections and how to practice safe sex. Once a patient has been diagnosed with one STD, the nurse should inform the patient on getting tested for other STDs. The pharmacist should ensure compliance with antibiotics to ensure that full healing occurs. Finally, the social worker should recommend that the partner be examined and treated, otherwise the cycle of infection transmission will continue. [14][15](Level V)

Outcomes

When patients with gonococcal arthritis are treated with antibiotics, there is usually full recovery without any sequelae. For those who have other manifestations besides the arthritis, the prognosis may depend on the severity of the infection. For example, if a patient has gonococcal endocarditis, antibiotics may be required for 4-6 weeks and if the valve is damaged, valve replacement may be required. In general, complications following gonococcal arthritis are rare. [8][16](Level V)

 

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Gonococcal Arthritis - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the treatment of choice for a native joint gonococcal infection?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a septic knee secondary to gonorrhea is treated with intravenous ceftriaxone and is clinically improved in 72 hours. The patient requests discharge to home. His chlamydia polymerase chain reaction test is positive. Which of the following is appropriate in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient with gonococcal arthritis, what is the treatment protocol?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following features is characteristic of gonococcal arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient with gonococcal arthritis, what is the treatment protocol?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding gonococcal arthritis or disseminated gonococcal infection?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents to the emergency department for complaints of joint pain and fever. These symptoms started several days ago and were associated with body malaise, pain in multiple joints, and skin rash. Physical examination reveals vesicular lesions in the trunk and extremities and tenderness along the flexor sheath of the right arm. Joints are nontender on exam with no swelling. The patient is sexually active with both men and women. He also claims to have been previously treated for a sexually transmitted infection though he is unable to recall what it was. Patient is admitted in the general wards. Blood cultures were and basic laboratories are obtained and are pending. Which of the following is the next step?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the preferred empiric antibiotic therapy in a patient diagnosed with gonococcal arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 28-year-old sexually active female is admitted for a swollen right knee joint with associated fever and chills. Nucleic acid amplification test (NAAT) of the urine specimen is positive for Neisseria. gonorrhoeae. Arthrocentesis and synovial fluid analysis reveal WBC count of more than 50,000/microL. Gram stain of synovial fluid shows gram-negative diplococci. Empiric ceftriaxone is started. After several days, the right knee is re-examined which shows re-accumulation of joint effusion, but the fever has resolved. Which of the following is the next most appropriate step?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Gonococcal Arthritis - References

References

Carlin E,Urban C,Sidle J,Cirilli A,Larson J,Richman M,Dexeus D, Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound. The Journal of emergency medicine. 2018 Jun     [PubMed]
Burns JE,Graf EH, The Brief Case: Disseminated Neisseria gonorrhoeae in an 18-Year-Old Female. Journal of clinical microbiology. 2018 Apr     [PubMed]
Benavent Núñez D,Tornero Marín C,Bonilla Hernán G,García Perea A,Balsa Criado A,Rico Nieto A, Gonococcal Arthritis and C2 Deficiency. Reumatologia clinica. 2017 Nov 1     [PubMed]
Gassiep I,Gilpin B,Douglas J,Siebert D, Gonococcal Prosthetic Joint Infection. Journal of bone and joint infection. 2017     [PubMed]
Rouanes N,Sanchez R,Cazanave C, [A case of gonococcal arthritis: Diagnostic difficulties and usefulness of synovial fluid PCR]. La Revue de medecine interne. 2018 Jan     [PubMed]
Tuttle CS,Van Dantzig T,Brady S,Ward J,Maguire G, The epidemiology of gonococcal arthritis in an Indigenous Australian population. Sexually transmitted infections. 2015 Nov     [PubMed]
Belkacem A,Caumes E,Ouanich J,Jarlier V,Dellion S,Cazenave B,Goursaud R,Lacassin F,Breuil J,Patey O, Changing patterns of disseminated gonococcal infection in France: cross-sectional data 2009-2011. Sexually transmitted infections. 2013 Dec     [PubMed]
Bleich AT,Sheffield JS,Wendel GD Jr,Sigman A,Cunningham FG, Disseminated gonococcal infection in women. Obstetrics and gynecology. 2012 Mar     [PubMed]
Mamane W,Falcone MO,Doursounian L,Nourissat G, [Isolated gonococcal tenosynovitis. Case report and review of literature]. Chirurgie de la main. 2010 Oct     [PubMed]
Lutro O,Lillebø K,Schrama JC,Dale H,Sjursen H, A man with fever and joint pain. Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke. 2016 Dec     [PubMed]
Guillot X,Delattre E,Prati C,Wendling D, Destructive septic arthritis of the sternoclavicular joint due to Neisseria gonorrhoeae. Joint, bone, spine : revue du rhumatisme. 2012 Oct     [PubMed]
Maharaj R,Mody GM, The rarity of gonococcal arthritis in association with HIV infection. Journal of infection in developing countries. 2014 Sep 12     [PubMed]
Zaia BE,Soskin PN, Images in emergency medicine. Man with severe shoulder pain. Gonococcal arthritis of the shoulder. Annals of emergency medicine. 2014 May     [PubMed]
Simmermacher NT, Patient trust crucial for diagnosing gonococcal arthritis. The Nurse practitioner. 2005 Aug     [PubMed]
Koss PG, Disseminated gonococcal infection. The tenosynovitis-dermatitis and suppurative arthritis syndromes. Cleveland Clinic quarterly. 1985 Summer     [PubMed]
Wise CM,Morris CR,Wasilauskas BL,Salzer WL, Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991). Archives of internal medicine. 1994 Dec 12-26     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Corrections (CCN). The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Corrections (CCN), it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Corrections (CCN), you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Corrections (CCN). When it is time for the Nurse-Corrections (CCN) board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Corrections (CCN).