Gonococcal Arthritis

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 (MSM), whose high incidence of asymptomatic gonococcal pharyngitis and proctitis predisposes them to disseminated gonococcal infection.

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).

Diagnostic Essentials

• 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.

Clinical Findings

Symptoms and Signs

1-4 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 < 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.

Laboratory Findings

The peripheral blood leukocyte count averages about 10,000 cells/mcL (10 × 10⁹/L) and is elevated in < 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 < 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.

Urinary nucleic acid amplification tests have excellent sensitivity and specificity for the detection of Neisseria gonorrhoeae in genitourinary sites.

Imaging

Radiographs are usually normal or show only soft tissue swelling.

Differential Diagnosis

Reactive arthritis can produce acute monoarthritis, urethritis, and fever in a young person but is distinguished by negative cultures and failure to respond to antibiotics.

Lyme disease involving the knee is less acute, does not show positive cultures, and may be preceded by known tick exposure and characteristic rash.

The synovial fluid analysis will exclude gout, pseudogout, and nongonococcal bacterial arthritis.

Rheumatic fever and sarcoidosis can produce migratory tenosynovitis.

Infective endocarditis with septic arthritis can mimic disseminated gonococcal infection.

Meningococcemia occasionally presents with a clinical picture that resembles disseminated gonococcal infection; blood cultures establish the correct diagnosis.

Rocky mountain spotted fever and dengue can produce arthritis and skin findings.

Early hepatitis B infection is associated with circulating immune complexes that can cause an urticarial rash and polyarthralgias.

Treatment

The treatment of disseminated gonorrhea (arthritis-dermatitis syndrome) per CDC guidelines is ceftriaxone (1 g daily IV or IM).

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.

Prognosis

Generally, gonococcal arthritis responds dramatically in 24–48 hours after initiation of antibiotics, and drainage of the infected joint(s) is rarely needed.

Complete recovery is the rule.