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General Considerations
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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 male homosexuals, 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; this may explain the frequent inability to culture organisms from skin and joint lesions Recurrent disseminated gonococcal infection should prompt testing of the patient s CH50 level to evaluate for a congenital deficiency of the terminal complement components C7 and C8
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Clinical Findings
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A Symptoms and Signs
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One to 4 days of migratory polyarthralgias involving the wrist, knee, ankle, or elbow is the most common initial course Thereafter, two patterns emerge, one (60% of patients) characterized by tenosynovitis (most often affecting wrists, fingers, ankles, or toes) and the other (40%) by purulent monarthritis (most frequently involving the knee, wrist, ankle, or elbow) 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 two to ten small necrotic pustules distributed over the extremities, especially the palms and soles
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Prognosis
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The outcome of septic arthritis depends largely on the antecedent health of the patient, the causative organism (eg, S aureus bacterial arthritis is associated with a poor functional outcome in about 40% of cases), and the promptness of treatment Five to 10 percent of patients with an infected joint die of respiratory complications of sepsis The mortality rate is 30% for patients with polyarticular sepsis Bony ankylosis and articular destruction commonly also occur if treatment is delayed or inadequate
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Margaretten ME et al Does this adult patient have septic arthritis JAMA 2007 Apr 4;297(13):1478 88 [PMID: 17405973] Ross JJ et al Septic arthritis Infect Dis Clin North Am 2005 Dec;19(4):799 817 [PMID: 16297733] Zimmerli W et al Prosthetic-joint infections N Engl J Med 2004 Oct 14;351(16):1645 54 [PMID: 15483283]
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B Laboratory Findings
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The peripheral blood leukocyte count averages about 10,000 cells/mcL and is elevated in less than one-third of patients The synovial fluid white blood cell count, however, is typically over 50,000 cells/mcL The synovial fluid Gram stain is positive in one-fourth of cases and culture in less than half Positive blood cultures are seen in 40% of patients with tenosynovitis and virtually never in patients with suppurative arthritis Urethral, throat, and rectal cultures should be done in all patients, since they 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
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GONOCOCCAL ARTHRITIS
ESSENTIALS OF DIAGNOSIS
Prodromal migratory polyarthralgias Tenosynovitis most common sign Purulent monarthritis in 50%
C Imaging
Radiographs are usually normal or show only soft tissue swelling
CMDT 2008
The rheumatic syndromes may follow the diagnosis of AIDS or may precede it by several months Thus, coexistent HIV infection must be considered in patients presenting with reactive arthritis The lower extremity joints, especially the knees and ankles, are most commonly affected Often, as in classic Reiter s syndrome (reactive arthritis), Achilles tendon inflammation (enthesopathy) or knee periarthritis is a prominent and distinguishing feature Many patients respond to NSAIDs, though a few are unresponsive and develop progressive deformities In the era of highly active antiretroviral therapies, immunosuppressive medications can be used if necessary in HIV patients, though with reluctance and great caution Finally, medications used to treat HIV, particularly the protease inhibitors, may be associated with musculoskeletal side effects, chiefly arthralgias
Calabrese LH et al Rheumatic complications of human immunodeficiency virus infection in the era of highly active antiretroviral therapy: emergence of a new syndrome of immune reconstitution and changing patterns of disease Semin Arthritis Rheum 2005 Dec;35(3):166 74 [PMID: 16325657]
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