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Differential Diagnosis
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Reactive arthritis can produce acute monarthritis in a young person but is distinguished by negative cultures, sacroiliitis, 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 but have other distinguishing features Infective endocarditis with septic arthritis can mimic disseminated gonococcal infection
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Treatment
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In most cases, patients in whom gonococcal arthritis is suspected should be admitted to the hospital to confirm the diagnosis, to exclude endocarditis, and to start treatment While outpatient treatment has been recommended in the past, the rapid rise in gonococci resistant to penicillin makes initial inpatient treatment advisable Approximately 4 5% of all gonococcal isolates produce a -lactamase that confers penicillin resistance An additional 15 20% of gonococcal species have chromosomal mutations that result in relative resistance to penicillin The recommendation for initial treatment is to give ceftriaxone, 1 g intravenously daily (or cefotaxime, 1 g intravenously every 8 hours; or ceftizoxime, 1 g intravenously every 8 hours; or ciprofloxacin, 400 mg intravenously every 12 hours; or ofloxacin, 400 mg intravenously every 12 hours; or levofloxacin, 250 mg intravenously daily); spectinomycin, 2 g intramuscularly every 12 hours, may be used for patients with -lactam allergies Quinolones should not be used when the chance of quinolone resistance is high (eg, cases from Hawaii or California or that involve men who have sex with men) Once improvement from parenteral antibiotics has been achieved for 24 48 hours, patients can be switched to oral cefixime, 400 mg orally twice daily, or, in regions with low rates of quinolone resistance, levofloxacin 500 mg orally daily or ciprofloxacin 500 mg orally twice daily, to complete a 7- to 10-day course
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VIRAL ARTHRITIS
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Arthritis may be a manifestation of many viral infections It is generally mild and of short duration, terminating without lasting ill effects Mumps arthritis may occur in the absence of parotitis Rubella arthritis, which occurs more commonly in adults than in children, may appear immediately before, during, or soon after the disappearance of the rash Its usual polyarticular and symmetric distribution mimics that of rheumatoid arthritis However, the seronegative tests for rheumatoid factor and the rising rubella titers in convalescent serum help confirm the diagnosis Post-rubella vaccination arthritis may have its onset as long as 6 weeks following vaccination and occurs in all age groups In adults, arthritis may follow infection with human parvovirus B19 and sometimes mimics rheumatoid arthritis Transient polyarthritis may be associated with type B hepatitis and typically occurs before the onset of jaundice; it may occur in anicteric hepatitis as well Urticaria or other types of skin rash may be present Indeed, the clinical picture may be indistinguishable from that of serum sickness Serum transaminase levels are elevated, and hepatitis B surface antigen is most often present Serum complement levels are usually low during active arthritis and become normal after remission of arthritis False-positive tests for rheumatoid factor, when present, disappear within several weeks The arthritis is mild; it rarely lasts more than a few weeks and is self-limiting and without deformity Hepatitis C infection may be associated with chronic polyarthralgia or polyarthritis that mimics rheumatoid arthritis, both in the distribution of involved joints and the fact that many patients infected with hepatitis C are rheumatoid factor positive in at least low titers
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Calabrese LH et al Viral arthritis Infect Dis Clin North Am 2005 Dec;19(4):963 80 [PMID: 16297742]
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Prognosis
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Generally, gonococcal arthritis responds dramatically in 24 48 hours after initiation of antibiotics so that daily joint aspirations are rarely needed Complete recovery is the rule
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Rice PA Gonococcal arthritis (disseminated gonococcal infection) Infect Dis Clin North Am 2005 Dec;19(4):853 61 [PMID: 16297736]
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