Disseminated gonococcal arthritis
Disseminated gonococcal infection is hematogenous spread of Neisseria gonorrhoeae from a mucosal site into the bloodstream, producing either an arthritis-dermatitis triad with usually sterile joint fluid or purulent monoarthritis with a positive culture. Blood, synovial, and mucosal cultures plus nucleic acid amplification testing establish the diagnosis, and treatment is parenteral ceftriaxone with drainage of any purulent joint.
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What this article covers
- Overview
Definition: disseminated gonococcal infection is hematogenous spread of Neisseria gonorrhoeae from a mucosal site (urethra, cervix, pharynx, or rectum) into the bloodstream and joints, occurring in about 1% to 3% of infected patients.
- Epidemiology
Age pattern: Neisseria gonorrhoeae infection is most frequent at ages 20 to 24, and dissemination develops in 1% to 3% of those infected.
- Risk factors
Young, sexually active adults: the population in whom Neisseria gonorrhoeae infection is most prevalent.
- Pathophysiology
Mucosal acquisition: Neisseria gonorrhoeae first infects the urethra, cervix, pharynx, or rectum; infection is commonly asymptomatic, especially in women, delaying recognition.
- Clinical features
Arthritis-dermatitis (triad) syndrome: the most common manifestation: acutely painful tenosynovitis, migratory polyarthralgia, and pustular or vesiculopustular skin lesions, with fever, chills, and malaise.
- Differential diagnosis
Nongonococcal bacterial septic arthritis (Staphylococcus aureus or streptococci): an acutely inflamed single joint with high synovial leukocyte count, but Gram stain and culture grow gram-positive…
- Diagnosis
What establishes the diagnosis: definitive diagnosis is isolation of Neisseria gonorrhoeae from blood, synovial fluid, or a skin lesion; because culture yield from all of these sites is frequently…
- Management
First, start empiric ceftriaxone once cultures are drawn: ceftriaxone 1 g IV or IM every 24 hours, begun without waiting for culture results because increasing resistance of Neisseria gonorrhoeae to…
- Complications
Irreversible joint damage: delayed diagnosis or inadequate drainage of purulent gonococcal arthritis can cause chronic pain and permanent joint destruction, as with other bacterial arthritis.
- Prognosis
Rapid response to therapy: most patients improve within 24 to 48 hours of starting ceftriaxone, the basis for the oral step-down at that point.
- Prevention
Routine gonorrhea screening: annual nucleic acid amplification testing for women younger than 25 years and for older women with risk factors such as a new partner or a partner with a sexually transmitted infection.
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Related articles
- Neisseria gonorrhoeae gonococcal infection
Neisseria gonorrhoeae is a gram-negative intracellular diplococcus that infects columnar and transitional epithelium of the cervix, urethra, rectum, pharynx, and conjunctiva, and disseminates hematogenously in 1% to 3% of infections to cause the arthritis-dermatitis syndrome or purulent monoarthritis; treatment is ceftriaxone-based because cephalosporin resistance is emerging and fluoroquinolones are no longer reliable.
- Septic arthritis
Septic arthritis is bacterial infection of a joint, most often Staphylococcus aureus seeding the knee hematogenously, and is a medical and surgical emergency diagnosed by expeditious arthrocentesis showing a synovial leukocyte count generally above 50,000/microliter. Treatment combines empiric intravenous antibiotics such as vancomycin plus ceftriaxone with urgent joint drainage, since delayed source control destroys cartilage within days.
- Reactive arthritis
Reactive arthritis is a sterile, human leukocyte antigen B27 (HLA-B27)-associated spondyloarthritis that follows a genitourinary or enteric infection by 1 to 4 weeks, producing asymmetric lower-limb oligoarthritis, enthesitis, and the urethritis-conjunctivitis-arthritis triad. It is a clinical diagnosis of a culture-negative joint. First-line treatment is an NSAID such as piroxicam for at least 2 weeks, escalating to glucocorticoids and then sulfasalazine or a tumor necrosis factor (TNF) inhibitor for disease persisting beyond 3 to 6 months.
- Pelvic inflammatory disease
Pelvic inflammatory disease is an ascending polymicrobial infection of the upper female genital tract, most often caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, diagnosed clinically on uterine, adnexal, or cervical motion tenderness. Most women are treated as outpatients with a single dose of ceftriaxone plus 14 days of doxycycline, while parenteral cefotetan or cefoxitin plus doxycycline, or clindamycin plus gentamicin, is reserved for hospitalized patients, with tubo-ovarian abscess and infertility among the major complications of delayed treatment.
- Infectious urethritis
Infectious urethritis is inflammation of the urethra from a sexually transmitted pathogen, most often Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, presenting with dysuria and urethral discharge. Diagnosis rests on urethral or urine leukocytes plus nucleic acid amplification testing, and empiric treatment covers gonorrhea with ceftriaxone and chlamydia with doxycycline while results are pending.