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Gonococcal Arthritis

Gonococcal arthritis is one of the several types of infection caused by Neisseria gonorrhoeae, a Gram-negative diplococcus. It is one of the most prevalent sexually transmitted diseases (STDs) worldwide, and the leading cause of septic arthritis. Asymmetric polyarthralgia preceded or accompanied by fever and subsequent swelling of one or two joints is the typical clinical presentation. Aspiration of synovial fluid and subsequent microbiological testing is necessary to make the diagnosis.


Presentation

Gonorrhea is one of the most commonly encountered sexually transmitted diseases (STDs) worldwide and is most frequently diagnosed in younger sexually active males and females [1] [2] [3] [4]. Humans are the only known host of Neisseria gonorrhoeae, and transmission through a sexual intercourse with an infected individual (who is often asymptomatic) is the mode of infection [1] [3]. After the development of a localized infection (urethritis, cervicitis, pharyngitis etc.), bacterial spread through the blood stream can cause a disseminated gonococcal infection (DGI), and gonococcal arthritis is one of the manifestations [2] [3]. Risk factors for this complication include multiple sexual partners, intravenous drug use, pregnancy, menstruation at the time of infection, immunosuppression caused by human immunodeficiency virus (HIV) infection, systemic lupus erythematosus (SLE), or complement deficiency, but also African American ancestry [3] [4] [5]. Gonorrhea is the most common cause of septic arthritis in young adults, and the initial signs and symptoms of gonococcal arthritis are fever, chills, and asymmetric polyarthralgia involving the knees, ankles, and elbows [1] [2] [3] [4] [6]. In addition, tenosynovitis, most commonly involving the smaller extensor tendons of the hand and feet, is seen in 50-60% of cases [4] [6]. However, this stage may be completely absent in some patients, and immediate progression to the suppurative stage of gonococcal arthritis, characterized by a joint swelling and arthritis of only one or two joints (known as septic arthritis), can be observed [2] [3] [5]. The knee, the wrist, the ankle and sometimes the elbow exhibit such changes in most cases [4]. Because gonococcal arthritis stems from DGI, other manifestations, such as dermatitis, and in rare cases, endocarditis and meningitis, might concomitantly develop [2] [3].

Fever
  • [ 713.6 ] Staphylococcus 711.0 Streptococcus 711.0 syphilis (see also Syphilis) 094.0 [ 711.4 ] syringomyelia 336.0 [ 713.5 ] thalassemia (see also Thalassemia) 282.40 [ 713.2 ] tuberculosis (see also Tuberculosis, arthritis) 015.9 [ 711.4 ] typhoid fever[icd9data.com]
  • Abstract Acute venereal arthritis, a syndrome of fever and inflammatory arthritis following recent sexual intercourse, is a frequently misdiagnosed arthritic presentation.[ncbi.nlm.nih.gov]
  • Gonorrhea is the most common cause of septic arthritis in young adults, and the initial signs and symptoms of gonococcal arthritis are fever, chills, and asymmetric polyarthralgia involving the knees, ankles, and elbows.[symptoma.com]
  • At that time, it was observed during a course of fever therapy for syphilis that the gonococcal arthritis also present had improved. 1 Further studies confirmed this original observation and fever became the accepted form of therapy.[annals.org]
Chills
  • Patients with the septic form characteristically had, early in the course of their illness, chills and fever, polyarthritis, skin lesions of gonococcemia and relatively little joint effusion.[nejm.org]
  • Gonorrhea is the most common cause of septic arthritis in young adults, and the initial signs and symptoms of gonococcal arthritis are fever, chills, and asymmetric polyarthralgia involving the knees, ankles, and elbows.[symptoma.com]
  • Fever and chills Joints are painful or tender especially during movement Limited range of movement of the joint Skin lesions What are the possible causes? The bacterium Neisseria gonorrhoeae is responsible for gonorrhea.[firstaidcprvictoria.ca]
  • Symptoms of infectious arthritis include Intense pain in the joint Joint redness and swelling Chills and fever Inability to move the area with the infected joint One type of infectious arthritis is reactive arthritis.[icdlist.com]
  • Symptoms may include: red and swollen joints joints that are tender or painful, especially when you move restricted joint range-of-motion fever chills skin lesions In infants, symptoms may include: difficulty feeding irritability crying fever spontaneous[healthline.com]
Reiter's Syndrome
  • Nearly half of 39 patients admitted with a diagnosis of acute gonococcal arthritis were subsequently recognized as having acute Reiter syndrome.[ncbi.nlm.nih.gov]
  • These symptoms were consistent to the features of Reiter syndrome. Bacterial culture of urine was negative, as were rheumatoid factor(RF)and HLA-B27 antigens.[webview.isho.jp]
  • Reactive arthritis ----- 2 categories 1 after genitourinary involvement ( URETHRITIS ) is the REITERs syndrome--- along with urethritis, conjunct, and arthritis patients have keratoderma blenorrhagicum ( Clear vesicles on palms and soles, closely resemble[usmleforum.com]
  • “Reactive” (sterile) arthritis, formerly known as Reiter’s syndrome, may occur following chlamydial genital infection or bacterial gastroenteritis caused by campylobacter, salmonella, and other agents.[clinicaladvisor.com]
  • syndrome : - less common in women; - presents with the triad of urethritis, conjunctivitis, and axial arthritis; - onset is subacute, without fever; - hyperkeratotic skin lesions in palms and soles are typical; - Clinical Presentation: - migratory arthritis[wheelessonline.com]
Malaise
  • Nonspecific constitutional symptoms may include myalgias, fever, and malaise. Septic arthritis form Joint symptoms begin within days to weeks of gonococcal infection.[odlarmed.com]
  • Other cutaneous lesions of DGI that have been reported are abscesses, cellulitis, petechiae, purpuric macules, necrotizing fasciitis, and vasculitis. [10] Nonspecific constitutional symptoms may include myalgias, fever, and malaise.[emedicine.medscape.com]
  • There followed progressive malaise and diminished appetite. Painful palms ensued. Inasmuch as her symptoms and overall condition worsened, she returned to The Emergency Department for reassessment.[hopkinsarthritis.org]
  • Our patient's initial presentation with urethritis, accompanied by fever, malaise and polyarthritis is classic [ 1, 11 ].[jbji.net]
  • Essential Core Tested Community Questions (4) Sorry, this question is for PEAK Premium Subscribers only (M2.ID.4691) A 24-year-old man presents to the clinic with a one week history of pain in his left hand and stiffness in his right knee, with associated malaise[medbullets.com]
Rigor
  • URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services.[lutheranhealthcare.org]
  • Schlapbach P, Ambord C, Blochlinger AM et al (1990) Bacterial arthritis: are fever, rigors, leucocytosis and blood cultures of diagnostic value? Clin Rheumatol 9:69–72. doi: 10.1007/BF02030245 PubMed CrossRef Google Scholar 16.[link.springer.com]
  • Fevers are usually low-grade and rigors are only present in a minority of cases.[patient.info]
Respiratory Disorders
  • disorder NEC 519.9 [ 713.4 ] reticulosis, malignant (M9720/3) 202.3 [ 713.2 ] rubella 056.71 salmonellosis 003.23 sarcoidosis 135 [ 713.7 ] serum sickness 999.59 [ 713.6 ] Staphylococcus 711.0 Streptococcus 711.0 syphilis (see also Syphilis) 094.0 [[icd9data.com]
Arthritis
  • However, this stage may be completely absent in some patients, and immediate progression to the suppurative stage of gonococcal arthritis, characterized by a joint swelling and arthritis of only one or two joints (known as septic arthritis), can be observed[symptoma.com]
  • Abstract Acute venereal arthritis, a syndrome of fever and inflammatory arthritis following recent sexual intercourse, is a frequently misdiagnosed arthritic presentation.[ncbi.nlm.nih.gov]
  • Convert to ICD-10-CM : 098.50 converts directly to: 2015/16 ICD-10-CM A54.42 Gonococcal arthritis Approximate Synonyms Gonococcal infection of joint Gonococcal osteomyelitis Gonorrhea, arthritis Gonorrhea, osteomyelitis Applies To Gonococcal infection[icd9data.com]
Joint Effusion
  • Patients with the septic form characteristically had, early in the course of their illness, chills and fever, polyarthritis, skin lesions of gonococcemia and relatively little joint effusion.[nejm.org]
  • effusion, warmth, tenderness, decreased range of motion, and marked erythema.[odlarmed.com]
  • In patients with purulent joint effusions, synovial fluid culture is often positive with negative blood cultures [ 9 ]. Gonococcal arthritis responds well to antibiotics and prognosis is good when appropriate therapy is quickly initiated.[panafrican-med-journal.com]
  • effusion in large joint such as hip can be used in guiding aspirations MRI indications detects joint effusion, and may detect adjacent bone involvement such as osteomyelitis Studies Serum labs WBC 10K with left shift ESR 30 ESR is often elevated but[orthobullets.com]
Arthralgia
  • The gonococcal arthritis-dermatitis syndrome includes tenosynovitis, arthralgias, arthritis, skin lesions, and constitutional symptoms.[ncbi.nlm.nih.gov]
  • Migratory arthralgias are the most common presenting symptom in persons with DGI and are usually polyarticular. The arthralgias are typically asymmetric and tend to involve the upper extremities more than the lower extremities.[odlarmed.com]
  • In SLE, any organ system can be involved, with the most common complaints of fever, arthralgia, and arthritis to be the presenting symptoms which can be difficult to differentiate from a Gonococcal infection.[pediatric-infectious-disease.imedpub.com]
Joint Swelling
  • In this instance, our patient was a 16-year-old girl suffering from persistent polyarthralgia with joint swelling presenting with brief flare-ups for a period of 1 year.[ncbi.nlm.nih.gov]
  • However, this stage may be completely absent in some patients, and immediate progression to the suppurative stage of gonococcal arthritis, characterized by a joint swelling and arthritis of only one or two joints (known as septic arthritis), can be observed[symptoma.com]
  • In addition to joint swelling and pain, an untreated gonorrhea infection can lead to other more serious health complications, including: pelvic inflammatory disease (a serious infection of the uterus lining, ovaries, and fallopian tubes that can lead[healthline.com]
  • Symptoms like joint swelling and pain may ease to some degree after drainage. However, drainage is not an effective way of treating the infection and antibiotics are still necessary.[healthhype.com]
Migratory Polyarthritis
  • Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis.[odlarmed.com]
  • polyarthritis, tenosynovitis, and dermatitis. [9] Migratory arthritis has an asymmetric distribution, most commonly affecting wrists, ankles, and elbows.[emedicine.medscape.com]
  • This patient has disseminated gonococcal infection (DGI) with classic symptoms of tenosynovitis, characteristic skin lesions and a migratory polyarthritis.[rheumatology.org]
Pustular Rash
  • Gonococcal septic arthritis usually occurs as part of the syndrome of disseminated gonococcal infection, in which patients have some combination of urethritis, tenosynovitis, septic arthritis, and a hemorrhagic and pustular rash.[rheumatologyadvisor.com]
Cutaneous Manifestation
  • Cutaneous manifestations of disseminated gonococcemia. Dermatol Online J. 2017 Jan 15. 23 (1): [Medline]. Low SY, Ong CW, Hsueh PR, Tambyah PA, Yeo TT. Neisseria gonorrhoeae paravertebral abscess. J Neurosurg Spine. 2012 Jul. 17(1):93-7. [Medline].[emedicine.medscape.com]

Workup

Having in mind the specific features and the evident risk factors of this STD, the diagnosis of arthritis caused by Neisseria gonorrhoeae can be made after a thorough clinical workup. A detailed patient history is the first step, which will assess the course and progression of symptoms and identify if any of the mentioned risk factors are present, meaning that an assessment of prior sexual contacts is necessary. Secondly, if a complete physical examination reveals joint-related changes, sufficient evidence are obtained to make a presumptive diagnosis. Microbiological studies are the cornerstone in confirming Neisseria gonorrhoeae as the underlying cause of arthritis, and blood cultures, as well as Gram staining of the obtained samples, yield a very good rate of identification [1] [2] [3] [6] [7]. Additionally, the introduction of more advanced methods, such as the nucleic acid amplification test (NAAT), have shown to be even better compared to blood cultures [2] [3]. Aspiration of synovial fluid can be performed in patients who present with evident signs of arthritis, which will reveal an inflammatory white blood cell count (10 000 to 100 000 cells/mm3), while the inoculation of aspirated fluid onto specific media for cultivation often confirm the presence of Neisseria gonorrhoeae in the setting of negative blood cultures [4] [5]. Because patients are highly likely to suffer from some other STD in addition to gonorrhea, a complete STD panel testing is recommended.

Neisseria Gonorrhoeae
  • Humans are the only known host of Neisseria gonorrhoeae, and transmission through a sexual intercourse with an infected individual (who is often asymptomatic) is the mode of infection.[symptoma.com]
  • Disseminated Neisseria gonorrhoeae gonococcal infections are the leading cause of acute arthritis in young adults.[ncbi.nlm.nih.gov]
  • Joint inflammation occurring as a consequence of an infection with Neisseria gonorrhoeae.[medical-dictionary.thefreedictionary.com]

Treatment

  • Recommended treatment protocols for localized gonorrhea and DGI are reviewed as well as the occurrence and implications for treatment of penicillinase-producing N. gonorrhoeae (PPNG) infection in the U.S.[ncbi.nlm.nih.gov]
  • A new standardized treatment routine is recommended by the Centers for Disease Control and Prevention (CDC). Your health care provider will determine the best and most up-to-date treatment.[lutheranhealthcare.org]

Prognosis

  • Prognosis The prognosis for patients with gonococcal arthritis is excellent provided that there is prompt medical treatment through the appropriate antibiotics and joint drainage.[healthhype.com]
  • Coverage of each disorder includes more details on treatment and prognosis.[books.google.de]
  • Outlook (Prognosis) Symptoms usually improve within 1 to 2 days of starting treatment. Full recovery can be expected. Possible Complications Untreated, this condition may lead to persistent joint pain.[dxline.info]
  • Gonococcal arthritis responds well to antibiotics and prognosis is good when appropriate therapy is quickly initiated. Destructive arthritis may be observed in HIV patients or in chronic infections due to inappropriate treatment.[panafrican-med-journal.com]

Etiology

  • A three-phase bone scan was performed, which demonstrated increased uptake in the right sternoclavicular junction of undetermined etiology (Fig 3).[healio.com]
  • Etiology Pathogen Neisseria gonorrhoeae ( N. gonorrhoeae, gonococcus ) Gram-negative, intracellular, aerobic, diplococci Transmission Risk factors Multiple sexual partners Low socioeconomic status Lack of barrier protection (e.g., condomless sex ) Men[amboss.com]
  • […] patients, including IV drug users risk factors age 80 years medical conditions diabetes rheumatoid arthritis cirrhosis HIV history of crystal arthropathy endocarditis or recent bacteremia IV drug user recent joint surgery Pathophysiology pathoanatomy 3 etiologies[orthobullets.com]
  • GONOCOCCAL INFECTIONS Etiology Caused by Neisseria gonorrhoeae. Epidemiology Since 1997, there has been a gradual but steady increase in reported cases of gonococcal infection.[canada.ca]
  • However, the short duration of symptoms, accompanied by flu-like symptoms and rash make an infectious etiology more likely.[rheumatology.org]

Epidemiology

  • Three factors that should be considered are regional epidemiology, the anatomical site of the primary infection, and the possible coexistence of other infectious agents.[ncbi.nlm.nih.gov]
  • The epidemiology of gonococcal arthritis in an Indigenous Australian population. Sex Transm Infect. 2015 Mar 19. [Medline]. Balsa A, Martin-Mola E. Infectious arthritis I: bacterial arthritis.[emedicine.medscape.com]
  • Epidemiology. 1992; 3:531-535. 10. Biro FM, Rosenthal SL, Wildly LS. Selfreported healtii concerns and sexual behaviors in adolescents with cervical dysplasia. J Adolesc Health. 1991; 12:391-394. 11. Nussbaum MP, Shenker IR, Feldman JG.[healio.com]
  • Epidemiology References: [1] [2] [3] [4] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Epidemiology Since 1997, there has been a gradual but steady increase in reported cases of gonococcal infection. Most affected are males 20–24 years of age and females 15–19 years of age.[canada.ca]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology N gonorrhoeae is a highly infectious organism capable of colonizing diverse mucosal surfaces. The risk of infection from a single contact is estimated at 60-90% among women and 20-50% among men.[odlarmed.com]
  • Pathophysiology The highly infectious N. gonorrhoeae bacteria enter the body by invading the thin mucosal lining of the genitalia, rectum, mouth or throat. can colonize mucosal surfaces of the urethra (tube connecting the urinary bladder to the genitals[healthhype.com]
  • O’Brien JP, Goldenberg DL, Rice PA (1983) Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms.[link.springer.com]
  • Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Medicine (Baltimore). 1983; 62(6):395-406. PubMed Google Scholar Schwebke JR, WittingtonW, Rice RJ et al.[panafrican-med-journal.com]
  • Disseminated gonococcal infection: A prospective analysis of 49 patients and a review of the pathophysiology and immune mechanisms. Medicine. 1983;62:395-406. 9. Davoli M, Perucci CA, Sangalli M.[healio.com]

Prevention

  • The second is to locate, test, and treat all sexual contacts of the infected person to prevent further spread of the disease. A new standardized treatment routine is recommended by the Centers for Disease Control and Prevention (CDC).[lutheranhealthcare.org]
  • Read also: Common Symptoms and Treatments for Foot Osteoarthritis Preventions You should not have sexual activity that becomes the only method in preventing the gonorrhea.[fitnesstreatments.com]
  • Prevention Not having sexual intercourse (abstinence) is the only absolutely sure method of preventing gonorrhea. A monogamous sexual relationship with an individual known to be free of any sexually transmitted disease (STD) can reduce risk.[dxline.info]
  • Abstract Disseminated gonococcal infection is a preventable communicable disease. It is an important cause of arthritis in sexually active adults.[ncbi.nlm.nih.gov]
  • Prevention Not having sexual intercourse (abstinence) is the only sure method to prevent gonorrhea. A monogamous sexual relationship with a person who you know does not have any sexually transmitted disease (STD) can reduce your risk.[stlukes-stl.com]

References

Article

  1. Shim BS. Current Concepts in Bacterial Sexually Transmitted Diseases. Korean Journal of Urology. 2011;52(9):589-597.
  2. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.
  3. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology. Seventh edition. Philadelphia: Elsevier/Saunders; 2013.
  4. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2016.
  5. El Mezouar I, Tahiri L, Lazrak F, Berrada K, Harzy T. Gonococcal polyarthritis with sternoclavicular joint involvement in pregnant woman: a case report. Pan Afr Med J. 2014;17:242.
  6. Mayor MT, Roett MA, Uduhiri KA. Diagnosis and management of gonococcal infections. Am Fam Physician. 2012;86(10):931-938.
  7. Ng L-K, Martin IE. The laboratory diagnosis of Neisseria gonorrhoeae. Can J Infect Dis Med Microbiol. 2005;16(1):15-25.

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Last updated: 2019-06-28 11:10