Gonococcal Arthritis - Diagnosis

10/06/2003

Question: What are distinguishing features of gonococcal arthritis?

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Unique Identifier:12787521

Authors: Bardin T.

Institution: Universite Paris VII, Hopital Lariboisiere, 2 rue Ambroise pare, 75475 Paris Cedex 10, France. thomas.bardin@lrb.ap-hop-paris.fr

Title: Gonococcal arthritis. [Review] [41 refs]

Source: Best Practice & Research in Clinical Rheumatology. 17(2):201-8, 2003 Apr.

Abstract: Gonococcal arthritis results from blood dissemination of Neisseria gonorrhoeae from primary sexually acquired mucosal infection. The disease has become rare in Western countries since the introduction of effective control programmes, but it still needs to be recognized promptly to avoid systemic, potentially life-threatening involvement, destructive changes associated with chronic arthritis and spread of the infection. Sexually active women are predominantly affected. Clinical features include polyarthralgia, sometimes migratory, tenosynovitis, arthritis, constitutional symptoms and skin lesions, which are mild and easily unnoticed. True arthritis occurs in less than 50% of cases. Primary mucosal infection may be asymptomatic.N. gonorrhoeae is a fragile micro-organism which is difficult to culture. Sampling of blood, synovial fluid, skin lesion, genito-urinary tract, pharynx and rectum must be performed before starting antibiotics. Samples should be plated immediately on fresh, pre-warmed appropriate media and sent quickly to the laboratory. Culture of N. gonorrhoeae is of tremendous importance not only for definite diagnosis but also for determination of drug susceptibility. When culture is negative, rapid response to antimicrobial treatment will allow a probable diagnosis. Penicillin resistance has developed worldwide in recent years, and penicillin is no longer the initially recommended antibiotic for gonococcal arthritis. Patients should be started on a third-generation cephalosporin and later switched to ampicillin or penicillin only when sensitivity to these antimicrobials has been demonstrated. Oral therapy substitutes the intravenous or intramuscular route after signs and symptoms have improved, in order to complete 7 days of antimicrobial therapy. Effusions should be aspirated until disappearance. Purulent effusions are rare but may require longer antibiotic treatment. The patient's sexual partner must be examined and treated. Patients should be tested and eventually treated for Chlamydia, syphilis and HIV, and educated about the sexual mode of transmission and means of preventing sexually transmitted diseases. [References: 41]

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Unique Identifier:10364899

Authors: Weston VC. Jones AC. Bradbury N. Fawthrop F. Doherty M.

Institution: Rheumatology Unit, City Hospital, Nottingham.

Title: Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991.

Source: Annals of the Rheumatic Diseases. 58(4):214-9, 1999 Apr.

Abstract: AIMS: To determine the clinical features of a large number of unselected UK hospital patients with confirmed septic arthritis and to determine those features associated with a poor outcome. STUDY DESIGN: Retrospective, case-note survey. SETTING: A single English Health District. PATIENTS: All patients admitted to hospital in Nottingham during the period 1 January 1982 to 31 December 1991 with confirmed septic arthritis were included. OUTCOME MEASURES: Death, osteomyelitis and recorded functional impairment. RESULTS: The spectrum of causative organisms remains similar to that seen in previous studies with the Gram positive organisms Staphylococcus aureus and Streptococci responsible for 74% of cases, gonococcal infections though were less common. Culture of joint aspirates and or blood were positive in 82% of cases, with the Gram stain demonstrating the causative organism in 50% of cases. Pre-existing joint disease was evident in 35% of cases. The mortality remains high at 11.5% with a significant additional morbidity of 31.6%. Multivariate analysis suggests that important predictors of death are: confusion at presentation, age > or = 65 years, multiple joint sepsis or involvement of the elbow joint, and of morbidity are: age > or = 65 years, diabetes mellitus, open surgical drainage, and Gram positive infections other than S aureus. CONCLUSIONS: Septic arthritis continues to be associated with a considerable degree of morbidity and mortality. These results confirm the importance of obtaining synovial fluid and blood for culture before starting antimicrobial treatment. The apparent poorer outcome found with surgical intervention is in line with some previous suggestions but should be interpreted with caution in light of the retrospective nature of this study.

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Unique Identifier:7993152

Authors: Wise CM. Morris CR. Wasilauskas BL. Salzer WL.

Institution: Department of Medicine, Bowman Gray School of Medicine, Winston-Salem, NC.

Title: Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991).

Source: Archives of Internal Medicine. 154(23):2690-5, 1994 Dec 12-26.

Abstract: BACKGROUND: To assess the impact of recent reports of disseminated gonococcal infection caused by penicillin-resistant organisms, we reviewed the presenting features, clinical course, and outcomes of a group of patients with gonococcal arthritis treated in recent years. METHODS: We reviewed the records of all cases of acute arthritis associated with a culture positive for Neisseria gonorrhoeae at our institution from July 1985 through December 1991. RESULTS: Forty-one cases were identified. Patients included 34 women and 38 blacks; the mean age was 22.6 years. Duration of symptoms averaged 4.8 days at presentation. Other features included migratory arthralgias (n = 27), urogenital symptoms or signs (n = 26), fever (n = 21), and skin lesions (n = 16). Comorbid conditions included intravenous drug use (n = 8) and systemic lupus erythematosus (n = 3). The knee was the most commonly affected joint. Positive culture results were obtained from 32 urogenital samples (86%), 14 synovial fluid samples (44%), seven rectal samples (39%), four blood samples (12%), and two throat samples (7%). All synovial fluid samples with positive culture results had white blood cell counts higher than 20.0 x 10(9)/L. Response to therapy with penicillin and/or ceftriaxone was prompt, and mean duration of hospitalization was 5.8 days. Patients who required longer hospitalization had a higher mean erythrocyte sedimentation rate and higher frequencies of positive synovial fluid culture results and comorbid conditions. Penicillin sensitivity could be determined in 30 patients on the basis of clinical response or in vitro testing. Among these patients, two cases of penicillin-resistant organisms were identified, one beta-lactamase positive and one beta-lactamase negative. CONCLUSIONS: The clinical features of patients with gonococcal arthritis have changed very little since the last large reported series over a decade ago. Underlying conditions appear to be more common, but response to antibiotic therapy and eventual outcome remain excellent. The finding of penicillin-resistant organisms in at least 5% of patients reinforces recent recommendations that third-generation cephalosporin agents be used as initial therapy for disseminated gonococcal infections until drug susceptibilities are known.