Gonococcal Arthritis
المؤلف:
Longo, D., Fauci, A. S., Kasper, D. L., Hauser, S., Jameson, J. L., Loscalzo, J., Holland, S. M., & Langford, C. A.
المصدر:
Harrisons Principles of Internal Medicine (2025)
الجزء والصفحة:
22e , p1057-1058
2025-08-24
474
Epidemiology
In the past, gonococcal arthritis accounted for up to 70% of episodes of infectious arthritis in persons <40 years of age in the United States. As the rates of mucosal gonorrhea have fallen in the United States, it is likely that the proportion of septic arthritis caused by N. gonorrhoeae also has fallen considerably. Arthritis due to N. gonorrhoeae is a consequence of bacteremia arising from gonococcal infection or, more frequently, from asymptomatic gonococcal mucosal colonization of the urethra, cervix, or pharynx. Women are at greatest risk during menses and during pregnancy and overall are two to three times more likely than men to develop disseminated gonococcal infection (DGI) and arthritis. Persons with complement deficiencies, especially of the terminal components, are prone to recurrent episodes of gonococcemia. Eculizumab, which is a long-acting monoclonal antibody targeting the C5 complement com ponent and used mainly for the treatment of paroxysmal nocturnal hemoglobinuria, also has been reported to be associated with disseminated gonococcal infection.
Clinical Manifestations and Laboratory Findings
The most common manifestation of DGI is a syndrome of arthritis-dermatitis. Patients present with fever, chills, rash, tenosynovitis, and articular symptoms. Small numbers of papules that progress to hemorrhagic pustules develop on the trunk and the extensor surfaces of the distal extremities. Migratory arthritis and tenosynovitis of the knees, hands, wrists, feet, and ankles are prominent. The cutaneous lesions and articular findings are believed to be the consequence of an immune reaction to circulating gonococci and immune-complex deposition in tissues. Thus, cultures of synovial fluid are consistently negative, and blood cultures are positive in <45% of patients. Synovial fluid may be difficult to obtain from inflamed joints and usually contains only 10,000–20,000 leukocytes/μL.
True gonococcal septic arthritis is less common than the DGI syn drome and always follows DGI, which is unrecognized in one-third of patients. A single joint such as the hip, knee, ankle, or wrist is usually involved. Synovial fluid, which contains >50,000 leukocytes/μL, can be obtained with ease; the gonococcus is evident only occasionally in Gram-stained smears, and cultures of synovial fluid are positive in <40% of cases. Blood cultures are almost always negative.
Because it is difficult to isolate gonococci from synovial fluid and blood, specimens for culture should be obtained from potentially infected mucosal sites. NAAT-based urine tests also may be positive. Culture requires endocervical (in female patients) or urethral (in male patients) swab specimens. Culture is available for detection of rectal, oropharyngeal, and conjunctival gonococcal infection. Cultures and Gram-stained smears of skin lesions are occasionally positive.
All specimens for culture should be plated onto Thayer-Martin agar directly or in special transport media at the bedside and transferred promptly to the microbiology laboratory in an atmosphere of 5% CO2 . NAAT assays are extremely sensitive in detecting gonococcal DNA in synovial fluid, but they are not FDA approved for this purpose. A dramatic alleviation of symptoms within 12–24 h after the initiation of appropriate antibiotic therapy supports a clinical diagnosis of the DGI syndrome if cultures are negative.
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