Gonococcal Arthritis

Aka: Gonococcal Arthritis, Septic Joint due to Gonorrhea, Disseminated Gonococcal Infection, Disseminated Gonorrhea, Dermatitis-Arthritis Syndrome

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II. Epidemiology

  1. Disseminated Gonococcal Infection affects 3% of all Gonorrhea infections

III. Presentations: Two distinct presentations

  1. Gonococcal Arthritis
    1. Suppurative Monoarticular, Oligoarticular or Polyarticular presentations
    2. Seeding of joint from bacteremia
    3. Requires joint wash-out
  2. Dermatitis-Arthritis Syndrome
    1. See Gonorrhea for Management (this page refers primarily to Gonococcal Arthritis)
    2. Bacteremia Classic Triad (onset 2 weeks after initial infection)
      1. Tenosynovitis
      2. Polyarthralgia
        1. Joints are typically not purulent (do not require wash-out)
      3. Dermatitis (75% of cases)
        1. Distal extremity lesions on dorsal surfaces
        2. Papules or Pustules (2 to 10) on purpuric base with necrotic areas

IV. Signs

  1. Joints affected in order of involvement
    1. Knees (Most often involved)
    2. Elbows
    3. Ankles
    4. Wrists
    5. Hands or feet
  2. Rarely affected joints
    1. Shoulders
    2. Hips

V. Labs

  1. Broad-based cultures with lab notification of Gonorrhea suspicion
    1. Cervix or urine Gonorrhea PCR
    2. Rectal culture or PCR
    3. Throat Culture or PCR
    4. Eye Culture
    5. Blood Cultures
  2. Arthrocentesis for Synovial Fluid
    1. Clear to opaque Synovial Fluid
    2. Synovial Fluid WBC: 30,000 to 100,000 (>80% PMNs)
    3. Gram Stain Positive in <25% of cases
    4. Culture positive in <50% of cases

VI. Management

  1. Antibiotic management should be based on culture
  2. Initial empiric management
    1. Ceftriaxone (Rocephin) 1 gram IV q24 hours for at least 7 days AND
    2. Chlamydia management if not excluded (not indicated for Gonorrhea treatment without Chlamydia as of 2020)
      1. Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
      2. Azithromycin 1 g orally for 1 dose
      3. Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6 [PubMed]
        1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  3. Alternative empiric Antibiotic options
    1. Cefotaxime 1 g q8 hours IV
    2. Ceftizoxime 1 g q8 hours IV
    3. Spectinomycin 2 g q12 h IM (not available in U.S.)
  4. Continue IV Antibiotics until clinical improvement

VII. References

  1. Swadron and Shoenberger in Herbert (2018) EM:Rap 18(12): 1
  2. (2018) Sanford Guide, accessed on IOS 12/1/2018

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