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Gonococcal Arthritis

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

  • Presentations
  • Two distinct presentations
  1. Suppurative Monoarticular Arthritis
    1. Seeding of joint from bacteremia
    2. Requires joint wash-out
  2. Bacteremia Classic Triad: Dermatitis-Arthritis Syndrome (See Gonorrhea)
    1. Polyarthralgia (joints are typically not purulent, and do not require wash-out)
    2. Tenosynovitis
    3. Dermatitis (distal extremity necrotic lesions)
  • 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
  • Labs
  1. Broad-based cultures with lab notification of Gonorrhea suspicion
    1. Cervix or urine Gonorrhea PCR
    2. Rectal culture
    3. Throat Culture
    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
  • 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
  • References
  1. Swadron and Shoenberger in Herbert (2018) EM:Rap 18(12): 1
  2. (2018) Sanford Guide, accessed on IOS 12/1/2018