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Gonococcal Arthritis - Bacterial Inflammation of the Joints

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Gonococcal arthritis is a type of bacterial joint inflammation caused secondary to sexually transmitted gonococcal infection.

Medically reviewed by

Dr. Shubadeep Debabrata Sinha

Published At January 30, 2023
Reviewed AtAugust 28, 2023

Introduction

Gonococcal arthritis is a bacterial inflammation of the joints caused due to the presence of Neisseria gonorrhoeae bacteria in the body. Gonococcal arthritis is observed adjunct to urogenital bacterial infections transmitted through sexual activities with an infected individual.

Who Is Susceptible to Gonococcal Arthritis?

More than 10,60,00,000 cases of gonorrhea are reported worldwide, with around 5,00,000 individuals being diagnosed annually within the United States. Gonococcal arthritis is seen among individuals with predisposing gonorrhea. An estimated 0.5 to 3 percent of gonorrheal infections lead to Gonococcal arthritis, mostly in young adults, but the predilection is not specific to any age group. Sexually active young female teens are the most susceptible population. Females are more prone to Gonococcal arthritis than males.

What Causes Gonococcal Arthritis?

Gonococcal arthritis is a bacterial infection of the joints caused due to Neisseria gonorrhoeae which is a gram-negative diplococcus bacteria primarily transmitted through sexual intercourse with infected individuals, mostly among the young adolescent population. Occasionally, gonorrhea can be transmitted perinatally to newborns during childbirth.

What Is the Pathophysiology of Gonococcal Arthritis?

Neisseria gonorrhoeae transmit through sexual activities, so the urogenital tract, anus, or oral cavity are the loci of gonorrheal infection. Gonorrhea has an incubation period of two to seven days, during which the bacteria manipulates the host immune system to manifest symptoms. Gonococcus bacterias have pili appendages that lengthen to provide movement and adhesion to the epithelial cells, thus causing localized cellular invasion. Other proteins like OPA (opacity-associated proteins) and LOS (lipooligosaccharide) aid gonococcal spread and infiltration. LOS has an affinity to sperm cells and may be the mode of transmission from infected males to their sexual partners.

Gonococci interact with the host-cell-complement receptors (CR3), which results in extensive rearrangement of actin proteins of the host cell that produces larger projections called ruffles. The ruffling process aids the gonococci in entering the host cells in large vacuoles (macropinosomes) and then multiplying within the cell. Gonococci are serum sensitive or serum reactive and are named likewise based on their ability to evade complement activation. The serum-resistant variants are septicemic, which allows the gonococci to travel through the bloodstream reaching anywhere in the body. This serum-resistant gonococcus causes a type of infection called disseminated gonococcal infection (DGI). Serum-resistant gonococci have a special outer membrane protein of the porin a1 serotype, which makes it resistant, decreases the host inflammatory response, hastens host cell invasion, and produces the substrates required for its own growth.

Host risk factors associated with DGI that result in Gonococcal arthritis are:

  • Complement deficiencies.

  • Menstruation.

  • Pregnancy.

  • History of pelvic surgery.

  • Intra-uterine device.

Serum-resistant gonococci causing disseminated gonorrhea is the cause of gonococcal arthritis. The bacteria reach the joints through the bloodstream and cause inflammations symptomatic of arthritis.

What Are the Types of Gonococcal Arthritis?

Gonococcal arthritis comprises two major clinical forms:

  1. Localized septic arthritis.

  2. Arthritis-dermatitis syndrome.

What Are the Signs and Symptoms of Gonococcal Arthritis?

Although localized infection of the genitourinary tract, rectum, or pharynx by gonorrhea predates dissemination, patients with clinical manifestations of DGI often do not manifest symptoms of localized gonococcal infection.

  • Arthritis-dermatitis syndrome: A triad of tenosynovitis, dermatitis, and polyarthralgia, along with nonspecific symptoms of fever, chills, and body malaise.

  • Tenosynovitis is tenderness along the flexor sheath and pain in multiple tendons, commonly the fingers, wrists, toes, and ankles, on passive extension during physical examination.

  • Polyarthralgia is asymmetric, affecting both large and small joints.

  • Skin lesions (seen in 75 percent of the cases) show pustular or vesicular lesions, macules, papules, bullae, or nodules and are transient, disappearing without treatment in a few days.

  • Localized septic arthritis: Monoarthritis or asymmetric oligo or polyarthritis.

  • The clinical manifestations include pain and swelling in one or more joints without any nonspecific symptoms. Knees, ankles, wrists, and elbows are the most commonly affected joints.

How to Diagnose Gonococcal Arthritis?

A thorough medical and sexual history, along with a physical examination, is required in patients with suspected gonococcal arthritis. Menstrual and pregnancy history is indicated in premenopausal women. Further, skin observation and joint examination are done to rule out Arthritis-dermatitis syndrome. Microbiological cultures from swabs of mucosal surfaces (throat or mouth or nose, or vagina) are positive, which is in contrast to specimens obtained from non-mucosal sites like blood, synovial fluid, and skin lesions. HIV (human immunodeficiency virus), syphilis, and chlamydia screening are required as gonococcal arthritis often occurs in conjunction with other STIs.

Two sets of blood cultures are collected and tested to distinguish gonococcal arthritis from other specimens causing septic arthritis. Blood culture gives positive results in less than 35 percent of the patients, mostly in patients with Arthritis-dermatitis syndrome. Nucleic acid amplification testing (NAAT) of urine specimens in both men and women (vaginal swabs in women is preferred over urine samples) can be performed to confirm the presence of gonococci.

In patients with joint swelling and effusion, arthrocentesis and synovial fluid analysis can be performed. Typically synovial fluid analysis reveals a WBC count of over 50,000 cells per square millimeter. Sometimes due to reduced glucose concentration and elevated LDH level, WBC count may fall below 10,000 cells per square millimeter. Gonococci are isolated from about 50 percent of the synovial fluid samples collected from patients with localized septic arthritis, even less in patients with Arthritis-dermatitis syndrome. NAAT of synovial fluid samples is more sensitive than bacterial cultures providing results in about 75 percent of the patients. Specimens from skin lesions are not feasible as they yield poor results.

How Gonococcal Arthritis Differs from Reactive Arthritis?

Gonococcal arthritis is the inflammation of joints secondary to disseminated gonococcal infection while reactive arthritis (also known as Reiter syndrome) is an autoimmune response to salmonella, shigella, campylobacter, or chlamydia infections in the urogenital or gastrointestinal tract.

How to Treat Gonococcal Arthritis?

The primary treatment involves treating the underlying gonorrheal infection, irrespective of its type or variant. Parental (IV or IM) administration of Ceftriaxone is the most effective treatment option. 1 gm per day Cefatriaxone IV is preferred in patients with septic arthritis. Additionally, oral administration of 1 gram/day of Azithromycin is provided to prevent potential co-infections. Alternatively, Cefotaxime or Ceftizoxime (1 gm every 8 hours) in place of Ceftriaxone and 100 gm Doxycycline twice a day for seven days in place of Azithromycin can be prescribed.

A complete 7-day therapy of antibiotics should be completed along with a confirmatory study to verify the diagnosis. Septic and immunocompromised patients may require up to 14 days of antibiotic therapy. After confirming the culture test, in non-septic patients, the antibiotic regime can be deescalated to Cefixime, Fluoroquinolones, or Penicillin. The partners of the diagnosed individual (within the last two months) must be tracked, tested, and treated for gonococcal infections. Individuals with repetitive gonococcal infections must be evaluated for complement deficiencies.

Patients with β-lactam allergies can usually tolerate ceftriaxone and must undergo an allergy test with desensitization followed by an infectious disease specialist consultation. Patients with purulent arthritis must undergo joint drainage, either arthroscopically or via joint aspirations, until the fever, leukocytosis, joint pain, and effusions subside. Open surgical drainage may be indicated in case of inadequate aspiration. Even after recovery, the patient has to be observed and tested for another three to six months along with the partners.

What Is the Prognosis of Gonococcal Arthritis?

With early diagnosis and prompt implementation of a treatment regimen, disseminated gonococcal arthritis has an excellent prognosis. A delay in treatment can lead to various complications in several other organ systems all over the body.

What Is the Differential Diagnosis of Gonococcal Arthritis?

  • Septic arthritis (arthritis due to an acquired infection).

  • Poststreptococcal arthritis (arthritis in patients with a recent streptococcal infection).

  • Crystal arthropathy(joint problem due to salt crystal deposition).

  • Rheumatoid arthritis (autoimmune joint disorder).

  • Reactive arthritis (joint disorder due to infection in another part of the body).

  • Psoriatic arthritis (joint disorder affecting people with psoriasis-a skin disorder).

  • Lyme disease (a disease caused by Borrelia bacteria).

  • Infective endocarditis (infection traveling from other body parts and settling within the heart).

  • Viral infections.

What Are the Complications of Gonococcal Arthritis?

  • Meningitis (inflammation of the meninges-protective covering of the neurons).

  • Osteomyelitis (bone infection).

  • Endocarditis (inflammation of the inner lining of the heart chamber and valves).

  • Joint damage.

  • Perihepatitis (inflammation of the liver capsule without affecting the liver parenchyma).

Conclusion

Gonococcal arthritis is ideally treated with an interprofessional team of healthcare professionals, especially an orthopedic surgeon and infectious disease specialist. Many patients may require physical and occupational therapy to regain complete mobility of the joint. Partner tracing and testing should be done diligently, a lack of which may lead to an uncontrolled spread of gonococcal infection. More importantly, the patients and their partners must be educated about the risks of STDs, safe sex practices, and barrier contraception methods.

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Dr. Shubadeep Debabrata Sinha
Dr. Shubadeep Debabrata Sinha

Infectious Diseases

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