Trends in susceptibility of Neisseria gonorrhoeae to ceftriaxone from 1985 through 1991. 2017 Jan 15. Gonococcus strain characteristics (Protein 1A serotype, Lack of protein II), Protein Por B1A on the outer membrane – This inhibits host factor H and C4-binding protein, making host complement cascade less effective, Strains with nutritional requirements for arginine, hypoxanthine, and uracil (ie, AHU strains) – These are often associated with protein IA, Colony opacity (Opa) protein-independent invasion – Opa proteins are adhesins crucial to the process of N gonorrhoeae attachment to host cells, particularly avoidance of carcinoembryonic antigen-related cell adhesion molecule-3 (CEACAM3). When they do occur, they may include any of the following: A high clinical suspicion is necessary for patients who present with joint pain or swelling that is concerning for septic arthritis especially in those who are sexually active and younger than 40 years old and in certain at-risk populations such as in men who have sex with men (MSM) 30). The erythrocyte sedimentation rate (ESR) is elevated in most cases. Guillot X, Delattre E, Prati C, Wendling D. Joint Bone Spine. Bottled blood culture media containing sodium polyethylene sulfate inhibits growth. Tuttle CS, Van Dantzig T, Brady S, Ward J, Maguire G. The epidemiology of gonococcal arthritis in an Indigenous Australian population. Clinical features include polyarthralgia, sometimes migratory, tenosynovitis, arthritis, constitutional symptoms and skin lesions, which are mild and easily unnoticed. 2010 Oct;29(5):335-7. Sex Transm Infect. Gonococcal arthritis is an infection of a joint. The foot of this patient is swollen due to gonococcal arthritis. Cutaneous manifestations of disseminated gonococcemia. Parenteral antibiotics should be continued until symptoms have improved for 24-48 hours. Repeat arthrocentesis should be performed when inflammatory synovial effusions recur in order to remove inflammatory mediators, debris, and purulence. 333612-overview Gonococcal arthritis results from blood dissemination of Neisseria gonorrhoeae from primary sexually acquired mucosal infection. Atlanta: U.S. Department of Health and Human Services; 2017. The bacteremic form of disseminated gonococcal infection usually comprises a triad of manifestations which include tenosynovitis, dermatitis, and polyarthralgia. Disseminated gonococcal infection in a homosexual man diagnosed by nucleic acid amplification testing from a skin lesion swab. Gonococcal arthritis is a bacterial arthritis that develops in approximately 42-85% of patients with disseminated gonococcal infection of Gram-negative diplococcus Neisseria gonorrhoeae from primary sexually acquired mucosal gonococcal infection 1). A single dose of 1 gram of azithromycin by mouth is usually added to cover potential coinfection with Chlamydia trachomatis. Gonococcal arthritis is a complication of gonorrhea. 2018 Jun. 65 (7):1-19. Rheumatology. 23 (1):[Medline]. 2005 Dec. 19(4):853-61. Davis BT, Pasternack MS. Case records of the Massachusetts General Hospital. Joint pain – Pain may be experienced in a single joint or in multiple joints, and usually lasts for around one to four days. 6th ed. 236299-overview Case report and review of literature]. J Neurosurg Spine. Christopher A. Ohl, Derek Forster, in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (Eighth Edition), 2015. 55:370. Diseases & Conditions, 2002 Gonorrhea, colloquially known as the clap, is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. Gonococcal arthritis results from blood dissemination of Neisseria gonorrhoeae from primary sexually acquired mucosal infection. In: StatPearls [Internet]. Michael P Keith, MD, FACP, FACR Chief of Rheumatology, Walter Reed National Military Medical Center; Associate Professor of Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine Patients presenting with acute joint swelling, pain, erythema, warmth, and joint immobility should be screened for risk factors associated with septic arthritis (Table 1812). Rheumatol Int. 2008 Nov. 29(1):81-5. Migratory arthralgias are the most common presenting symptom in persons with disseminated gonococcal infection and are usually polyarticular. Sexually Transmitted Infections (STIs). [13] Plain radiography findings of the affected joint are usually normal. [Medline]. 61:590-4. World Health Organization. Definitive diagnosis of disseminated gonococcal infection or gonococcal arthritis is made through the identification of the etiologic pathogen in a specimen taken from a non-mucosal site (such as blood, synovial fluid, or skin lesions). Carlin E, Urban C, Sidle J, Cirilli A, Larson J, Richman M, Dexeus D. Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound. Gonococcal arthritis is a rare disorder. This website also contains material copyrighted by 3rd parties. Pan Afr Med J. Maharaj R, Mody GM. Suppurative gonococcal arthritis is frequently monoarticular. [14, 15, 16] However, an important limitation of polymerase chain reaction (PCR) and other NAATs is they do not provide antibiotic sensitivities to guide choice of antibiotic for treatment. A thorough history and physical examination including an emphasis on sexual history are needed in patients with suspected gonococcal arthritis. In the geriatric population, gonococcal… Dalla Vestra M, Rettore C, Sartore P, Velo E, Sasset L, Chiesa G, et al. Arthritis, Gonococcal. Infection may involve the genitals, mouth, and/or rectum. 1991 Aug; 50(8):572-3. 1983 Nov; 62(6):395-406. An unusual presentation of gonococcal arthritis in an HIV positive patient. Sexual partners should also be treated to prevent dissemination and gonococcal re- infection 17). Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance - The Gonococcal Isolate Surveillance Project, 27 Sites, United States, 2014. [Full Text]. Gonococcal arthritis. Obtaining skin lesion specimens is usually not done because of the difficulty of sampling and its very poor yield. Rheumatology. Published 2014 Mar 31. doi:10.11604/pamj.2014.17.242.4181 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145263. The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis. However, it may also be acquired perinatally during childbirth and may cause gonococcal infection in newborns 18). [Medline]. Centers for Disease Control and Prevention. Dalla Vestra M, Rettore C, Sartore P, Velo E, Sasset L, Chiesa G, et al. Most patients do not present with systemic symptoms such as fever or chills. Beatrous SV, Grisoli SB, Riahi RR, Matherne RJ, Matherne RJ. A high clinical suspicion is necessary for patients who present with joint pain or swelling that is concerning for septic arthritis especially in those who are sexually active and younger than 40 years old and in certain at-risk populations such as in men who have sex with men (MSM) 30). Dermatol Online J. Mamane W, Falcone MO, Doursounian L, Nourissat G. [Isolated gonococcal tenosynovitis. Disseminated gonococcal infection (DGI) frequently results in petechial or pustular acral skin lesions, asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis (581). Identification of Neisseria gonorrhoeae as the causative agent in a case of culture-negative dermatitis-arthritis syndrome using real-time PCR. Share cases and questions with Physicians on Medscape consult. Patients who test positive for these tests should undergo desensitization. The tenosynovitis of disseminated gonococcal infection is asymmetric and may affect both large and small joints and most commonly occurs over the dorsum of the wrist and hand, as well as over the metacarpophalangeal joints, ankles, and knees. Patients should be tested for other sexually transmitted infections, including Chlamydia trachomatis, HIV, syphilis, Mycoplasma genitalium, and herpes simplex virus. Arthrocentesis and Synovial Fluid Analysis, Arthrocentesis, Arthroscopy, and Surgical Drainage, http://www.who.int/mediacentre/factsheets/fs110/en/index.html, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm, Association of Program Directors in Internal Medicine, American Association for the Advancement of Science. Read P, Abbott R, Pantelidis P, Peters BS, White JA. Innate recognition by neutrophil granulocytes differs between Neisseria gonorrhoeae strains causing local or disseminating infections. People with this type of … 2013 Jul. [1]. This patient had disseminated gonococcal infection including multiple cutaneous lesions on the feet (black arrows). Patients with recurrent disseminated gonococcal infection or gonococcal arthritis will require further evaluation for complement deficiency. Victoria Fernandes Sullivan, MD Fellow in Rheumatology, Walter Reed National Military Medical CenterDisclosure: Nothing to disclose. The risk of dissemination after mucosal gonococcal infection depends on both the ability of the patient’s immune system to control the infection and the virulence of the organism 20). Gonococcal arthritis is more commonly seen in young healthy individuals although it may occur in any age group 3). Infected joints should be aspirated to monitor the decrease in leukocyte count of synovial fluid. After 1 to 2 days of clinical improvement with ceftriaxone as parenteral therapy, a seven-day course of antibiotics may be completed with daily intramuscular ceftriaxone given at 250 mg daily. Disseminated gonococcal infection causes. Partners of patients diagnosed with disseminated gonococcal infection within 2 months should be contacted and treated whenever possible. … In cases wherein the microbiologic diagnosis is not established, the course of therapy should be completed with a parenteral cephalosporin. Disseminated gonococcal infection-associated morbidity has decreased dramatically in the postantibiotic era. However, not all laboratories are capable of performing Neisseria gonorrhoeae culture and sensitivity testing. 2012 Jul. Laboratory tests typically performed on synovial fluid include cell count, crystal analysis, Gram stain, and culture. Best Pract Res Clin Rheumatol. O’Leary AJ, Tejura H, Latibeaudiere M, Edwards G. J Obstet Gynaecol. Gonococcal arthritis – Gonococcal arthritis typically presents acutely in sexually active individuals with fever, chills, skin … Bacterial arthritis: Epidemiology, pathogenesis, and microbiology in infants and children …is an important cause of bacterial arthritis … [Medline]. When a synovial effusion is present, it should be aspirated. The rash associated with the bacteremic form of disseminated gonococcal infection may be overlooked by patients because it is painless and nonpruritic and consists of small papular, pustular, or vesicular lesions. Nucleic acid amplification testing (NAAT) of either urine specimens in both men and women or vaginal swabs in women is preferred, if available. Gonococcal bacteremia is more likely to be associated with polyarthralgias and skin lesions. Surgical treatment is exceptionally indicated 16). 1013-28. 1995 Apr; 39(4):917-20. MMWR Surveill Summ. Footnote: Disseminated gonococcal infection with skin Lesions. Acute septic arthritis: remember gonorrhea. Nucleic acid amplification tests (NAATs) may be used as an adjunct to cultures and can be performed on samples from the cervix, urethra, rectum, urine, pharynx, synovial fluid, ICD-9-CM 098.50 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, 098.50 should only be used for claims with a date of service on or before September 30, 2015. 23 (1). Available at http://www.who.int/mediacentre/factsheets/fs110/en/index.html. Gonococcal septic arthritis of the hip. Li R, Gossman WG. This is inflammation of a joint due to a bacterial or fungal infection. Synovial fluid can be collected from the affected joint in a procedure called arthrocentesis. Gonococcal arthritis. 2011 Jun; 25(3):407-21. Patients with a history of beta-lactam allergy are often able to tolerate ceftriaxone. Destructive arthritis may be observed in HIV patients or in chronic infections due to inappropriate treatment. Carlin E, Urban C, Sidle J, Cirilli A, Larson J, Richman M, et al. Neisseria gonorrhoeae paravertebral abscess. If the woman is allergic to β lactam drugs, spectinomycin, 2 g IM every 12 hours may be used. The wrist, elbows, ankles, and knees are most commonly affected. Cutaneous manifestations of disseminated gonococcemia. Philadelphia, PA: Mosby Elsevier; 2015. Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Strongin IS, Kale SA, Raymond MK, Luskin RL, Weisberg GW, Jacobs JJ. Menstrual history and pregnancy need to be assessed in premenopausal patients. Atlanta: U.S. Department of Health and Human Services; 2017. Gonococcal arthritis is one of the several types of infection caused by Neisseria gonorrhoeae, a Gram-negative diplococcus. 2012 Oct; 79(5):519-20. If risk factors are present, consider further testing for hepatitis B and C. The CDC recommends that the initial laboratory testing for HIV be an HIV-1/2 antigen/antibody combination immunoassay.. Point-of-care ultrasound in the emergency department can aid in diagnosis by identifying tenosynovitis and excluding arthritis or simple soft-tissue swelling. These include strains containing a specific outer membrane called the porin 1A serotype that promotes resistance, diminished host inflammatory response, and host cell invasion and strains that require specific substrates for growth. The time from initial infection to initial manifestations of disease ranges from 1 day to 3 months 24). NAAT of skin specimens may be slightly more sensitive, but this is not widely available. 2017 Jan 15. A prospective study in the Netherlands of patients diagnosed with septic arthritis found that 84 percent of adults had an underlying medical condition and 59 percent had a previous joint disorder.13 In a review of musculoskeletal infections in patients with human immunodeficiency virus infection, about 0.5 per… Positive blood cultures, however, are only positive in less than 1/3 of cases and is more frequently seen in patients who present with arthritis-dermatitis syndrome. Infected men may experience pain or burning with urination, discharge from the penis, or testicular pain. Yield is highest if the culture is obtained from the primary infection site. The pharynx is an important site of infection in pregnant women and in men who have sex with men. J Emerg Med. 2018 Jun;54(6):844-848. Infect Immun. Gonococcal arthritis is inflammation of the joints caused by a disseminated gonococcal infection. Lee AH, Chin AE, Ramanujam T, Thadhani RI, Callegari PE, Freundlich B. J Rheumatol. J Infect Dev Ctries. Schwebke JR, Whittington W, Rice RJ, Handsfield HH, Hale J, Holmes KK. In the bacteremic form or arthritis-dermatitis syndrome, symptoms are typically present 3-5 days before diagnosis 25). Reactive arthritis can sometimes also involve inflammation of the urethra (non-gonococcal urethritis), which is the tube that carries urine out of the body. A dose of 100 mg of doxycycline twice a day for 7 days is an alternative to azithromycin 32). Two sets of blood cultures should be obtained, and a positive result helps distinguish gonococcal arthritis from other pathogens that cause septic arthritis. Hip involvement is rare 7). More detailed information about the symptoms, causes, and treatments of Gonococcal urethritis is available below.. 81(7):2358-70. INTRODUCTION Disseminated gonococcal infection (DGI) results from bacteremic spread of the sexually transmitted pathogen, Neisseria gonorrhoeae, which can lead to a variety of clinical symptoms and signs, such as arthritis or arthralgias, tenosynovitis, and multiple skin lesions. This is even less in patients who present with the arthritis-dermatitis syndrome. N Engl J Med. Host risk factors that are associated with disseminated gonococcal infection include complement deficiencies, menstruation, pregnancy, history of pelvic surgery, and intrauterine devices (IUD). The leukocyte count in synovial fluid is inflammatory, usually in the range of 10 000 to 100 000 cells/mm³ 13). As a rule, complications of gonococcal arthritis are rare. Cultures of likely sites of gonococcal infection are the most important tests to perform for the diagnosis of disseminated gonococcal infection (DGI) and consequent gonococcal arthritis. Gonococcal Arthritis. Due to the absence of effective alternative parenteral agents, patients who have a history of IgE mediated hypersensitivity reaction to beta-lactams may undergo either skin testing or graded challenge testing. Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. The cell count is usually higher than 50,000 WBC/µL (with polymorphonuclear leukocytes [PMNs] typically accounting for more than 90%). Li R, Gossman WG. https://emedicine.medscape.com/article/333612-overview, Li R, Hatcher JD. Destructive septic arthritis of the sternoclavicular joint due to Neisseria gonorrhoeae. Notice to readers: discontinuation of spectinomycin. Sexually Transmitted Disease Surveillance 2016. Localized gonococcal septic arthritis symptoms begin within days to weeks of gonococcal infection 28). A complete blood count (CBC) should be obtained; most patients with gonococcal arthritis have mild leukocytosis. 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