By Dr. Ajala Osagie
23 year-old man s/p treatment for primary syphilis at an outside clinic about 6 weeks ago presents to fast track with worsening joint pain and swelling x 1 month. Symptoms started shortly after receiving the penicillin treatment; he had one day of fever (now resolved). He reports being tested for HIV, gonorrhea, and chlamydia at that time (all these tests were negative). Of note, he has sex with one male partner, and over the past few days he reports anal mucous-like discharge.
What diagnosis are we most worried about? — Disseminated Gonorrhea
This is the second most common sexually transmitted infection reported (after chlamydial infections). The infection is spread through the columnar or transitional epithelium; therefore, this organism can affect the urethra, rectum, cervical canal, pharynx, upper female genital tract, and conjunctival sac. In women, primary infectious are often asymptomatic or symptoms may include vaginal discharge, abnormal vaginal bleeding, abdominal/pelvic pain, dyspareunia, dysuria or frequency. In men, the common presentation is acute urethritis (dysuria and penile discharge) starting 1 to 14 days after exposure
Anorectal involvement is more common in those engaging in receptive anal intercourse, but is it also common in women from contamination from cervicovaginal secretions. Patient with anal involvement may report rectal pain, tenesmus, constipation, dyspareunia, pruritus ani, or purulent/mucoid anal discharge or bleeding
Disseminated Gonococcal Infection (DGI)
This results from gonococcal bacteremia and only occurs in up to 3% of those with gonorrhea. The lower incidence of DGI is caused by a lower prevalence of gonococcal strains able to enter the bloodstream and survive, going on to seed joint, tendon sheath, skin, and other tissues. DGI is more common in women than men; for women, it commonly occurs within one week of menstruation. This may be due to hormonal changes and pH of genital secretions making it easier for the bacterial to grow and spread.
The rash: This typically presents as an arthritis-dermatitis syndrome associated with fevers, chills, conjunctivitis, monoarticular or oligo-articular arthritis, rash, and tenosynovitis (these are signs of early bacteremia). The rash is due to septic emboli to small blood vessel. It is described as petechial or pustular acral skin lesions, usually found peripherally on extremities; there are necrotic pustules on an erythematous base that tender to palpation
The joint involvement: There is acute monoarticular or oligoarticular septic arthritis or arthralgias. The knees are most commonly involved (followed by elbows, ankles, wrists, and small joints of hands/feet). As such, joints may be erythematous, warm and there may be an effusion and pain on ROM.
The rare stuff (late signs of bacteremia): There may be development of osteomyelitis, hepatitis, mycocarditis, endocarditits, and meningitits, and even septic shock and ARDS.
How to diagnose
Definitively, diagnosis is made by isolating gonococci from bloody, synovial fluid or infected skin. However, cultures from these sights have relatively poor sensitivity. For example, only about 50% of synovial fluids cultures grow out positive. Good sensitivity and specificity for detecting gonorrhea can come from endocervical, urethral, and urine samples.
How to treat
Hospitalization is indicated if the diagnosis of DGI is unclear. the patient has frank, suppurative arthritis, or if the patient cannot be relied on to comply with treatment. DGI may require higher dosages of antibiotics and longer durations of therapy. Ceftriaxone, 1 g intravenously given daily, is the mainstay of antibiotic therapy.
As far as joints, gonococcal arthritis is not as destructive on the joints as staphylococcal infections. For DGI that involves the endocardium and CNS, the consequences may be more dire (i.e., valvular damage, CHF, focal neurological deficits, hearing loss, cognitive delay).
Birnbaumer, Diane. “Sexual Transmitted Diseases”. Rosen’s Emergency Medicine – Concepts and Clinical Practice. Chapter 98, 1312-1325.e1 Elsevier (2014).
2015 Sexually Transmitted Diseases Treatment Guidelines. http://www.cdc.gov/std/tg2015/gonorrhea.htm
Rice, Peter. “Gonococcal Arthritis (Disseminated Gonococcal Infection)”. Infectious Disease Clinics of North America (2005) Vol 19.
Ross, John. “Septic Arthritis”. Infectious Disease Clinics of North America. Vol 19. Dec 2005
Edited by Dr. deSouza