Gonococcal arthritis

Gonococcal arthritis results from blood dissemination of Neisseria gonorrhoeae from primary sexually acquired mucosal infection. The disease has become rare in Western countries since the introduction of effective control programmes, but it still needs to be recognized promptly to avoid systemic, potentially life-threatening involvement, destructive changes associated with chronic arthritis and spread of the infection. Sexually active women are predominantly affected. Clinical features include polyarthralgia, sometimes migratory, tenosynovitis, arthritis, constitutional symptoms and skin lesions, which are mild and easily unnoticed. True arthritis occurs in less than 50% of cases. Primary mucosal infection may be asymptomatic. N. gonorrhoeae is a fragile micro-organism which is difficult to culture. Sampling of blood, synovial fluid, skin lesion, genito-urinary tract, pharynx and rectum must be performed before starting antibiotics. Samples should be plated immediately on fresh, pre-warmed appropriate media and sent quickly to the laboratory. Culture of N. gonorrhoeae is of tremendous importance not only for definite diagnosis but also for determination of drug susceptibility. When culture is negative, rapid response to antimicrobial treatment will allow a probable diagnosis. Penicillin resistance has developed worldwide in recent years, and penicillin is no longer the initially recommended antibiotic for gonococcal arthritis. Patients should be started on a third-generation cephalosporin and later switched to ampicillin or penicillin only when sensitivity to these antimicrobials has been demonstrated. Oral therapy substitutes the intravenous or intramuscular route after signs and symptoms have improved, in order to complete 7 days of antimicrobial therapy. Effusions should be aspirated until disappearance. Purulent effusions are rare but may require longer antibiotic treatment. The patient's sexual partner must be examined and treated. Patients should be tested and eventually treated for Chlamydia, syphilis and HIV, and educated about the sexual mode of transmission and means of preventing sexually transmitted diseases.