From the Guidelines
Diagnosing gonorrhea arthritis requires a combination of clinical evaluation and laboratory testing, with a focus on joint fluid analysis and nucleic acid amplification tests (NAATs) to identify Neisseria gonorrhoeae. The diagnosis is established through joint fluid analysis showing inflammatory changes and the presence of Neisseria gonorrhoeae, which can be identified through Gram stain, culture, or NAATs 1. Blood cultures should be obtained, though they are positive in only 50% of cases. Additional testing should include screening for gonorrhea at all potential exposure sites (urogenital, pharyngeal, rectal) using NAATs, as many patients with disseminated gonococcal infection may have asymptomatic mucosal infection.
Some key points to consider in the diagnosis of gonorrhea arthritis include:
- Synovial fluid analysis typically reveals white blood cell counts between 50,000-100,000 cells/mm³ with predominant neutrophils
- Imaging studies like X-rays may show soft tissue swelling in early disease but are generally normal
- The clinical presentation of migratory polyarthralgia, tenosynovitis, and dermatitis (pustular or vesiculopustular lesions), especially in sexually active young adults, should raise suspicion for this condition
- Early diagnosis is crucial as prompt antibiotic treatment with ceftriaxone 1g intramuscularly or intravenously daily for 7-14 days (depending on severity) can prevent joint destruction and other complications, as noted in guidelines for treatment of sexually transmitted diseases 1.
It is essential to note that DGI results from gonococcal bacteremia and can be complicated by perihepatitis, endocarditis, or meningitis, highlighting the importance of prompt diagnosis and treatment 1.
From the Research
Diagnosis of Gonorrhea Arthritis
- The diagnosis of gonorrhea arthritis is contingent on clinical presentation, with urine nucleic acid amplification testing as the preferred diagnostic modality 2.
- Synovial fluid cultures, along with imaging, can confirm diagnosis 2, 3, 4.
- PCR from the joint fluid can also be used to diagnose gonococcal septic arthritis, especially in patients with high risk of N. gonorrhoeae infection 4.
Clinical Presentation
- Typical presentations of gonorrhea arthritis include tenosynovitis, dermatitis, polyarthralgia, or oligoarticular purulent arthritis affecting the distal joints 2.
- Septic arthritis caused by N gonorrhoeae is monoarticular or pauciarticular, and is more commonly associated with positive synovial fluid cultures and negative blood cultures 3, 5.
- Gonococcal bacteremia is more likely to be associated with polyarthralgias and skin lesions 3.
Treatment
- The recommended treatment is a third-generation cephalosporin, such as intravenous ceftriaxone for 7-14 days and a dose of oral azithromycin 2.
- Initial treatment with ceftriaxone or another advanced-generation cephalosporin is warranted until signs and symptoms have improved; continuation of treatment for a total period of therapy of 1 week can be accomplished with a fluoroquinolone 3, 6.
- Hospitalization is indicated in patients with suppurative arthritis or when the diagnosis is in doubt 3.