What disease presents with urinary tract infection, septic arthritis, and conjunctivitis?

Reiter's Syndrome (Reactive Arthritis)

The classic triad of urethritis, conjunctivitis, and arthritis describes Reiter's syndrome, also known as reactive arthritis, though this presentation can also occur with disseminated gonococcal infection (DGI).

Disseminated Gonococcal Infection as Primary Consideration

When a patient presents with the triad of urinary tract symptoms, septic arthritis, and conjunctivitis, disseminated gonococcal infection must be ruled out first because it requires immediate antimicrobial therapy to prevent irreversible joint destruction, endocarditis, and meningitis. 1

Clinical Presentation of DGI

• DGI occurs in 0.5-3% of patients with gonorrhea when Neisseria gonorrhoeae spreads from mucosal sites to distant body parts. 2
• The infection presents with septic arthritis (commonly affecting wrists, ankles, hands, and feet), dermatitis (papules progressing to pustules, petechiae, and necrotic lesions on extremities), and tenosynovitis with migratory polyarthralgia. 3, 2
• Conjunctivitis in gonococcal infection presents with marked eyelid edema, severe purulent discharge, preauricular lymphadenopathy, and can rapidly progress to corneal ulceration and perforation within 24 hours if untreated. 4, 5
• Many patients with DGI have asymptomatic or minimally symptomatic urogenital infection, making the diagnosis challenging. 6, 3

Diagnostic Approach

• Obtain cultures from all potentially infected sites: blood, synovial fluid, conjunctival exudate, urogenital tract, rectum, and pharynx on chocolate agar and gonococcal selective medium. 1
• Gram stain showing intracellular gram-negative diplococci from conjunctival exudate, synovial fluid, or urethral discharge provides presumptive diagnosis. 1, 4
• Nucleic acid amplification testing (NAAT) from urine or genital sites has comparable sensitivity and specificity to culture for urogenital infection. 6
• Culture remains essential for definitive diagnosis, antibiotic susceptibility testing, and medicolegal purposes. 4, 6

Treatment Protocol

For disseminated gonococcal infection with arthritis and conjunctivitis, initiate ceftriaxone 1-2 g IV every 24 hours immediately. 1, 7

• Continue parenteral therapy for 24-48 hours after clinical improvement begins. 1
• After improvement, switch to oral cefixime 400 mg twice daily to complete at least 7 days of total antimicrobial therapy. 1, 7
• Always add azithromycin 1 g orally as a single dose to cover likely Chlamydia trachomatis coinfection. 4, 6
• For gonococcal conjunctivitis specifically, add saline lavage of the infected eye for comfort and faster resolution. 4, 5

Critical Management Points

• Hospitalize patients with suspected DGI for monitoring of disseminated complications including endocarditis and meningitis. 1
• If meningitis is documented, extend ceftriaxone therapy to 10-14 days. 1
• If endocarditis is present, continue treatment for at least 4 weeks. 1
• Daily ophthalmology follow-up is mandatory until complete resolution when conjunctivitis is present. 4, 5

Partner Management and Follow-Up

• All sexual partners must be evaluated and treated according to adult gonococcal infection guidelines. 1, 7
• Test for other sexually transmitted infections including HIV, syphilis, and chlamydia. 6, 3
• Retest the patient in 3 months due to high reinfection rates. 6

Reactive Arthritis (Reiter's Syndrome) as Alternative Diagnosis

If gonococcal cultures are negative and the patient has recent history of urethritis (often chlamydial) or gastrointestinal infection, consider reactive arthritis as a post-infectious inflammatory syndrome rather than active disseminated infection.

Key Distinguishing Features

• Reactive arthritis typically develops 1-4 weeks after the initial infection has resolved, whereas DGI represents active ongoing infection. 6
• The arthritis in reactive arthritis is typically oligoarticular, asymmetric, and affects large joints of the lower extremities. 3
• Conjunctivitis in reactive arthritis is usually mild and bilateral, unlike the severe purulent unilateral presentation of gonococcal conjunctivitis. 4

Common Pitfalls to Avoid

• Never rely on topical antibiotics alone for gonococcal conjunctivitis—systemic therapy is mandatory to prevent corneal perforation and treat disseminated infection. 1, 4
• Do not use fluoroquinolones for gonorrhea treatment due to widespread antimicrobial resistance. 6, 8
• Failing to test and treat sexual partners perpetuates transmission and reinfection. 1, 7
• Missing the diagnosis in women, who are frequently asymptomatic with urogenital gonorrhea but can still develop DGI. 6, 3