eMedicine Specialties > Rheumatology > Infectious Arthritis

Gonococcal Arthritis: Follow-up

Author: Michael P Keith, MD, FACP, Chief of Rheumatology, National Naval Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences
Coauthor(s): Robert John Oglesby, MD, Chief of Rheumatology Service, Department of Medicine, Walter Reed Army Medical Center; Associate Professor of Medicine, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: Jul 27, 2009

Follow-up

Further Inpatient Care

  • See Medical Care.
  • Daily aspiration with synovial fluid drainage has also been recommended for purulent effusions associated with gonococcal arthritis.
  • Examine patients with disseminated gonococcal infection (DGI) for clinical evidence of endocarditis and meningitis, although both of these complications are rare.

Further Outpatient Care

  • Re-evaluate patients to ensure resolution of illness.
  • Reculture all known infected sites at least 5-7 days after the last dose of antibiotic therapy.
  • Patients screened for syphilis must be screened again in 4-6 weeks, and HIV screening must be repeated again in 6 months.
  • Contact, examine, and possibly treat the patient's sexual partners.

Inpatient & Outpatient Medications

  • Continue parenteral antibiotic therapy for at least 24-48 hours to allow for improvement, at which time an oral antibiotic regimen may be instituted.
  • Oral antibiotic duration may vary depending on the presence of any complications of DGI (endocarditis), but all patients should continue for at least 7 more days. See Medical Care.

Transfer

  • Although patients with persistent joint effusion despite early antibiotic therapy may require frequent joint aspiration, arthroscopic evaluation or surgical drainage that requires an orthopedic surgeon is rarely needed.
  • Patients with acute endocarditis secondary to gonococcus may require cardiothoracic surgery.

Deterrence/Prevention

  • Patient education
  • Identification of high-risk sexual practices
  • Promoting use of protective barrier contraceptives (ie, condom)
  • Contacting the patient's sexual partners for education, examination, and possible treatment

Complications

  • All complications are rare but include the following:
    • Permanent joint damage
    • Meningitis
    • Endocarditis
    • Osteomyelitis

Prognosis

  • With the proper antibiotic treatment and joint drainage, full recovery is expected in patients determined to have septic arthritis from gonococcus infection.
  • The prognosis in patients with more severe manifestations of DGI varies depending on the complication or comorbidities. Patients with acute endocarditis, for example, may require valve surgery and can expect at least 4-6 weeks of antibiotics.

Patient Education

  • Patient education is an integral part of proper therapy. Patients should learn about the sexual transmission of the disease and barrier methods of prevention (condoms). In addition, education regarding specific risk factors or high-risk behaviors may be a deterrent for further infections from gonococcus or more severe sexually transmitted diseases such as HIV. Also important is the identification, examination, and treatment of patients' sexual partners.
  • For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center and Arthritis Center. Also, see eMedicine's patient education articles Gonorrhea, Knee Pain, Birth Control Overview, and Birth Control FAQs.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis in a patient who presents with acute septic arthritis
  • Failure to treat for adequate duration with effective antibiotics
  • Failure to recognize endocarditis, meningitis, or osteomyelitis as complications of disseminated gonococcal infection (DGI)
  • Failure to treat for concomitant infection with Chlamydia or to properly screen for other sexually transmitted diseases (eg, HIV, syphilis)
  • Failure to recognize that recurrent DGI may represent a complement deficiency
  • Failure to treat sexual partners for the same disease
  • Failure to provide adequate follow-up care

Special Concerns

  • In the pediatric population, the diagnosis must be considered if the patient is sexually active or abused.
  • In the geriatric population, gonococcal arthritis is uncommon but should be considered based on the patient's sexual history.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Timothy M Straight, MD, to the development and writing of this article.



More on Gonococcal Arthritis

Overview: Gonococcal Arthritis
Differential Diagnoses & Workup: Gonococcal Arthritis
Treatment & Medication: Gonococcal Arthritis
Follow-up: Gonococcal Arthritis
References
[ CLOSE WINDOW ]

References

  1. Dalla Vestra M, Rettore C, Sartore P, Velo E, Sasset L, Chiesa G, et al. Acute septic arthritis: remember gonorrhea. Rheumatol Int. Nov 2008;29(1):81-5. [Medline].

  2. Bardin T. Gonococcal arthritis. Best Pract Res Clin Rheumatol. Apr 2003;17(2):201-8. [Medline].

  3. Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. Dec 2005;19(4):853-61. [Medline].

  4. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2005 supplement, gonococcal isolate surveillance project (GISP) Annual Report 2005. Atlanta, GA. US Department of Health and Human Services, Centers for Disease Control and Prevention, January 2007. Available at http://www.cdc.gov.std.gisp2005/. Accessed May 12, 2009.

  5. World Health Organization Fact Sheet Number 110. Available at http://www.who.int/mediacentre/factsheets/fs110/en/index.html. Accessed May 12, 2009.

  6. Marker-Hermann E. Septic arthritis, osteomyelitis, gonococcal and syphilitic arthritis. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. Rheumatology. 4th ed. Philadelphia, PA: Mosby Elsevier; 2008:1013-28.

  7. Davis BT, Pasternack MS. Case records of the Massachusetts General Hospital. Case 19-2007 - a 19-year-old college student with fever and joint pain. N Engl J Med. Jun 21 2007;356(25):2631-7. [Medline].

  8. Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T, et al. Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. Arthritis Rheum. May 1994;37(5):702-9. [Medline].

  9. Read P, Abbott R, Pantelidis P, Peters BS, White JA. Disseminated gonococcal infection in a homosexual man diagnosed by nucleic acid amplification testing from a skin lesion swab. Sex Transm Infect. Oct 2008;84(5):348-9. [Medline].

  10. Kimmitt PT, Kirby A, Perera N, Nicholson KG, Schober PC, Rajakumar K, et al. Identification of Neisseria gonorrhoeae as the causative agent in a case of culture-negative dermatitis-arthritis syndrome using real-time PCR. J Travel Med. Sep-Oct 2008;15(5):369-71. [Medline].

  11. Update to CDC's Sexually Transmitted Diseases Treatment Guidelines 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm. Accessed May 1, 2009.

  12. [Guideline] Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55(No. RR-11):42-49.

  13. Newman LM, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in the United States. Clin Infect Dis. Apr 1 2007;44 Suppl 3:S84-101. [Medline].

  14. MMWR. Availability of Cefixime 400 mg tablets---United States, April 2008. Available at http://www.cdc.gov.mmwr/preview/mmwrhtml/mm5716a5.htm. Accessed May 1, 2009.

  15. Centers for Disease Control and Prevention. Notice to readers: discontinuation of spectinomycin. MMWR. 2006;55:370.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

gonococcal arthritis, acute septic arthritis, Neisseria gonorrhoeae, N gonorrhoeae, disseminated gonococcal infection, DGI, arthritis-dermatitis syndrome, localized septic arthritis, dermatitis, tenosynovitis, migratory polyarthritis, migratory arthralgia, migratory arthritis, Fitz-Hugh and Curtis syndrome, gonococcal perihepatitis, Waterhouse-Friderichsen syndrome, gonococcal endocarditis, gonococcal meningitis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael P Keith, MD, FACP, Chief of Rheumatology, National Naval Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences
Michael P Keith, MD, FACP is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and Clinical Immunology Society
Disclosure: Nothing to disclose.

Coauthor(s)

Robert John Oglesby, MD, Chief of Rheumatology Service, Department of Medicine, Walter Reed Army Medical Center; Associate Professor of Medicine, Uniformed Services University of the Health Sciences
Robert John Oglesby, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and Arthritis Foundation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

RELATED MEDSCAPE ARTICLES
Articles
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.