History
The clinical presentation of disseminated gonococcal infection (DGI) is typically divided into a bacteremic form and a septic arthritis form. Approximately 60% of patients with DGI present with symptoms consistent with the bacteremic form, and the remaining 40% present with symptoms of more localized infection. Although each form has its own symptom complex, the overlap can be considerable. The time from initial infection to initial manifestations of disease ranges from 1 day to 3 months. [1]
Bacteremic form
In the bacteremic form (arthritis-dermatitis syndrome), symptoms are typically present 3-5 days before diagnosis. [10]
Migratory arthralgias are the most common presenting symptom in persons with DGI and are usually polyarticular. The arthralgias are typically asymmetric and tend to involve the upper extremities more than the lower extremities. The wrist, elbows, ankles, and knees are most commonly affected. Symptoms resolve spontaneously in 30-40% of cases or evolve into a septic arthritis in 1 or several joints.
Pain may also be due to tenosynovitis. The tenosynovitis of DGI is asymmetric and most commonly occurs over the dorsum of the wrist and hand, as well as over the metacarpophalangeal joints, ankles, and knees. Diffuse involvement of fingers can result in dactylitis. [1]
The rash associated with the bacteremic form of DGI may be overlooked by patients because it is painless and nonpruritic and consists of small papular, pustular, or vesicular lesions. Other cutaneous lesions of DGI that have been reported are abscesses, cellulitis, petechiae, purpuric macules, necrotizing fasciitis, and vasculitis. [11]
Nonspecific constitutional manifestations may include myalgias, fever, and malaise.
Septic arthritis form
Joint signs and symptoms begin within days to weeks of gonococcal infection. [10] Patients may experience pain, redness, and swelling in 1 joint (or sometimes multiple joints), most commonly in a knee, wrist, ankle, or elbow. [1]
Physical Examination
Bacteremic form
The bacteremic form of gonococcal arthritis comprises the classic triad of migratory polyarthritis, tenosynovitis, and dermatitis. [10] Migratory arthritis has an asymmetric distribution, most commonly affecting wrists, ankles, and elbows. About 70% of patients have 1-3 joints with clear inflammatory signs after just a few days. Symmetric polyarthritis is less common but may occur in approximately 10% of patients.
Tenosynovitis is asymmetric, usually affecting the dorsum of wrists, hands, and ankles. Tenosynovitis of the fingers may result in dactylitis.
Dermatitis occurs in 40-70% of patients and typically involves the extremities. Lesions are usually tiny maculopapular, pustular, or vesicular lesions on an erythematous base. The center may become necrotic or hemorrhagic. Despite their appearance, these lesions are painless and nonpruritic. They tend to disappear within a few days after treatment is initiated. Usually, 4-50 lesions are reported. Rarely, the lesions may resemble erythema nodosum or erythema multiforme.
Fever rarely involves a temperature higher than 39°C.
Other presentations of DGI include the following, which now occur in only 1-3% of cases [1, 12] :
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Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis)
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Sepsis with Waterhouse-Friderichsen syndrome
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Gonococcal endocarditis (rare in the antibiotic era)
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Gonococcal meningitis (very rare in the antibiotic era)
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Paravertebral abscess
Septic arthritis form
Septic arthritis is characterized by acute arthritis with signs of joint effusion, warmth, tenderness, decreased range of motion, and marked erythema. It most commonly involves the wrists, hands, knees, and elbows. Chronic arthritis with joint destruction is rare when appropriate antibiotic therapy is provided.
Complications
As a rule, complications of gonococcal arthritis are rare. When they do occur, they may include any of the following:
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Permanent joint damage
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Pericarditis
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Perihepatitis
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Pyomyositis
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Glomerulonephritis
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Synovial joint.
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The lesion on this patient's heel was due to the systemic dissemination of the N gonorrhoeae bacteria.
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The foot of this patient is swollen due to gonococcal arthritis.
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This patient presented with cutaneous foot lesions that were diagnosed as a disseminated gonococcal infection.
