GONOCOCCAL ARTHRITIS by HANY MOHAMED ALI Rheumatologist, ALAzhar university

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GONOCOCCAL ARTHRITISbyHANY MOHAMED ALI
Rheumatologist, AL-Azhar university
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Definition

• Syndrome of polyarthritis, tenosynovitis
  and dermatitis caused by gram ve Neisseria
  gonorrhea.

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History

• Description of gonorrhea was found in medical
  writings from ancient Egypt.
• In the early 18th century there was controversy
  about gonorrhea and syphilis was the same
  disease.
• In 1838 Ricord's studies established that
  gonorrhea and syphilis were different diseases
  and In 1879 Albert Neisser identified the
  organism.

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• Lindeman recovered the gonococcal organism from a
  patient with septic arthritis in 1892,
  establishing the gonorrheal rheumatism.
• DGI was more common in men until treatment of
  urethritis with sulfonamides and penicillin
  reduced the number of men with DGI.

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Epidemiology and risk factors

• There are 200 million cases of neisseria
  gonorrhea worldwide each year.
• The risk factors include
• 1- Urban residence.
• 2- Non-caucasian.
• 3- Low socioeconomic status.
• 4- Low educational status.

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• 5- Unmarried.
• 6- Prostitution.
• 7- Intravenous drug abuse.
• 8- Previous gonococcal infection.
• 9- Complement deficiency (C5-C8).

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• The epidemiology of DGI is dependent on the
  epidemiology of gonorrhea and is modified by
  microbiological features of infecting strains of
  various regions.
• Estimation of dissemination range from 0.5 to 3
  of local infection.
• Gonorrhea has a short incubation period
  (1-14days) with high rate of transmissibility.

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Clinical features

• 1- Fever.
• 2- Migratory polyarthritis (may be additive),
  usually assymetric and affect upper extremity
  more than lower extremity but 10-15 have
  symmetric polyarthritis.

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• The time from to infection to initial
  presentation may range from 1 day to 3 months.
• Some patients present with arthralgia which may
  resolve spontaneously without treatment or evolve
  into septic arthritis (knee, ankle, elbow or
  wrist or shoulders).
• In some patients there are no or minimal symptoms
  of bactraemia before the onset of septic
  arthritis.
• It has been said that DGI symptoms typically
  begins 7 days after manses.

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• 3- Tenosynovitis, most commonly over the dorsum
  of the hands, wrist, ankles or knees.
• Extensor tenosynovitis usually accompanies wrist
  involvement

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• 4- Dermatitis , on the trunk, extremities. Tiny
  papules, pustules or vesicles with an
  erythematous base which are not painful or
  pruritic. The center may be necrotic or
  haemorragic.
• May be erythema nodosum or erythema multiformis.

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• 5- Purulent arthritis.
• 6- Meningitis.
• 7- Myopericarditis.
• 8- Clinical sepsis.
• 9- Gonococcal perihepatitis (Fitz-Hugh-Curtis
  syndrome).
• DGI may be caused by penicillin resistant strains
  accompanied with high rates of comorbidity
  factors including I.V. drug abuse, SLE,
  malignancy, D.M. and complement deficiency.

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Investigations

• Leucocytosis and elevated ESR.
• Synovial fluid analysis leucocytes gt30 000 and
  gram stain gram -ve intra and extracellular cocci
  in lt25 of purulent effusion.
• All potential ports should be cultured and
  examined (pharynx, cervix, urethra and rectum).

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• Gonococcus is fragile and growth is inhibited by
  drying or plating on cold or dehydrated culture
  medium.
• Fluid samples should be plated immediately on
  fresh prewarmed medium and incubated within 15
  minutes in a CO2 atmosphere (candle extinction
  jar) on chocolate agar.
• Synovial fluid specimens should be plated on
  blood agar for other pathogens.

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• Patients with septic gonococcal arthritis will
  rarely have ve blood culture.
• Gonorrhea may be demonstrated in synovial fluid
  by PCR.
• Specimens from other mucosal surfaces should
  inoculated on Thayer Martin.
• Radiologically, only evidence of soft tissue
  swelling and effusion.

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Differential diagnosis

• 1- Reiter's syndrome, affects men (20-40 years)
  and develops over few weaks.
• Affects lower extremity than upper extremity.
• Conjunctivitis and painless mucosal ulcerations.
• L.B.P with sacroiliac affection.
• Keratoderma blenorrhagicum.

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• 2- Non-gonococcal septic arthritis, affects
  larger joints of lower extremity.
• Can be differentiated by microbiological
  tests.
• 3- Anicteric prodrome of hepatitis B, Urticarial
  skin lesion followed by arthralgia, arthritis or
  tenosynovitis which clear when the patient become
  icteric.
• 4- Hepatitis C infection, fever, arthralgias,
  arthritis and peticheal lesions but in symmetric
  and non-migratory fashion.
• Cryoglobulinaemia and ve RF.

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• 5- Acute and subacute bacterial (SBE)
  endocarditis, arthralgia, myalgia, tendinitis and
  back painare common in SBE, however splinter
  hemorrhage and Osler's nodules not occur in DGI.
• 6- Other STDs must be considered, 2ry syphilis,
  nonmigratory arthritis, with an extensive
  nonpruritic papulosquamous rash generalized
  lymphadenopathy, condylomata lata (perigenital
  mucosal plaques and a ve serologic test for
  syphilis.

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Basic science

• Gram ve coccus charecteristically grows in
  pairs.
• Features of clinical isolates which are
  associated with dissemination include the
  presence of pili, nutritional requirements for
  HAU and proline, serotype 1A and resistance to
  bactiricidal activity of normal human serum.

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• Cell envlope components participate in the
  pathogenesis of infection and host defence. It
  contains an inner cytoplasmic membrane, middle
  layer of peptidoglycan and an outer layer of
  lipo-oligosaccharide (LOS), Exposed phospholipids
  and an outer membrane proteins.
• Pili are cell surface proteins, antigenic and
  enhance adhesion of gonococcus to mucosal surface
  and synovium.

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• Pili interfere with phagocytosis and killing by
  PMNs and mononuclear cells .
• Protein 1 is a major cell surface protein
  responsible for resistance.
• Opacity associated protein (opa) is expressed on
  the cell surface and acts as adhesion for
  attachment and susciptibilty for bactiricidal
  acyivity of normal human serum.

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Pathogenesis

• The gonococcus attaches to mucosal epithelial
  cells via opa and pili and penetrates the
  epithelial cells via 24-48 hours.
• Vigorous neutrophilic infiltration produces
  microabscesses with exudation of pus in the
  submucosa.
• Neutrophils are replaced lymphocytes and
  monocytes.

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• Neisseria can release membrane fragments into the
  surrounding environment resulting in circulation
  of toxic antigenic fragments.
• Dissemination of gonococcal infectionis dependent
  on the resistance of infecting strain to
  bactiricidal activity.
• Gonococcal arthritis occurs 2ry to bacteremic
  spread from mucosal site of infection, bacteria
  replicate in the synovium, release of prteolytic
  enzymes from synovial lining and PMNs.

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• If infection untreated articular cartilage will
  be destroyed.
• Migratory polyarthritis, tenosynovitis,
  dermatitis and sterile phase arthritis is immune
  complex mediated rather than septic embolization
  during bacteremia.
• There is little or no lasting protective immunity
  following N.G. infection.

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Management

• Objectives
• 1- Eradication of infection.
• 2- Pain control.
• 3- Prevention of joint destruction.
• 4- TTT of co-existent STDs.

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• The recent increase in antibiotic resistant
  strains necessitates hospitalization.
• 30-50 of indinviduals infected with N.G. are
  co-infected with chlamydia which is not sensetive
  to ceftrixone.
• Azithromycin and quinolones (ofloxacin and
  norfloxacin are effective against both.
• During the past 50 years, antibiotic ttt of NG
  with antibiotics resulted in the development of
  resistant strains.

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• The recommended ttt is
• Parentral ceftriaxone (Rocephin 1-2 gram/day)
  until clinical response can be ascertained or
  sensetevity testing completed, plus Doxymycin
  100mg p.o. b.i.d. for 7 days.
• Ceftriaxone (alternatively cefizoxime or
  cefotaxime) should be given I.V. until symptoms
  and signs resolve, then can be followed by
  cefixime (400mg b.i.d.) or ciprofloxacin (500mg
  b.i.d.) to complete 7-10 days of ttt.

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• If the infecting strain is known to be penicillin
  sensitive, therapy can be penicillin G (10
  million units/day I.V.), amoxicillin (500mg
  q.i.d.) with probenecid (1gram/day).
• Tetracyclin, erythromycin, azithromycin
  ciprofloxacin and ofloxacin should not be given
  during pregnancy.
• Infected joints should be aspirated daily and
  saline lavage may be helpful.
• Surgical drainage or arthroscopy rarely needed.

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• Beacause of high rate of other STDs, all patients
  should be tested for chlamydia infection and
  treated wuth tetracyclin or doxymycin for 7 days
  or azithromycin ( single 1g oral dose).
• For pregnant women erythromycin (500mg p.o.
  q.i.d.) or amoxicillin (500mg p.o. t.i.d. for
  10 days).
• Education regarding sexual mode is paramount.

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CASE REPORT
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• Female patient Mrs. Eman, 35 years old
  complaining of left knee swelling and inability
  to bear weight.
• The condition started 7 days ago by left knee
  arthritis with massive effusion associatd with
  fever after normal delivery of full term fetus by
  3 weeks.
• Patient was unable to walk and she was on a
  wheele chair due to arthritis of the knee joint.

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• 3 days later patient complained of arthritis of
  2nd and 3rd MCPs of left hand and tenosynovitis
  of middle finger of the same hand.
• There is vaginal discharge and history of husband
  urogenital infection and discharge.
• No history of morning stiffness.

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• On examination
• Massive effusion and arthritis of left knee.
• Arthritis of 2nd and 3rd MCPs of left hand and
  tenosynovitis of middle finger of the same hand.
• No other joint affection.
• No axial affection or ensthesopathy.
• No skin manifestations.
• Temperature 38 c
• VAS 8/10

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• Lab. Results
• CBC WBC23000
• CRP48
• ESR56
• RF -VE
• Plain x-ray both hands and knees
• Only evidence of soft tissue swelling without
  evidence of cartilage or bone affection.

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• Management
• Knee aspiration under complete aseptic
  conditions, saline wash followed by local
  injection of antibiotic and local anaesthetic.
• Synovial fluid examination
• Color greenish
• Clarity opaque
• Viscosity low
• Mucin clot friable
• WBC 75000
• Differential gt70 PMN
• Culture no growth

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• Parentral antibiotics (ampicillin 1000mg
  sulbactam 500mg) twice daily for 5 days and
  erythromycin 500mg twice daily orally started at
  day 0.
• At day 5, there were marked improvement of
  arthritis (moderate effusion) and tenosynovitis,
  the patient can bear weight and no fever.
• Improvement of VAS 3/10
• Aspiration repeated, saline wash followed by
  local injection of antibiotic and local
  anaesthetic.

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• Continue on the same ttt orally for another 5
  days and the patient showed complete resolution
  after 10 days of ttt.
• Treatment of the husband with penicillin at the
  same time.
• Strenghthening exercises of quadriceps muscles,
  range of motion exercises of left knee joint and
  hand joints.
• Electrical stimulation of quadriceps muscles.
• Patient and husband education about STDs.

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Thank you