Disseminated Gonococcal Infection

Disseminated gonococcal infection is commonly manifested by arthritis, tenosynovitis, and characteristic rash (arthritis-dermatitis syndrome). Other, less common complications include abscesses, pyomyositis, osteomyelitis, pericarditis, and perihepatitis (Fitz-Hugh-Curtis syndrome). Gonococcal arthritis, unlike other causes of bacterial arthritis, has a very good prognosis; full recovery of the joint is the norm. The groups at highest risk include women who are pregnant, postpartum, or near menstruation (1 week) and promiscuous homosexual men.

Causes

This infection occurs in people who have been infected with gonorrhea. It affects women more frequently than men and its highest incidence is among sexually active adolescent girls. There is also increased risk during menstruation and pregnancy.

Two forms of arthritis exist one with skin rashes and multiple joint involvement, and a second, less common, form in which disseminated gonococcemia leads to infection of a single joint and joint fluid cultures are positive.

Single joint arthritis follows generalized spread (dissemination) of the gonococcal infection. Dissemination is associated with symptoms of fever, chills, multiple joint aches, and rashes. This episode may end as a single joint becomes infected. The most commonly involved joints are the large joints such as the knee, wrist, and ankle.

Symptoms

• Polyarthralgia +++, which is frequently migratory and occasionally progresses to septic arthritis. The wrist, ankle, or knee is commonly involved.
• Periarticular pain ++++ is slightly more common than monarthritis.
• Rash ++++
• Fever and chills +++

Signs

• Rash ++++ ; painful red papules on digits and distal extremities. May have gray necrotic center +++. The lesions are usually few in number ("countable" and often <10). More than 100 suggests the possibility of infection with Neisseria meningitidis.
• Tenosynovitis is most commonly seen in the wrist and fingers, whereas arthritis is usually found in the knee, ankle, hip or elbow.

Treatment

The decision to implement antimicrobial therapy should be made quickly. The choice of which regimen to use should be based on the clinical presentation.

Hospitalization is recommended for initial treatment of DGI, purulent joint infections, meningitis, and endocarditis and hospitalization is also recommended for initial treatment of PID cases in the presence of the following factors:

• Tuboovarian abscess
• Severe pain, high fever, persistent nausea and vomiting is a severe symptoms
• Immunodeficiency
• Uncertain diagnoses, with any possibility of ectopic pregnancy or appendicitis masquerading as PID
• Pregnancy
• Failure of outpatient treatment

Most authorities recommend removal of intrauterine devices in women with PID.

Examining and treating all sexual partners of women with gonococcal PID is crucial.