Gonococcal Arthritis

Gonococcal arthritis is a manifestation of disseminated gonococcal infection (DGI), occurring when Neisseria gonorrhoeae spreads hematogenously from a mucosal site (genital, rectal, or pharyngeal) to distant sites, most commonly joints and skin.

It remains the most common cause of septic arthritis in sexually active young adults in many settings, and disproportionately affects women, in whom the primary mucosal infection is more often asymptomatic and therefore untreated before dissemination occurs.

DGI classically presents in one of two overlapping patterns. The arthritis-dermatitis syndrome (more common) features fever, migratory polyarthralgia, tenosynovitis (particularly of the wrists, fingers, ankles, and toes, a relatively distinctive feature), and a sparse pustular or vesiculopustular rash on an erythematous base, typically on the distal extremities and trunk.

The purulent arthritis syndrome features a true septic monoarthritis or oligoarthritis, most commonly affecting the knee, wrist, or ankle, without the preceding migratory or dermatologic features, and mimics other causes of septic arthritis clinically.

• Blood cultures are positive in a minority of cases (particularly the arthritis-dermatitis pattern), but should always be sent
• Synovial fluid analysis and culture (from the purulent arthritis pattern) has low culture sensitivity for gonococcus specifically, given its fastidious growth requirements; NAAT of synovial fluid, where available, offers substantially higher sensitivity
• NAAT testing of all mucosal sites (urethral/vaginal, rectal, pharyngeal) regardless of symptoms is essential, since this is often where the organism is most reliably detected, even when disseminated cultures and joint fluid are negative
• Skin lesion Gram stain and culture, if pustules are present
• Synovial fluid should still be sent for standard cell count, Gram stain, and culture as for any suspected septic arthritis (see that entry), given the differential includes other bacterial causes

• Ceftriaxone 1 g IV/IM once daily, continued for 24 to 48 hours after clinical improvement begins, then stepped down to an oral agent (guided by susceptibility if available, otherwise cefixime 400 mg PO bd, or per local resistance patterns) to complete a total treatment course of 7 days
• Given the frequency of chlamydial coinfection, add doxycycline 100 mg PO bd for 7 days empirically unless chlamydia has been specifically excluded
• Purulent arthritis with a significant joint effusion may require joint aspiration or surgical drainage in addition to antibiotics, following the same principles as any septic arthritis (see that entry)
• Sexual partners in the preceding 60 days should be tested and treated
• Follow local antimicrobial resistance guidance closely given rising, regionally variable gonococcal resistance

Referral: rheumatology or orthopedics for joint aspiration/drainage where indicated; sexual health services for partner notification and full STI screening.