What is gonococcal arthritis?
Gonococcal arthritis is an infection and inflammation of the joints caused by the gonorrhea bacteria. Arthritis is the medical term for joint inflammation. There are several different types of arthritis that can affect humans. By far the two most common types of arthritis arise with joint cartilage degeneration (osteoarthritis) and immune-medicated joint inflammation (rheumatoid arthritis). When the joint becomes inflamed due to an infection with microbes then it is referred to as septic arthritis. Gonococcal arthritis is a common type of septic arthritis caused by the bacteria Neisseria gonorrhoeae. This is the same bacteria that are responsible for gonorrhea – a common sexually transmitted disease (STD). Gonococcal infection is common globally. Females are at a greater risk and particularly the 15 to 30 year age group. Any sexually active person is at risk although it may also occur in newborns. However, gonococcal arthritis is rarely seen in babies.
Gonococcal arthritis can be of two types :
- Localized gonococcal septic arthritis, which affects usually one joint. Seen in 40% cases of gonococcal arthritis.
- Gonococcal arthritis-dermatitis (bacteremic) syndrome, which shows characteristic features like inflammation of the skin and of the fluid-filled synovium surrounding a tendon, and arthritic pain moving from one joint to another. It is the more common type of gonococcal arthritis.
The highly infectious N. gonorrhoeae bacteria enter the body by invading the thin mucosal lining of the genitalia, rectum, mouth or throat. can colonize mucosal surfaces of the urethra (tube connecting the urinary bladder to the genitals), cervix, throat, and rectum. Usually it causes a localized infection in these areas as the disease commonly known as gonorrhea.
The immune system ensures that the bacteria do not spread beyond the initial site of infection and surrounding tissues. However, the bacteria may spread throughout the body by traveling through bloodstream. At times changes in the strain of N. gonorrhoeae bacteria increase its chances of spreading throughout the whole body like svariation in the pili (the hair-like attachment found on the surface of the bacteria) and changes in some proteins found in the bacteria.
In these cases, the disseminated bacteria may eventually reach the joints and trigger inflammation (arthritis). It is therefore termed gonococcal arthritis. All other types of septic arthritis (joint inflammation caused by the gonorrhea bacteria) are therefore referred to as non-gonococcal arthritis.
Signs and Symptoms
Symptoms of gonococcal arthritis appear after 1 to 90 days of initial infection with N. gonorrhoeae. The symptoms may be categorized according to the type of gonococcal arthritis.
Bacteremic (arthritis-dermatitis syndrome)
- Arthritic pain moving from one joint to another.
- Pain affecting many joints.
- Hands more affected than the legs.
- Wrist, elbows, knees, and ankles most commonly affected.
- Symptoms resolving on their own in about 40% of cases or developing into septic arthritis in one or more joints.
- Inflammation of synovium surrounding the tendons.
- Tendons of wrist, ankles, and knees most affected.
- Inflammation of an entire finger or toe.
- Painless, non-itchy skin rash.
- Non-specific symptoms muscle pain, low-grade fever, and general discomfort.
Localized gonococcal septic arthritis
- Joint pain.
- Joint redness and swelling.
- Mostly one (or sometimes more than one) joint affected.
- Knee, ankle, wrist, or elbow joint most commonly affected.
- Decreased ability to move the joints.
Causes and Risk Factors
Gonococcal arthritis is joint inflammation caused by N. gonorrhoeae infection. It is usually a consequence of gonorrhea. People who are at risk of developing gonococcal arthritis include :
- Women are at a greater risk than men. Pregnancy and menstruation increases the risk further.
- Patients with systemic lupus erythematosus (SLE).
- Weakened immune system as seen in diseases like HIV and AIDS.
- Sexually active individuals with multiple partners.
- People who are sexually active from a young age.
Alcoholism, illicit drug use and socioeconomic status can all be risk factors.
Tests and Diagnosis
Gonorrhea affecting the genitalia can often be diagnosed by the skin symptoms although laboratory testing should be conducted. With gonococcal arthritis, the body fluids needs to be tested for the presence of the gonorrhea bacteria.
- Cultures (of synovial fluid, blood, cervix, urethra, rectum, and throat) are performed for diagnosing gonococcal infection and subsequent gonococcal arthritis. Synovial fluid can be collected from the affected joint in a procedure called arthrocentesis.
- X-rays may be taken to rule out bone fracture as a cause of pain.
Gonococcal arthritis is treated with the same medication used for gonorrhea.
Antibiotics are used to eliminate the infection. This subsequently provides relief from symptoms and prevents complications associated with gonococcal infection and gonococcal arthritis.
- Ceftriaxone, ceftizoxime, or cefotaxime are the main antibiotics that are prescribed.
- Cephalosporin or azithromycin are prescribed for pregnant patients with gonococcal infections.
- Ceftriaxone or cefotaxime is used to treat children.
None of these antibiotics (ceftriaxone, ceftizoxime, or cefotaxime) are effective against Chlamydia co-infection, which is seen in around 50% patients. Therefore other antibiotics like azithromycin may also be used.
Excessive fluid within the joint, pus and synovial fluid, may require drainage of the joint (arthrocentesis). Symptoms like joint swelling and pain may ease to some degree after drainage. However, drainage is not an effective way of treating the infection and antibiotics are still necessary.
Supportive measures help ease the discomfort, can assist with faster healing and play a role in reducing the chance on complications. With gonococcal arthritis, the primary supportive measure is immobilizing the joint. Ideally patients who do not have to be physically active should be restricted to bed rest for at least the first few days after starting antibiotics. Anti-inflammatory drugs can be used for pain relief.
Gonococcal arthritis can be prevented. Firstly the focus should be on preventing gonorrhea by avoiding high risk sexual practices. This includes limiting abstaining from sex, limiting the number of sexual partners and using appropriate barrier protection like condoms during intercourse. Secondly, gonococcal arthritis can be prevented if there is prompt treatment for gonorrhea contracted during sex. Patients should immediately seek medical attention when the first symptoms are present on the mouth, rectum and genitalia. Ignoring these symptoms and allowing the infection to spread leads to gonococcal arthritis.
Untreated gonorrhea can lead to gonococcal arthritis. Once the bacteria have entered the bloodstream it can infect any other organ and tissue in the body apart from just the joints. The infection may spread to the heart, bones, brain and spinal cord as well as its lining (meninges) and the kidneys. These complications can be life threatening over time.
The prognosis for patients with gonococcal arthritis is excellent provided that there is prompt medical treatment through the appropriate antibiotics and joint drainage. The prognosis may not be as promising in patients with a weakened immune system like those living with HIV and AIDS, patients who are re-infected several times and those who delay in seeking medical attention. The prognosis is also significantly worse once the bacteria have disseminated and has infected several other sites in the body, and in particular the central nervous system.