Introduction

Gonococcal arthritis is a manifestation of disseminated gonococcal infection (DGI) caused by Neisseria gonorrhoeae. It is the most common cause of infectious arthritis among sexually active young adults. The condition develops when N. gonorrhoeae spreads hematogenously from a primary mucosal infection of the urogenital tract, rectum, or pharynx. Many patients have asymptomatic primary infections, particularly women.

Gonococcal arthritis is considered a medical emergency because delayed diagnosis and treatment can result in irreversible cartilage destruction, osteomyelitis, septicemia, and permanent joint dysfunction. Early recognition, prompt antimicrobial therapy, and drainage of infected joints generally result in an excellent prognosis.

Epidemiology

• Most common in sexually active individuals aged 15–40 years.

• More common in women than men, particularly during menstruation and pregnancy.

• Represents approximately 0.5–3% of untreated gonococcal infections.

• Higher incidence in individuals with multiple sexual partners.

• Increased risk among people with complement deficiencies, especially terminal complement component deficiencies.

• Coinfection with Chlamydia trachomatis is common.

Etiology

The disease is caused by Neisseria gonorrhoeae, a Gram-negative intracellular diplococcus transmitted through sexual contact.

Primary sites of infection include:

• Cervix

• Urethra

• Rectum

• Pharynx

• Conjunctiva (rare)

Dissemination occurs through hematogenous spread.

Pathophysiology

1. Acquisition of Neisseria gonorrhoeae through sexual transmission.

2. Colonization of mucosal surfaces.

3. Invasion through the mucosa into the bloodstream.

4. Hematogenous dissemination.

5. Deposition within the synovial membrane.

6. Acute inflammatory response.

7. Synovial effusion and purulent arthritis.

8. Untreated infection may result in cartilage destruction and joint damage.

Risk Factors

• Multiple sexual partners

• New sexual partner

• Previous gonococcal infection

• Unprotected sexual intercourse

• Female sex

• Pregnancy

• Menstruation

• Complement deficiency

• HIV infection

• Other sexually transmitted infections

Clinical Presentation

Two clinical syndromes are recognized.

Disseminated Gonococcal Infection (Arthritis-Dermatitis Syndrome)

• Fever

• Malaise

• Migratory polyarthralgia

• Tenosynovitis

• Pustular or vesiculopustular skin lesions

• Mild joint swelling

Localized Septic Gonococcal Arthritis

Usually affects a single large joint.

Common features include:

• Acute severe joint pain

• Joint swelling

• Warmth

• Erythema

• Markedly restricted movement

• Tenderness

• Fever (may be absent)

Most commonly affected joints include:

• Knee

• Wrist

• Ankle

• Elbow

Diagnostic Criteria

Diagnosis is based on clinical suspicion supported by microbiological confirmation.

Major Criteria

• Isolation of Neisseria gonorrhoeae from synovial fluid

• Positive nucleic acid amplification test (NAAT) from a genital, rectal, pharyngeal, or synovial specimen

• Positive synovial fluid Gram stain or culture where available

Minor Criteria

• Acute inflammatory monoarthritis or oligoarthritis

• Tenosynovitis

• Characteristic pustular skin lesions

• Positive blood cultures (uncommon)

• Elevated CRP

• Elevated ESR

• Leukocytosis

• Positive NAAT from mucosal sites

Investigations

Laboratory Investigations

• Complete blood count

• C-reactive protein (CRP)

• Erythrocyte sedimentation rate (ESR)

• Blood cultures before antibiotics

• Renal and liver function tests

Synovial Fluid Analysis

Joint aspiration should be performed before antibiotic therapy whenever feasible.

Evaluate for:

• Appearance

• White blood cell count

• Gram stain

• Culture and sensitivity

• Crystal analysis

Microbiological Investigations

• NAAT from urethral, cervical, vaginal, rectal, and pharyngeal specimens

• Synovial fluid culture

• Blood culture

• Culture from genital specimens where available

Screening for Other Sexually Transmitted Infections

All patients should be screened for:

• Chlamydia trachomatis

• HIV

• Syphilis

• Hepatitis B

• Hepatitis C where risk factors exist

Imaging

Plain X-ray

Usually normal early.

Late findings include:

• Joint space narrowing

• Bone erosion

• Cartilage destruction

Ultrasound

• Detects joint effusion

• Guides aspiration

MRI

Useful for:

• Early joint infection

• Soft tissue involvement

• Associated osteomyelitis

Differential Diagnosis

• Nongonococcal septic arthritis

• Reactive arthritis

• Crystal arthritis

• Rheumatoid arthritis

• Viral arthritis

• Lyme disease

• Tuberculous arthritis

Management

Management includes:

• Prompt intravenous antibiotics

• Joint drainage when indicated

• Pain control

• Monitoring inflammatory markers

• Identification and treatment of sexual partners

• Screening for concurrent sexually transmitted infections

Pharmacological Treatment

Benzyl penicillin

• 2.5–5 million units IV every 6 hours for 7 days

AND

Ceftriaxone

• 1 g IV every 12 hours for 7 days

OR

Cefepime

• 2 g IV every 12 hours for 7 days

Important Notes

• Adjust antimicrobial therapy according to culture and antimicrobial susceptibility results.

• Repeat serial CRP, full blood picture (FBP), and ESR beginning 48 hours after initiation of appropriate treatment and continue until inflammatory markers normalize.

Surgical Management

Joint drainage is indicated in patients with significant purulent effusion or inadequate response to medical therapy.

Surgical options include:

• Open surgical drainage

• Arthroscopic drainage and irrigation (where available)

Following drainage:

• Temporary joint immobilization

• Early physiotherapy after infection control

• Regular reassessment for persistent infection

Monitoring and Follow-up

Patients should be monitored for:

• Resolution of pain and swelling

• Improvement in joint function

• CRP, ESR, and FBP trends

• Adverse drug reactions

• Recurrence of symptoms

Sexual partners within the preceding 60 days should be evaluated and treated according to national sexually transmitted infection guidelines to prevent reinfection.

Complications

• Cartilage destruction

• Chronic arthritis

• Osteomyelitis

• Septicemia

• Joint stiffness

• Reduced range of motion

• Recurrent gonococcal infection

• Infertility related to untreated gonococcal infection

• Disseminated infection

Prevention

• Consistent and correct condom use

• Early diagnosis and treatment of gonorrhoea

• Prompt treatment of sexual partners

• Routine STI screening for high-risk individuals

• Sexual health education

• Reduction in high-risk sexual behaviours

Patient Education

Patients should be advised to:

• Complete the full course of antibiotics.

• Abstain from sexual activity until treatment is completed and symptoms have resolved.

• Ensure all recent sexual partners are evaluated and treated.

• Attend follow-up appointments.

• Return immediately if joint symptoms worsen or recur.

• Undergo screening for other sexually transmitted infections, including HIV and syphilis.

Prognosis

The prognosis is generally excellent when gonococcal arthritis is recognized early and treated promptly with appropriate antimicrobial therapy and joint drainage when indicated. Most patients recover fully without permanent joint damage. Delayed diagnosis, inadequate treatment, or persistent infection may result in cartilage destruction, chronic arthritis, osteomyelitis, or systemic complications. Reinfection may occur if sexual partners are not identified and treated.