Miller KE. To detect effusion in the ankle, the joint should be palpated anteriorly. 1(July 1, 2003) Infectious arthritis complicating rheumatoid arthritis and other chronic rheumatic disorders. 23. Ruiz MT. If the history and diagnostic studies suggest an infection, aggressive treatment can prevent rapid joint destruction. An asymptomatic course is common, particularly in women, and increases the risk of further spreading and complications! However, a patient with inflammation of certain bursae (e.g., prepatellar bursitis, olecranon bursitis) may present with redness or swelling that mimics joint inflammation. Needle-shaped monosodium crystals seen by light microscopy of synovial fluid in a patient with gout. Sex Transm Infect. Philadelphia: Saunders, 2001:367–77. For example, elbow pain resulting from septic arthritis occurs with active and passive motion in any direction. In tendonitis or bursitis, joint movements against resistance elicit pain. Gonococcal arthritis is caused by infection with the gram-negative diplococcus Neisseria gonorrhoeae. Reactive arthritis, formerly known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Baker DG, Atlanta: Arthritis Foundation, 2001:117–24. Prompt diagnosis of joint infection, which often is acquired hematogenously, is crucial because of its destructive course. A description of 4454 patient visits to 138 family physicians. A prospective study. Pseudogout affecting the wrists and knees is most common among elderly persons. Reactive arthritis, the currently accepted term, is a systemic, seronegative spondyloarthropathy defined by a temporal relation… Light microscopy may be useful to identify gout crystals, but polarized microscopy is preferred. Ghanem KG. Schumacher HR Jr. The problem is in the joint, because the patient complains of “joint pain.”. Blood cultures should be obtained in patients with suspected septic arthritis. In: Haran Chandrasekar P. 2. The epidemiology, pathophysiology, repertoire of potential infecting pathogens, clinical presentation and treatment differ for these two forms of infectious arthritis, but both are associated with significant morbidity and mortality. Superimposed cellulitis is a relative contraindication to arthrocentesis. Gonococcal arthritis – Neisseria gonorrhoeae is a common cause of septic arthritis in people who are sexually active and under 40 years old. Am Fam Physician. If needle drainage is ineffective, urgent arthroscopic or surgical drainage is indicated. Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. 16. True intraarticular problems cause restriction of active and passive range of motion, whereas periarticular problems restrict active range of motion more than passive range of motion. Goldenberg DL. McCune WJ, Golbus J. Monoarticular arthritis. 37(5):702-9. . van de Laar MA. Patients with reactive arthritis may have inflamed eyes. 2 Despite this high prevalence of gonococcal infection in homosexuals with HIV infection, there have been few reports of gonococcal … Crystal-induced monoarthritis (e.g., gout, pseudogout), Juvenile rheumatoid arthritis, Lyme disease, other crystalline arthritides. A more recent article on acute monoarthritis is available. gonococcal infection. Another feature of gonococcal infection includes small, painless, maculopapular, pustular, or vesicular lesions on an erythematous base involving the extremities. What you should be alert for in the history The classic triad of arthritis, urethritis, and conjunctivitis became known as ‘Reiter’s disease’ after a large number of cases were reported during World War I and II. Specific maneuvers can be diagnostic for other conditions, such as medial epicondylitis; bicipital and rotator cuff tendonitis; troch-anteric bursitis; and patellar, prepatellar, and anserine bursitis.15, Joint effusion may not be readily visible. Diagnosis and treatment of Neisseria gonorrhoeae infections. 1985;44:537–43. The condition was named for Hans Reiter, who published a case in 1916, but the uncovering of Reiter’s affiliation with the Nazi party led to a change in designation for this condition. Dr. Mody’s work was funded by the U.S. Department of Veterans Affairs. Sources of funding: Drs. Schaffer TC. Crystals can be present in a septic joint. Patients with gonococcal infection may have a rash, pustules, or hemorrhagic bullae. Infectious arthritis of native and prosthetic joints may be caused by viruses, or fungi, but the most common cause is bacteria. Acute monoarthritis can be the initial manifestation of many joint disorders. Acute monoarthritis can be the initial manifestation of many joint disorders. Reactive arthritis sometimes can develop after a gastrointestinal or sexually transmitted disease. Normal synovial fluid is colorless and transparent. Stange KC, Spontaneous osteonecrosis may occur in patients with risk factors such as alcoholism or chronic corticosteroid use. The soft tissues around the joint can be the source of the pain (e.g., olecranon bursitis of the elbow, prepatellar bursitis of the knee). 1980;243:2314–6. Esterhai JL Jr, 12. Want to use this article elsewhere? 6. Assessment, investigation, and management of acute monoarthritis. 11. 14. Aside from being interchangeable with the term “infectious arthritis,” this condition may also be known as suppurative arthritis due to its characteristic of producing purulent substances or pus, and may also be known as “bacterial arthritis,” even though the condition may at times be of fungal or viral origin instead of the commonly bacterial origin. 1998;41:736–9. In patients with rheumatoid arthritis, pain in one joint out of proportion to pain in other joints always suggests infection.13. Minor trauma can precipitate gout or introduce infection through a break in the skin.8. Acute monoarticular arthritis. Arthritis Rheum. Sheon RP, Moskowitz RW, Goldberg VM. Cahn P, Gonococcal arthritis is caused by infection with the gram-negative diplococcus Neisseria gonorrhoeae. 7. Is it arthritis?. The inflammatory reaction is designated by activation of the innate immune defense mechanisms by e.g., microbial invasion, autoimmune reaction, or synovial deposition of crystals, such as monosodium urate monohydrate or calcium pyrophosphate crystals. Atlanta: Arthritis Foundation, 2001:117–24. A suggested algorithm for the evaluation of patients who present with acute monoarthritis. Describe the presentation of septic arthritis caused by Disseminated Gonoccocal Infection (DGI). Illuminating the ‘black box’. Referred pain should be suspected in patients with a normal joint examination. Freed JF, Louie JS. Reginato AJ, Alarcon GS. Common pitfalls in the diagnostic approach to acute monoarthritis (Table 4) must be avoided, and the rough guidelines on synovial fluid classification (Figure 1 and Table 3) should not be interpreted too rigidly. Wise CM, Spindler A, Illuminating the ‘black box’. A more recent article on acute monoarthritis is available. 6.  In Western Europe, however, gonococcal arthritis is uncommon,  probably because of the 70% decline in gonococcal infections over the past 2 decades. Joint and soft-tissue arthrocentesis. Gelb I. Paz S, Goldenberg DL. sterile process of reactive arthritis Sexual partners must be treated simultaneously to avoid reinfections! Cucurull E, Gonococcal arthritis is a rare complication of the sexually transmitted infection (STI) gonorrhea. Purulent gonococcal arthritis requires frequent joint drainage. Additional details on performing arthrocentesis are available elsewhere.17,18. Tovar J, Fye KH. A positive culture from skin, joint fluid, or blood is diagnostic of disseminated gonococcal infection, but a positive culture from the urethra or cervix does not rule out reactive arthritis. Not all patients with reactive arthritis have Reiter syndrome (also see History and etymology below). Kelly RB, Reactive arthritis, formerly known as Reiter's syndrome, is a condition that causes inflammation (redness and swelling) in various places in the body. Acute monoarthritis. Stange KC, Snaith ML. Schumacher HR Jr. Gonococcal Infections in Adolescents and Adults. Assessment, investigation, and management of acute monoarthritis. Rheumatology: 4. Jaen CR, The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. Gonococcal arthritis is an infection of a joint. Wise CM, The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. J Fam Pract. Morris CR, Mayor MT, Roett MA, Uduhiri KA. Gonococcal arthritis is the most common type of nontraumatic acute mono-arthritis in young, sexually active persons in the United States. Serum uric acid levels often are lowered in patients with acute gout. Paz S, AMI MODY, M.D., is a clinical fellow in the Division of Rheumatology at Washington University School of Medicine. The procedure can be performed safely in patients who are taking warfarin (Coumadin).19 An experienced physician should perform arthrocentesis in these patients and use the smallest possible needle size. Disseminated gonococcal infection, reactive arthritis, and ankylosing spondylitis affect young adults. Choose a single article, issue, or full-access subscription. Coming into contact with bacteria and developing an infection can trigger the disease. Acute bacterial arthritis is a potentially serious and rapidly progressive infection that may involve native or prosthetic joints. van de Laar MA. To see the full article, log in or purchase access. Lancet. Gonococcal arthritis in an era of increasing penicillin resistance. In symptomatic cases, typical clinical symptoms include purulent vaginal or urethral discharge, dysuria, and signs of epdidymitis (e.g., scrotal pain) or PID (e.g., pelvic pain, dyspareunia). Rice PA. It generally causes painful inflammation of the joints and tissues. Disseminated gonococcal infection (DGI), also called the arthritis-dermatitis syndrome, reflects bacteremia and typically manifests with fever, migratory pain or joint swelling (polyarthritis), and pustular skin lesions.In some patients, pain develops and tendons (eg, at the wrist or ankle) redden or swell. Arthritis Rheum. 15. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Gonorrhea can present with a wide variety of symptoms and courses. N Engl J Med. The presence of chondrocalcinosis could support but not confirm CPPD arthritis. Nongonococcal bacterial arthritis. Centers for Disease Control and Prevention. J Rheumatol. Arch Intern Med. Diagnostic tests include nucleic acid amplification testing , gram stains, and bacterial cultures from urine or swabs of the genitourinary tract as well as blood and synovial fluid in disseminated infection. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Cultures of blood, urine, or another primary site of infection (e.g., abscess) must be obtained and repeated as necessary if infection is strongly suspected clinically. The bacteria is spread through the blood to the joint following sexual transmission. Sign up for the free AFP email table of contents. Copyright © 2003 by the American Academy of Family Physicians. If a polarized microscope is not available, a tentative diagnosis can be made if needle-shaped monosodium urate crystals are identified using an ordinary light microscope22 (Figure 2). CHOKKALINGAM SIVA, M.D., CELSO VELAZQUEZ, M.D., AMI MODY, M.D., and RICHARD BRASINGTON, M.D., Washington University School of Medicine, St. Louis, Missouri. Sequential monoarthritis in several joints is characteristic of gonococcal arthritis5 or rheumatic fever. Jaen CR, 1990;264:1009–14. Gonococcal arthritis. Diagnosing Acute Monoarthritis in Adults: A Practical Approach for the Family Physician. 24. Risk factors for septic arthritis in patients with joint disease. Goldenberg DL, 1998;24:305–22. Goldenberg DL, Sexton DJ. Contact Gonorrhea - CDC Fact Sheet (Detailed Version). Is it arthritis?. Atlanta: Arthritis Foundation, 2001:138–9. Septic arthritis. Without treatment, prolonged infection may lead to complications, such as a hymenal and tubal synechiae that lead to infertility in women. For arthrocentesis, the joint line is identified, and a pressure mark is made on the overlying skin with the closed end of a retractable pen. Boyer RS, Habbema JD, Leukocyte counts vary widely in septic and sterile synovial fluids and should be interpreted cautiously. In: Klippel JH, Weyand CM, Crofford LJ, Stone JH. Reprints are not available from the authors. 1993;19:311–31. 12th ed. 1993;329:1013–20. Rarely, disseminated disease may occur, which typically manifests with a triad of arthritis, pustular skin lesions, and tenosynovitis. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. Ann Rheum Dis. Baltimore: Williams & Wilkins, 1996:79–146,209–74. Until infection has been ruled out, corticosteroids should not be injected into a joint. Globally, about 89 million cases of nongonococcal urethritis and 63 million cases of gonococcal urethritis are reported every year. In: 9. It is three to four times more common in women than in men.4,5 Nongonococcal septic arthritis, the most destructive type, generally is monoarticular (80 percent of cases) and most often affects the knees (50 percent of cases).3,6 Staphylococcus aureus is the most common pathogen in nongonococcal septic arthritis (60 percent in some series), but non–group-A beta-hemolytic streptococci, gram-negative bacteria, and Streptococcus pneumoniae can be present.3, Anaerobic and gram-negative infections are common in immunocompromised persons. Gillanders WR, Cucurull E, Rice PA. Presentations and outcomes in 41 recent cases (1985–1991). / Introduction. The general physical examination may provide other diagnostic clues (Table 2) or reveal involvement of other joints. A careful history and physical examination are important because diagnostic studies frequently are only supportive. Till SH, Start studying Septic & Reactive Arthritis. Monoarthritis occasionally is the first presenting symptom of an inflammatory polyarthritis such as psoriatic arthritis but is an unusual initial symptom of rheumatoid arthritis. Thumboo J, Asking the patient to point to the exact site may be helpful.14 Unlike with true joint inflammation, redness or swelling generally is not present with periarticular pain. Shmerling RH, CMAJ. JAMA. If even the smallest suspicion of infection exists, synovial fluid should be sent for a white blood cell (WBC) count with differential (specifically, the percentage of polymorphonuclear neutrophilic leukocytes), crystal analysis, Gram staining, and culture. 12. Gonorrhea generally causes either a suppurative arthritis resembling septic arthritis caused by other bacteria, or a distinct syndrome of disseminated gonococcal infection, with tenosynovitis, skin lesions, and polyarthralgias, rather than frank arthritis. What should be ordered?. 8. psoriatic arthritis. In patients with disseminated gonococcal infection, immune complexes closely paralleled the disease activity and … Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae that leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease (PID) and epididymitis. Berman A, Wasilauskas BL, disseminated gonococcal infection syndrome (migratory polyarthalgias, skin lesions, tenosynovitis) very difficult to grow GC from a joint, but other cultures may well be +ve (e.g. If the fluid withdrawn is initially bloody rather than becoming bloody during aspiration, previous hemarthrosis should be suspected. Ensworth S. Reactive arthritis, formerly known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Lipid panels and synovial fluid tests for other chemistries, proteins,20 rheumatoid factor, or uric acid are not useful because the results may be misleading. Osteoarthritis may worsen suddenly and manifest as pain and effusion. Septic arthritis. Kelley’s Textbook of rheumatology. Trentham DE. 1. Read P, Abbott R, Pantelidis P, Peters BS, White JA. 8. Zyzanski SJ, Trentham DE. It generally causes painful inflammation of the joints and tissues. 4. Tests for HIV and Lyme disease antibodies may be obtained if appropriate, but serologies usually are not helpful in identifying the cause of acute monoarthritis.9,23 Indiscriminately ordering tests such as rheumatoid factor and antinuclear antibodies can result in confusion, because false-positive results are common. | STEP 2 CK 10. Human immunodeficiency virus infection associated arthritis: clinical characteristics. Cibere J. Transient arthritis sometimes results from intra-articular injection of corticosteroids. Morris CR, Ruiz MT. Arthrocentesis, synovial fluid analysis, and synovial biopsy. Arthritis Rheum. Reactive arthritis was formerly known as Reitersyndrome/disease, which is the combination of urethritis, arthritis and conjunctivitis. El-Gabalawy H. Evaluation of the patient: history and physical examination. In Western Europe, however, gonococcal arthritis is uncommon, probably because of the 70% decline in gonococcal infections over the past 2 decades. Dr. Velazquez graduated from the National University of Asuncion, Paraguay, and completed an internal medicine residency at Rush-Presbyterian-St. Luke’s Medical Center, Chicago. In the USA, disseminated gonococcal infection (DGI) is the most common form of bacterial arthritis in young, healthy sexually active adults . When an infection is suspected, culture and Gram staining should be performed and antibiotics should be started. Rheum Dis Clin North Am. Siva and Velazquez received funding from the Arthritis Foundation, Eastern Missouri Chapter. Siva and Velazquez received funding from the Arthritis Foundation, Eastern Missouri Chapter. Kaandorp CJ, 1994 May. To detect effusion in the elbow joint, the triangular recess (area between lateral epicondyle, olecranon process, and radial head) in the lateral aspect should be palpated. Patients with longstanding gout may have tophi (i.e., firm subcutaneous deposits of urate) over the olecranon prominence, first metatarsal joints, or pinnae. Fever may be absent in patients with infectious monoarthritis but can be a presenting feature in acute attacks of gout or pseudogout. Delbanco TL, : Reiter’s syndrome: The presence of urethritis, conjunctivitis, and arthritis in a patient with infectious dysentery. Radionuclide scanning can detect infection in deep-seated joints. This page includes the following topics and synonyms: Gonococcal Arthritis, Septic Joint due to Gonorrhea, Disseminated Gonococcal Infection, Dermatitis-Arthritis Syndrome. 5. Atlanta: Arthritis Foundation, 2001:138–9. El-Gabalawy H. Evaluation of the patient: history and physical examination. 10. Thumboo J, A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. We list the most important complications. | STEP 2 CS 12th ed. Sterile tubes should be used for culture. Sheon RP, Moskowitz RW, Goldberg VM. Kelly RB, 2015 Sexually Transmitted Diseases Treatment Guidelines: Gonococcal Infections. Schumacher HR, Synovial fluid tests. Rarely, disseminated disease may occur, which typically manifests with a triad of arthritis, pustular skin lesions, and tenosynovitis. Fungal or mycobacterial infections usually have an indolent and protracted course but can mimic bacterial arthritis. 1991;22:503–14. Primer on the rheumatic diseases. The prevalence of gonococcal urethritis in homosexuals with human immunodeficiency virus (HIV) infection ranges between 1.7% and 19% 1 and the prevalence of asymptomatic gonococcal infection in this population is around 10%. Study with AMBOSS for USMLE: STEP 1 Rabinowitz JL. Mikhail IS, Synovial fluid tests. Acute monoarthritis. Aseptic loosening is often the source of pain in a prosthetic joint. Allan DA, In the United States, an estimated 820,000 new N. gonorrhoeae infections occur each year ().Gonorrhea is the second most commonly reported communicable disease ().Urethral infections caused by N. gonorrhoeae among men can produce symptoms that cause them to seek curative treatment soon enough to prevent sequelae, but often not … The ordinary light microscope: an appropriate tool for provisional detection and identification of crystals in synovial fluid. 6th ed. The complete blood cell count may show leukocytosis in some patients with infection. RICHARD BRASINGTON, M.D., is associate professor and director of clinical rheumatology at Wash-ington University School of Medicine, where he also directs the Center for Clinical Studies and the fellowship program in rheumatology. Baker DG, / Journals Infection, commonly from a skin source, is also possible and requires urgent attention. 17. Many types of crystals can trigger acute monoarthritis, but monosodium urate (which causes gout) and calcium pyrophosphate dihydrate (CPPD, which causes pseudogout) are the most common. Joints always suggests infection.13 identify with light microscopy may be caused by infection a..., such as a hymenal and tubal synechiae that lead to infertility women. To access AMBOSS HLA-B27 positive preantibiotic era, gonococcal arthritis is a complication of the joints via... Present in Lyme disease, other crystalline arthritides the bacteria is spread the. In 41 recent cases ( 1985–1991 ) sexual partners must be suspected penicillin resistance frequently! 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