1 / 53

Gonococcal Arthritis

Gonococcal Arthritis. Outline. Background Epidemiology Pathogenesis Clinical features Diagnosis Treatment/Resistance Summary. Background. Galen – 130 AD, “gonorrhea” Greek gonos (seed) and rhoea (flow) urethral discharge mistaken for semen Paris – Middle Ages

purity
Download Presentation

Gonococcal Arthritis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Gonococcal Arthritis

  2. Outline • Background • Epidemiology • Pathogenesis • Clinical features • Diagnosis • Treatment/Resistance • Summary

  3. Background • Galen – 130 AD, “gonorrhea” • Greek gonos (seed) and rhoea (flow) • urethral discharge mistaken for semen • Paris – Middle Ages • house of prostitution known as “clapiers” • “clap” common name used • 18th century gonorrhea vs. syphilis? • Hunter’s experiment • Inoculated his urethra with pus from gonorrhea patient • Unfortunately patient had both • Developed chancers and concluded 2 diseases are same • Later presumably died from syphilitic aortic aneurysm

  4. Epidemiology • Colonize diverse mucosal surfaces • Most frequently reported communicable dz in US • Produce local and disseminated infections • DGI 0.5 to 3% of cases of mucosal infection • Most common cause of acute septic arthritis in young sexually active adults • Arthritis is most common complication

  5. Epidemiology • Prevalence greater in developing countries • 1975 peak 486/100k in US with decline 1995 149.5/100K • Increased incidence in: • Southern US states • Women • African Americans • Peak incidence in men 20-24 women 15-19

  6. GISP Annual Report 2006 www.cdc.gov - Gonococcal Isolate Surveillance Project

  7. GISP Annual Report 2007 www.cdc.gov

  8. GISP Annual Report 2006 www.cdc.gov

  9. GISP Annual Report 2006 www.cdc.gov

  10. Pathogenesis

  11. Pathogenesis • Risk factors • Women 3~4:1 • More often asymptomatic, delayed treatment, • Pregnancy and menses • Multiple sexual partners • Low socio-economic status • Non-caucasian • Previous gonorrhea infection • IVDU • HIV • Inherited complement deficiency (C5-9) • SLE

  12. Pathogenesis • Microbial factors • Pili • Outer membrane proteins: I (Porin), II, and III • 1A • Nutritional requirements (auxotyping) • AHU • Encapsulation • IgA proteases

  13. Microbial FactorsHochberg, Rheumatology, 4th edition

  14. Pathogenesis • Physical contact with mucosa • Highly infectious • 60-90% in females • 20-50% in males with single contact • Serum-sickness-like reaction • Vs. septic embolization • C5-C9 critical for lysis

  15. Immune Factors: Animal Models • Arthritis – unable to culture from symptomatic sites • Does not respond to steroids but to antibiotics • Perhaps can only recover bug in early phases • Is it an aseptic inflammatory response • Goldenberg et al. injected organism into rabbit knee resulted in synovitis but couldn’t recover organism • Also injected PCN-killed organism and LPS resulting in indistinguishable synovitis • Sterile microbial antigenic components involved?

  16. Clinical Features

  17. Gonococcal vs. Nongonococcal Adapted from: Rheumatology Secrets 2nd Ed. 2002 by S. West

  18. Clinical Features • Classification (controversial) • Arthritis dermatitis syndrome (aka bacteremic – 60%) • Fever, rash, tenosynovitis • Vs. Localized septic arthritis (40%) • Features of both, different stages of evolution?

  19. Clinical SpectrumHochberg, Rheumatology, 4th edition

  20. Clinical SpectrumHochberg, Rheumatology, 4th edition

  21. Clinical Features • Classic triad: • Dermatitis • Tenosynovitis • Migratory polyarthritis (polyarthralgias) • Initial manifestation, 1 d to 3 mo, or asymptomatic • Joint sx – peak within days

  22. Clinical Features • Dermatitis • 40-70% • Non-pruritic, painless • Tiny papules, pustules or vesicles with erythematous base, various states • Trunk, limbs • Sparing face and scalp • Resolve over 4-5 days without scarring • New lesions may appear after ABX

  23. SkinHochberg, Rheumatology, 4th edition

  24. Clinical Features • Tenosynovitis • 2/3, with or without joint involvement • Most common dorsum of hands, wrist, fingers, feet, ankles • Polyarthralgia/arthritis • >2/3, asymmetric, migratory • UE>LE • Peaks within few days • Small distal joints involvement****** • Rarely destructive • 1/3 spontaneously resolve

  25. Arthritis/Tenosynovitis Hochberg, Rheumatology, 4th edition

  26. Clinical Features - Other • Raremanifestations: pericarditis, endocarditis, perihepatitis, pyomyositis, osteomyelitis, meningitis

  27. Clinical Features • Raremanifestations: pericarditis, endocarditis, perihepatitis, pyomyositis, osteomyelitis, meningitis • Fitz-Hugh-Curtis syndrome – RUQ/upper belly pain/tenderness with friction rub

  28. Clinical Features • Rare manifestations: pericarditis, endocarditis, perihepatitis, pyomyositis, osteomyelitis, meningitis • Fitz-Hugh-Curtis syndrome – RUQ/upper belly pain/tenderness with friction rub • Waterhouse-Friderichsen syndrome – form of septicemia with shock, DIC, purpura, adrenal insuff., bilateral adrenal hemorrhage

  29. DDX • Non-gonococcal septic arthritis: • monoarticular, young and old, immunocompromised, prior joint damage, no dermatitis/tenosynovitis • Reiter’s: • less women, urethritis, conjunctivitis, arthritis, subacute, no fever, axial skeleton, hyperkeratotic lesions in palms and soles • Rheumatic fever: • follows strep infection, high fevers, marked systemic illness, rash, response to ASA or NSAIDs • Secondary syphilis: • rash on palms and soles • Hepatitis • SBE

  30. Secondary Syphilis

  31. Secondary Syphilis

  32. DDXUptodate, 2009 Adapted from UpToDate.com 2009

  33. Diagnosis

  34. Diagnosis • Fever, leukocytosis, elevated ESR, LFTs • Positive culture confirms diagnosis • Proven, probable, and possible based on culture • Proven <50%: blood, synovial fluid, skin lesions, or other sterile source • Probable: primary mucosal site, negative sterile site, clinical features • Possible: clinical features with expected response to therapy, negative cultures

  35. Diagnosis - Cultures • Synovial fluid culture • + <25% of time from purulent joints • Higher yield from primary mucosal site, 80% • cervical 90%, urethral 50-75%, pharyngeal 20%, rectal 15%) • Blood cultures 20-30% • Skin culture 5% • Check for Chlamydia, 30% association with Gc

  36. Diagnosis • Synovial fluid culture • + <25% of time • Higher yield from primary mucosal site, 80% • cervical 90%, urethral 50-75%, pharyngeal 20%, rectal 15%) • Blood cultures 20-30% • Skin culture 5% • Check for Chlamydia, 30% association with Gc DO MORE CULTURES!

  37. Diagnosis • Plate immediately, room temp • Chocolate agar (“dirty) or Thayer-Martin (or modified NY media; “clean”) “If it’s a clean site, use a dirty medium. If it’s a dirty site, use a clean medium.”

  38. Gram negative diplococciHochberg, Rheumatology, 4th edition

  39. Diagnosis • Antibody testing • <70% sensitive and <80% specific • Lower in asymptomatic patients than cultures • In low prevalence specificity unsatisfactory • PCR • 78-80% and 96-98% for sensitivity and specificity • Cannot test for antibiotic resistance and should not replace cultures.

  40. Treatment

  41. Treatment - Antibiotics • Hospitalization for initial therapy • Non-PCN Allergic: • First line = Ceftriaxone, 1 gram IM/IV q24h • Alt. = Cefotaxime or ceftizoxime 1 gram IV q8h • PCN Allergic • Spectinomycin 2 gram IM q12h, Cipro, Ofloxacin • Follow sensitivities • PCN Sensitive Organism? • PCN G, amox + probenecid, spectinomycin • Pregnant? • Ceftriaxone and Spectinomycin safe (Always consider checking IDSA or Sanford or CDC)

  42. CDC updated treatment recommendationMMWR, April 13, 2007 / 56(14);332-336

  43. Treatment - Duration • Continue IV 24-48 hrs after improvement begins • Then PO x at least 1 week • Cefixime 400mg po BID • Or Cipro 500mg po BID (contraindicated in children, pregnant, breast feeding) • All DGI get Chlamydia trachomatis treatment • Doxycycline 100mg BID x 7 days • Erythromycin 500mg daily x 7 days if pregnant • Sexual contacts need to seek evaluation • Consider checking beta-hCG in females!!

  44. Treatment • Synovial effusions • may require repeated aspiration • longer duration of ABX • open drainage rarely indicated • ABX into joint has no benefit • Recurrent DGI rare unless complement deficient • Repeat culture 5 days post ABX to ensure resolution

  45. GISP Annual Report 2007 www.cdc.gov

  46. Treatment Resistance • 2 mechanisms • chromosomal mutation • single step mutation, high pattern of resistance • mutation at several chromosomal loci, determine level and pattern of resistance • acquisition of plasmids • decrease membrane permeability to ABX • decrease affinity of PCN binding protein • increase concentration of binding proteins

  47. ABX Resistance Hochberg, Rheumatology, 4th edition

  48. MMWR, April 25, 2008 / 57(16);435 • Cefixime 400mg PO BID • Lupin Pharmaceuticals, Inc. (Baltimore, Maryland, 866-587-4617).

  49. Summary • Gonorrhea remains most common communicable disease in US • DGI is most common acute septic arthritis in young adults in US • DGI is spectrum of disease • Definite diagnosis challenging • Culture from all mucosal sites • Treatment challenge due to resistance

More Related