• Sexually active young person without prior joint disease.
  
• Typical presentation is triad of polyarthritis, tenosynovitis, and dermatitis.
  
• Synovial fluid Gram stain and culture are often negative.
  
• Urethral, cervical, pharyngeal, and rectal testing for Neisseria gonorrhoeae in aggregate are positive in up to 90% of cases.

Disseminated gonococcal infection (DGI) remains the most common cause of acute septic arthritis in young sexually active persons in the United States and affects persons without prior joint disease. Dissemination of Neisseria gonorrhoeae occurs in 0.5–3% of cases of untreated genital gonococcal infections. Women are affected with DGI 2–3 times more commonly than men, with dissemination of N gonorrhoeae observed most frequently within 7 days of menses, during pregnancy, or in the postpartum period.

The joint and skin manifestations of DGI are mediated by both circulating immune complexes and the direct effects of microbial proliferation. Mucosal infection with N gonorrhoeae always precedes the development of DGI, although this herald infection may be asymptomatic in the majority of cases. Inherited deficiencies in either the terminal complement components (C5–C9) or in properdin synthesis result in inefficient outer membrane attack of Neisseria species and predispose patients to dissemination of N gonorrhoeae from localized sites of infection.

Symptoms and Signs

The time from sexual contact to the onset of DGI varies from 1 day to 2 months. Only 25% of patients with DGI manifest genitourinary or pharyngeal symptoms of the precedent mucosal infection.

DGI usually presents with the clinical triad of polyarthritis, tenosynovitis, and dermatitis. N gonorrhoeae accounts for only 20% of cases of monoarticular septic arthritis in young adults, since the most common joint presentation of DGI involves an oligoarthritis or polyarthritis. The initial symptoms include fevers, chills, and migratory symptoms of polyarthralgias, which usually progress to frank monoarthritis or polyarthritis in the knees, ankles, or wrists. Migratory symptoms of tenosynovitis occur in two thirds of patients and are most often present over the dorsum of the hand, the wrist, the ankle, or the knee. Skin lesions are seen in approximately two thirds of patients with DGI, although they are usually painless and patients may be unaware of them. Biopsy of these skin lesions demonstrates perivascular inflammation, leukocytoclastic vasculitis, intra-epidermal neutrophilic infiltration, and microthrombi; N gonorrhoeae can be cultured from biopsy specimens of the skin lesions approximately 10% of the time.

Unusual clinical manifestations of DGI include pericarditis, meningitis, aortitis, endocarditis, myocarditis, pyomyositis, and osteomyelitis.

Physical Examination

Gonococcal suppurative arthritis usually involves one or two joints, with the knees, wrists, ankles, and elbows being involved with decreasing frequency. The physical examination of these joints resembles that of septic nongonococcal arthritis. When tenosynovitis is present, there is tenderness to palpation in the periarticular regions of the wrists, fingers, toes, and ankles. The skin lesions of DGI may be asymptomatic and require careful inspection for their detection. A tender necrotic pustular lesion on an erythematous base is the classic skin lesion (Figure 46–1). However, macules and papules also occur. The rash is typically found on the distal extremities (including digits) in a relatively sparse distribution (10–25 lesions are usually found in total). Hemorrhagic bullae, erythema multiforme, and vasculitic lesions have also been reported.