Case Presentation: A 52-year-old female with discoid lupus on immunosuppressive medications and a history of gout presented with acute right wrist pain and swelling and subjective fevers. There was no history of trauma or other joint involvement. Notable examination findings include significant swelling of the right wrist without overlying erythema or induration. She was noted to be febrile to 100.4°F but was otherwise hemodynamically stable. Initial labs, including complete blood count and basic metabolic profile, were normal. Inflammatory markers, including C-reactive protein and erythrocyte sedimentation rate, were elevated at 3.43 mg/dL and 118 mm/hr, respectively. X-ray of the wrist did not reveal fractures or malignment. Orthopedic surgery was consulted and aspirated the joint and synovial fluid revealed 1,871/uL total nucleated cells with no visualized crystals under normal and polarized light. She was started on empiric cefepime and vancomycin and admitted for intravenous antibiotics and incision and drainage of the joint. Synovial culture ultimately grew Neisseria gonorrhoeae, and urine nucleic acid testing also indicated gonorrhea infection. Blood cultures were negative. She was subsequently switched to ceftriaxone and completed 4 weeks of treatment. The patient never endorsed any vaginal discharge or itching, changes to menstruation, dysuria, abdominal pain, or rash. Human immunodeficiency virus and chlamydia trachomatis testing were negative.
Discussion: Disseminated gonorrhea infection (DGI) is a rare manifestation of gonorrhea infection and most commonly presents as a triad of arthritis or arthralgias, tеոοѕуոοvitiѕ, and multiple skin lesions; less than 50% of patients present with purulent arthritis alone. Most patients are asymptomatic until onset of illness, similar to our patient. Patients who present with the latter form of DGI present with abrupt onset of mono- or oligoarthritis, and the joints most commonly involved are knees, wrists, and ankles. Cultures for N. gonorrhoeae of the purulent synovial fluid is only positive in less than 50% of cases, as nucleic acid testing is more sensitive. Cell counts typically reflect septic arthritis (50,000 cells/microL), but lower counts have also been seen. Patients should also be screened for other sexually transmitted infections as co-infection is possible. Treatment includes antibiotics and joint drainage. Intravenous ceftriaxone is the therapy of choice, given growing resistance to oral regimens. Patients typically require 7 to 14 days of therapy, and longer if slower response to treatment. Our patient was treated for 4 weeks, which is not unreasonable given that she was immunocompromised.
Conclusions: This case illustrates an uncommon presentation of gonococcal infection with virtually no other symptoms to suggest active infection. Additionally, Patients with systemic lupus erythematosus (SLE), like our patient, have been known to be predisposed to DGI. SLE flares can mimic DGI so a high index of suspicion for the infection is warranted in these patients. This case highlights the importance of considering alternative causes of arthritis, especially in the absence of other symptoms for all patients, regardless of age or other risk factors. Therapeutic alliance with orthopedic surgery, for early source control with joint drainage, as well as infectious disease, who can notify the lab for suspicion of gonorrheal infection, is imperative to prevent complications and initiate appropriate therapy quickly.