Case Presentation: A 42-year-old female with past medical history of systemic lupus erythematosus (SLE) presented to the emergency department with two days of severe polyarthritis in her left wrist, right knee, and lower back. On admission, physical exam was notable for joint swelling and limited range of motion in the wrists, elbows, and knees. Bilateral knee effusion was present without warmth or erythema. Patient was afebrile with labs showing CRP 203 mg/L, ESR 119 mm/hr, WBC 6.7 10^3 /uL with 23% bands and C3/C4 complement 61/8 mg/dL. Rheumatology recommended high dose IV steroids and continuation of maintenance medications, azathioprine and hydroxychloroquine, for treatment of presumed lupus flare. However, on hospitalization day three, given minimal improvement on steroids, with persistently elevated CRP/ESR concerning for infection, the patient underwent a right knee aspiration. Aspirate showed 167,750 WBCs with 92% PMNs. Given the concern for septic arthritis, the patient underwent a right knee washout with drainage of grossly purulent fluid. Synovial culture resulted positive for Neisseria Gonorrhea, consistent with a positive urine NAAT. Postoperatively, patient was switched to stress dose steroids and began a two-week course of ceftriaxone. CRP began to downtrend and patient was discharged shortly after with significant symptomatic improvement.
Discussion: Disseminated gonococcal infection (DGI) is seen in approximately 3% of patients who have a N. gonorrhea infection (1). Classic manifestations of gonorrhea include cervicitis or urethritis while advanced manifestations of DGI include arthritis-dermatitis syndrome, septic arthritis, endocarditis, and meningitis (2). Risk factors for DGI include younger age, female sex, pregnancy, as well as SLE (3,4). Patients with SLE are at elevated risk for DGI due to lower complement levels, an impaired reticuloendothelial system, and exposure to immunosuppressant therapies (3,5). DGI can even mimic an SLE flare, so it should remain high on the differential for a chief complaint of polyarthritis in patients with SLE (4,6). In particular, in cases where there are signs of infection such as elevated inflammatory markers and bandemia, concurrent investigation into secondary processes other than an autoimmune flare should be considered. With appropriate antibiotic management, typically ceftriaxone, patients should recover rapidly (4). Of note, all sexual partners should also undergo antibiotic treatment. Though they were not present in our specific case, other features of DGI such as genitourinary symptoms, dermatitis, and a thorough sexual history can also be useful in early diagnosis and intervention.
Conclusions: While a SLE flare and DGI can have overlapping presentations, it is prudent for a hospitalist to keep gonococcal arthritis high on their differential for polyarthritis, and consider a urine or cervical sample gonococcal NAAT as a quick and non-invasive diagnostic test. In the setting of joint effusions and polyarthritis, there should be a low threshold for a joint aspiration and fluid analysis. Prompt diagnosis of DGI can shorten hospital stays and prevent long-term complications such as tenosynovitis, septic arthritis, skin lesions, endocarditis, and meningitis.