Case Presentation:
A 42 year-old woman with history significant for systemic lupus erythematous (SLE) for 20 years complicated by pleurisy and thrombocytopenia on belimumab presented with a 10-day history of migratory polyarthritis. Her pain started in her left wrist, traveled to her right wrist one day later and then to her right shoulder after two more days. She self-medicated with prednisone 30 mg, thinking that she was experiencing a SLE flare. One day later, the pain traveled to her right hip. She continued self-administering prednisone, added extra-strength acetaminophen and presented to urgent care. She was found to have a leukocytosis. A right shoulder arthrocentesis was unsuccessful. She subsequently started experiencing left ankle pain and again sought medical evaluation.
In the ED, she was found to be febrile, tachycardic with limited range of motion of the right shoulder and left ankle. An arthrocentesis of the left ankle revealed a WBC count of 85,000. Further history was significant for intermittent bacterial vaginosis and a monogamous relationship. She denied dysuria or purulent vaginal discharge. Further work-up revealed Neisseria gonorrhea in the urine. The patient was started on broad-spectrum antibiotics. Laboratory tests were significant for negative blood cultures, normal WBC count, and markers that did not support a SLE flare. Cultures from left ankle arthrocentesis revealed Neisseria gonorrhea.
Discussion:
The patient was diagnosised with septic arthritis secondary to disseminated gonoccocal infection (DGI). DGI occurs in about 0.5% – 3% of patients infected with Neisseria gonorrhea. Women are more likely to be affected with DGI than men, and the disease mostly affects those under 40 years. Risk factors for DGI include recent menstruation, pregnancy, complement deficiency as well as SLE. In addition, this patient was taking immunosuppressant therapy. Patients with DGI present with 2 clinical syndromes: 1.) the triad of polyarthritis, dermatitis and tenosynovitis without purulent arthritis and 2.) purulent asymmetric polyarthritis without skin manifestations. Our patient had the latter.
Essential to making this diagnosis is the procurement of a thorough health history, including her report of intermittent bacterial vaginosis, which increases her risk of contracting a sexually transmitted illness. This clue prompted the medical team to perform urine studies for gonorrhea, chlamydia and HIV. Despite the initial history, it was later ascertained that the patient’s partner of many years had not been monogamous. The patient was discharged home to complete a 2-week course of ceftriaxone.
Conclusions:
Polyarthritis in a SLE patient does not always represent an SLE flare and septic arthritis should be considered in the differential. A thorough health history, including sexual history and genitourinary symptoms, is essential in cinching the diagnosis.