Case Presentation: A 34-year-old male with history of methamphetamine use presented with a one-week history of neck, shoulder, and wrist pain, intermittent radiculopathy, fevers, chills, myalgias, and arthralgias, and a one-day history of confusion. He denied rash, urinary symptoms, diarrheal illness, IV drug use, recent travel, and new sexual contacts. On admission, he was afebrile, tachycardic to 120s, and normotensive. Physical examination was notable for nuchal rigidity, cervical spinal tenderness, & left greater than right upper extremity weakness. His left wrist & bilateral ankles were swollen, erythematous, warm, and tender. Labs were significant for white blood cell (WBC) count of 22, c-reactive protein of 120.6, and positive urine drug screen for methamphetamines. Arthrocentesis of the left wrist showed 47,000 WBCs and arthrocentesis of the left ankle showed 275 WBCs. Imaging could not be obtained due to pain with neck extension, so the patient agreed to remain intubated after an emergent wrist washout for additional imaging. Magnetic resonance imaging of his cervical spine demonstrated a C3-T2 fluid collection suggestive of spinal epidural abscess (SEA). He had an emergent cervical laminectomy for epidural washout. Blood, urine, synovial fluid, and epidural fluid bacterial, mycobacterial, and fungal cultures were negative. Urine was positive for chlamydia (CT) and negative for gonorrhea (GC) by nucleic acid amplification testing (NAAT). Oral & rectal testing for GC/CT collected after antibiotics was negative. A diagnosis of culture-negative SEA with concomitant urogenital chlamydia infection was made. Due to SEA and concern for disseminated gonococcal infection (DGI), the patient was treated broadly with ceftriaxone and doxycycline. Reactive arthritis was treated with anti-inflammatory agents. Antibiotics were transitioned to a 6-week course of doxycycline and levofloxacin as the patient declined continued hospital stay. He was lost to follow-up.
Discussion: Reactive arthritis is an inflammatory arthritis that occurs days to weeks after enteric or urogenital infection, with Chlamydia trachomatis the most endemic cause. Although aseptic inflammatory abscess syndromes have been reported with certain autoimmune conditions, there are no reported cases of chlamydia or reactive arthritis causing SEA. Reactive arthritis–related abscess syndromes may be under-recognized, as chlamydia often occurs concomitantly with gonorrhea, a known cause of bacterial abscesses in the setting of DGI, which also has diagnostic challenges & overlapping clinical features with reactive arthritis. Though sensitivity for NAAT for Neisseria gonorrhoeae is high (>90%) for urine/oral/rectal specimens, Gram stain of body fluid culture is only positive ~50% of the time in the setting of DGI. NAAT from mucosal samples is not always performed or positive in DGI. In this case, DGI cannot be excluded as the underlying etiology of the patient’s arthritis syndrome and SEA. This case highlights that clinical suspicion for DGI should be high in the setting of culture-negative abscesses, especially with another concomitant sexually transmitted infection.
Conclusions: Gonorrhea and chlamydia are under-recognized and challenging to diagnose as potential etiologies for culture-negative abscess syndromes. It is important to consider these organisms and pursue genital & extragenital testing for patients with culture-negative SEA accounting for epidemiologic and clinical context.