GONOCOCCAL ARTHRITIS IN AN ERA OF INCREASING PENICILLIN RESISTANCE - PRESENTATIONS AND OUTCOMES IN 41 RECENT CASES (1985-1991)

Background: To assess the impact of recent reports of disseminated gon ococcal infection caused by penicillin-resistant organisms, we reviewe d the presenting features, clinical course, and outcomes of a group of patients with gonococcal arthritis treated in recent years. Methods: We reviewed the records of all cases of acute arthritis associated wit h a culture positive for Neisseria gonorrhoeae at our institution from July 1985 through December 1991. Results: Forty-one cases were identi fied. Patients included 34 women and 38 blacks; the mean age was 22.6 years. Duration of symptoms averaged 4.8 days at presentation. Other f eatures included migratory arthralgias (n=27), urogenital symptoms or signs (n=26), fever (n=21), and skin lesions (n=16). Comorbid conditio ns included intravenous drug use (n=8) and systemic lupus erythematosu s (n=3). The knee was the most commonly affected joint. Positive cultu re results were obtained from 32 urogenital samples (86%), 14 synovial fluid samples (44%), seven rectal samples (39%), four blood samples ( 12%), and two throat samples (7%). All synovial fluid samples with pos itive culture results had white blood cell counts higher than 20.0X10( 9)/L. Response to therapy with penicillin and/or ceftriaxone was promp t, and mean duration of hospitalization was 5.8 days. Patients who req uired longer hospitalization had a higher mean erythrocyte sedimentati on rate and higher frequencies of positive synovial fluid culture resu lts and comorbid conditions. Penicillin sensitivity could be determine d in 30 patients on the basis of clinical response or in vitro testing . Among these patients, two cases of penicillin-resistant organisms we re identified, one beta-lactamase positive and one beta-lactamase nega tive. Conclusions: The clinical features of patients with gonococcal a rthritis have changed very little since the last large reported series over a decade ago. Underlying conditions appear to be more common, bu t response to antibiotic therapy and eventual outcome remain excellent . The finding of penicillin-resistant organisms in at least 5% of pati ents reinforces recent recommendations that third-generation cephalosp orin agents be used as initial therapy for disseminated gonococcal inf ections until drug susceptibilities are known.