Bellevue Morning Report Teaching Points 11/27
CC: Left knee swelling and pain x 1 week
54 yo male without past medical history in his usual state of health until 5 weeks prior when he had painful ejaculation and intermittent dysuria, denies penile discharge. Treated for a urinary tract infection with unknown antibiotic. 3 weeks later develops recurrent symptoms and again treated with another course of unknown abx by outside physician. However he develops left knee pain and swelling and is unable to ambulate normally. Is in a monogamous marriage and denies any other sexual contacts. No fevers.
Synovial Fluid Analysis Left Knee: WBC 2700, no crystals, no organisms on gram stain, cx pending
DDx: Gonococcal Septic Arthritis vs Reactive Arthritis
All acute, asymmetrically swollen joints need to be tapped immediately to rule out septic joints
Septic joint infection can be divided into gonococcal and non-gonococcal arthritis. Common causes of non-gonococcal septic arthritis are staph, strep, and E. Coli.
There is rising rate of quinilone resistant GC emerging from SE Asia. Risk factors for this are: sex workers, people with multiple sexual partners, MSM. Mainstay of treatment should be ceftriaxone for GC infections. Given almost 50% co-infection with Chlamydia, patients should also be treated with Doxycycline 100mg x 7 days.
It is NOT common to find GC on gram stain or by cultures in acute gonococcal septic arthritis. Furthermore, low white cell counts on synovial fluid analysis can be seen with GC.
Reactive arthritis usually occur 2-4 weeks after preceeding infection either by #1 GI bugs (salmonella, yersinia, campylobacter) or #2 GU infection (GC, Chlamydia). Mainstay of tx is NSAID.