Reumatología Clínica (English Edition) Reumatología Clínica (English Edition)
Reumatol Clin 2017;13:39-41 - Vol. 13 Num.1 DOI: 10.1016/j.reumae.2016.11.001
Case Report
Gonococcal Arthritis in Human Immunodeficiency Virus-infected Patients. Review of the Literature
Artritis gonocócica en pacientes con infección por el virus de la inmunodeficiencia humana. Revisión de la literatura
Gabriel Sena Corralesa, Laura Mora Navasa, Rosario Palacios Muñoza,b,, , Victoria García Lópeza,b, Manuel Márquez Soleroa,b, Jesús Santos Gonzáleza,b
a UGC de Enfermedades Infecciosas y Microbiología Clínica, Hospital Virgen de la Victoria, Málaga, Spain
b Instituto de Biomedicina de Málaga (IBIMA), Málaga, Spain
Received 27 September 2015, Accepted 03 December 2015
Abstract

We report a case of gonococcal arthritis in a patient with human immunodeficiency virus (HIV) infection and review 17 previously published cases; only one patient presented urethritis, and blood cultures were positive in one case. Gonococcal arthritis is rare in HIV-infected patients and is not usually associated with other symptoms. It should be considered in the differential diagnosis of acute arthritis in patients with HIV infection.

Resumen

Presentamos un caso de artritis gonocócica en un paciente con infección por el virus de inmunodeficiencia humana (VIH) y revisamos los 17 casos previamente publicados en sujetos con infección por este virus; solo un paciente presentó uretritis y los hemocultivos fueron positivos en un caso. La artritis gonocócica es infrecuente en pacientes con infección por el VIH y suele presentarse de forma aislada. Debe incluirse en el diagnóstico diferencial de las artritis agudas en pacientes con infección por el VIH.

Keywords
Human immunodeficiency virus, Neisseria gonorrhoeae, Arthritis, Homosexuals
Palabras clave
Virus de la inmunodeficiencia humana, N. gonorrhoeae, Artritis, Homosexuales
Introduction

The prevalence of gonococcal urethritis in homosexuals with human immunodeficiency virus (HIV) infection ranges between 1.7% and 19%1 and the prevalence of asymptomatic gonococcal infection in this population is around 10%.2 Despite this high prevalence of gonococcal infection in homosexuals with HIV infection, there have been few reports of gonococcal urethritis. We present a new case and review those published until now.

Case Report

The patient was a 65-year-old homosexual man with a 16-year history of HIV infection. He was undergoing regular follow-up and was receiving retroviral therapy with tenofovir, emtricitabine and neviirapine. He had a good adherence and tolerance and good immunovirological control (HIV viral load <20copies/mL and CD4+ lymphocytes at 870cells/μL). He presented with pain and inflammation of the left knee, which exhibited functional weakness, with no fever or other symptoms. On the physical examination, he reported pain on the mobilization of the knee, where there was a discreet effusion. The laboratory tests showed leukocytosis with 14,200cells/mL, 77% neutrophils, and C-reactive protein was 279mg/L. Magnetic resonance imaging showed joint effusion and synovitis with synovial thickening, especially in the suprapatellar synovial bursa. Arthrocentesis yielded a cloudy fluid with 24,000leukocytes/mL, predominantly polymorphonuclear, glucose level of 2mg/dL and proteins, 5.7g/dL. The culture produced Neisseria gonorrhoeae, which is sensitive to 3rd-generation cephalosporins and resistant to ciprofloxacin. The patient was treated with intramuscular ceftriaxone at 1g daily for 1 week, and his symptoms slowly resolved. The blood culture performed prior to the antibiotic therapy was negative. Three months before, he had been diagnosed as having early latent syphilis, which was treated with a dose of benzathine penicillin.

Discussion

Gonococcal arthritis is generally produced by hematogenous dissemination of N. gonorrhoeae, although this bacterium is uncommon in patients with urethritis.3 The prevalence is estimated to be 0.5%–3%.3 In the general population, the disseminated infection predominates in women and both men and women very often have an asymptomatic infection of the mucosa.3 In the series of cases of gonococcal arthritis and HIV infection published to date4–15 (Table 1), blood cultures were positive in only 1 of the 7 cases in which they were performed and only 1 patient had urethritis. It is striking that the 65-year-old patient who we present here was the oldest of those reported. There is male predominance because HIV infection, except in Africa, mostly affects men. Four individuals had skin involvement, and asymptomatic mucosal infection was detected in 3 of the 7 patients in whom urethral, pharyngeal, rectal or cervicovaginal specimens were taken. Although the immunosuppression associated with HIV has been proposed to favor the development of disseminated gonococcal infection,7,8 most of the patients with HIV infection and gonococcal arthritis had a good immunological status.

Table 1.

Published Cases of Gonococcal Arthritis in Patients With Human Immunodeficiency Virus.

Ref.  Country  Sex  Age (years)  Site  Skin  BC/joint fluid culture  Urethritis  Mucosa  CD4+ (cells/μL)  Treatment  Response 
11  UK  25  Shoulder  No  ND/positive  No  U, P, R negative  114  Penicillin  Yes 
        MTS            Ampicillin   
                    Erythromycin   
12  USA  27  Thigh  No  Negative/positive  No  U, P, R negative  –  Cephalosporin  Yes 
        SC            Amoxicillin   
5  USA  35  Wrist  Yes  Positive/ND    ND  380  Ceftriaxone  Yes 
        Ankle               
13  TH  40  Ankle  Yes  ND/positive  No  P positive  310  Ceftriaxone  Yes 
        Wrist        U, R, C negative       
        Elbow               
        Knee, foot               
8  SP    28  Knee    ND/positive           
9  SP                     
6  SP  37  Knee  No  ND/positive  No  228    Ceftriaxone  Yes 
                    Cefuroxime   
10  USA                     
7  RW  29  Knee    Negative/negative  Yes      Ofloxacin  Yes 
        Knee               
  RW  26  Knee    Negative/positive  No      Norfloxacin  Yes 
  RW  20  Knee    Negative/positive  No      Ofloxacin  Yes 
  RW    Knees    Negative/negative    C, V positive    Ofloxacin  Yes 
14  USA  47  Shoulders  No  ND/positive  No  Negative in both  329  Cefotaxime  Yes 
                    Doxycycline   
15  FR      Yes    No         
  FR      Yes    No         
4  SA  27  Wrist  Yes  ND/positive  No  U, P negative  86  Ceftriaxone  Yes 
        Elbow               
        Knee               
        Ankle               
  SA  24  Wrists  No  ND  No  P positive  680  Ceftriaxone  Yes 
Case reported here  SP  65  Knee  No  Negative/positive  No    870  Ceftriaxone  Yes 

BC, blood culture; C, cervix; FR, France; M, man; MTS, metatarsus; ND, not done; P, pharynx; R, rectum; RW, Rwanda; SA, South Africa; SC, sternoclavicular; SP, Spain; TH, Thai; U, urethra; UK, United Kingdom; USA, United States; V, vagina; W, woman.

The diagnosis of gonococcal arthritis requires a high index of suspicion and, aside from blood culture and joint fluid culture, it is necessary to take urethral, pharyngeal, rectal and cervical specimens, as well as from possible skin lesions; the treatment of choice is based on 3rd-generation cephalosporins. An emerging problem is an increase in the decline in susceptibility and resistance to ceftriaxone.3

Conclusions

Despite the high prevalence of gonococcal infection among homosexuals with HIV infection, gonococcal arthritis is uncommon. There must be a high index of suspicion and include it in the differential diagnosis of acute arthritis in patients with HIV infection, especially in those at risk for sexually transmitted infections.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of Interest

The authors declare they have no conflicts of interest.

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Please cite this article as: Sena Corrales G, Mora Navas L, Palacios Muñoz R, García López V, Márquez Solero M, Santos González J. Artritis gonocócica en pacientes con infección por el virus de la inmunodeficiencia humana. Revisión de la literatura. Reumatol Clín. 2017;13:39–41.


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Reumatol Clin 2017;13:39-41 - Vol. 13 Num.1 DOI: 10.1016/j.reumae.2016.11.001