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Primary Meningococcal Arthritis J Am Board Fam Med: first published as 10.3122/jabfm.2008.01.060145 on 4 January 2008. Downloaded from BRIEF REPORT Primary Meningococcal Arthritis Marc I. Harwood, MD, Jason Womack, MD, and Rahul Kapur, MD Meningitis and the clinical syndrome of acute me- ities. She was promptly transferred to the hospital ningococcemia are well-described sequelae from with the diagnosis of septic arthritis. infections caused by Neisseria meningitidis. Within Orthopedic surgery consultation was obtained the realm of this syndrome, secondary sites of in- on arrival to the emergency department. Aspiration fection are not uncommon. There is a concomitant of the left knee yielded grossly purulent synovial septic arthritis in 11% of cases of meningococce- fluid. It was sent for evaluation by Gram stain, mia.1 We describe below the rare clinical scenario culture, cell count, and crystal analysis. Serum lab- of a 29-year-old woman with primary meningococ- oratory testing for C-reactive protein, complete cal arthritis without the clinical syndrome associ- blood cell count, and 2 sets of blood cultures was ated with meningococcemia. performed (see Table 1). The patient was started on Vancomycin 1 g intravenously every 12 hours Case Report for Gram-positive bacteria, given the initial gram A 29-year-old woman presented to the outpatient stain result. She was taken to the operating room office with a chief complaint of an acutely painful for urgent arthroscopic incision, drainage, and la- and swollen left knee. On awaking that morning, vage of the left knee. During transportation to the she noted a decreased ability to flex and extend her operating room, the patient developed pain in the left knee and extreme pain during ambulation. She left shoulder. Examination at that time revealed had no medical or surgical history and was not on decreased range of motion secondary to pain. Ar- any medications. When doctors inquired about sex- throcentesis of the left shoulder, while the patient ual contacts, she stated she had not been sexually was under anesthesia, yielded grossly purulent active in the past 3 months. Three weeks before, fluid. Open incision and drainage of the left shoul- she had a negative screening test for Neisseria gon- der was performed, followed by arthroscopic inci- orrhea and Chlamydia trachomatis during an annual sion and drainage of the left knee. gynecologic examination. She was afebrile and On postoperative day 1, blood cultures and sy- http://www.jabfm.org/ other vital signs were normal. She appeared to be novial fluid cultures collected from operative inter- well, but an erythematous, warm, swollen left knee vention revealed Gram-negative diplococci. Ceftri- that was diffusely tender to palpation was found. axone 1 g intravenously every 24 hours was Active and passive range of motion was severely initiated for presumed gonococcal arthritis. Soon limited secondary to pain. An erythematous, mac- thereafter, the organisms were identified as Neisse- ular rash was noted on the bilateral lower extrem- ria meningitides; vancomycin was discontinued. Two sets of blood cultures revealed N. meningitidis. on 1 October 2021 by guest. Protected copyright. The patient had fever of 102.9° F on postoperative This article was externally peer reviewed. day 2, but she remained stable and never showed Submitted 21 August 2006; revised 14 July 2007; accepted 25 July 2007. signs or symptoms of meningitis or the clinical From the Department of Family and Community Medi- syndrome of meningococcemia during her hospi- cine, Jefferson Medical College, Thomas Jefferson Univer- sity, Philadelphia, PA (MIH); Department of Family Med- talization. Physical and occupational therapy was icine, Robert Wood Johnson Medical School, University of initiated, with gradual improvement of the patient’s Medicine and Dentistry of New Jersey, New Brunswick (JW); and Department of Family Medicine and Community range of motion of both her knee and shoulder. Health, University of Pennsylvania, Philadelphia, PA (RK). The macular rash on her extremities faded gradu- Funding: none. Conflict of interest: none declared. ally throughout her hospital course. At discharge, a Corresponding author: Jason Womack, MD, Sports Medi- 14-day course of Ceftriaxone 1 g intravenously ev- cine Fellow, Department of Family Medicine, UMDNJ- Robert Wood Johnson Medical School, MEB 2nd Floor, ery 24 hours was completed. After a 1-week course New Brunswick, NJ 08901 (E-mail: [email protected]). of inpatient physical therapy, the patient began 66 JABFM January–February 2008 Vol. 21 No. 1 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2008.01.060145 on 4 January 2008. Downloaded from Table 1. Initial Laboratory Data lone resistance may play a role in the re-emergence 3 Test Results Normal of this infection. It is associated with rash, migra- tory polyarthritis, and tenosynovitis. Neisseria men- Na 129 mEq/L 135–146 mEq/L ingitis is a less common cause of septic arthritis, but K 3.2 mEq/L 3.5–5.0 mEq/L its predilection for causing oligoarticular arthritis Cl 97 mEq/L 98–109 mEq/L makes it difficult to separate it from disseminated CO 21 mEq/L 24–32 mEq/L 2 gonococcal infection.4 BUN mg/dL 12 mg/dL 7–21 mg/dL Cr 1.5 mg/dL 0.7–1.4 mg/dL Arthritic complications of meningococcal dis- Glucose 121 mg/dL 50–100 mg/dL ease are common. Approximately 2% to 10% of Ca 9 mg/dL 8.5–10.5 mg/dL cases of acute meningococcal infection are associ- WBC 20.1 ϫ 103/mm3 4–11 ϫ 103/mm3 ated with some form of rheumatologic presenta- HGB 14 g/dL 12.5–15.0 g/dL tion.1,5 The pathogenesis of these manifestations HCT 41.3% 36–46% occurs through a variety of mechanisms: direct he- ϫ 3 ϫ 3 Plt 265 10 /mL 140–400 10 /mL matogenous seeding of the synovium by circulating CRP 23.6 mg/L 0-.8 mg/L bacteria, causing a pyarthrosis; the formation of PT 15.8 sec 12.0–15.4 sec immune complexes, causing reactive arthritis; and PTT 35 sec 22–38 sec hemarthrosis secondary to coagulopathy are 3 ESR 31 mm/hr 0–20 mm/hr Synovial Fluid pathways for meningococcus to cause arthritic dis- 1,5,6 Gram Stain Gram ϩ dipplococci ease. A 1985 case report of 4 patients described 5 Crystals None these polyarthritic complications. WBC 166,000 Primary meningococcal arthritis (PMA) repre- Neutrophils 85% sents a rare form of meningococcal disease. Over- Lymphocytes 1% all, rheumatic presentations of meningoccocus are Monocytes 12% common, but primary meningococcal arthritis is rare outside of the clinical syndrome of acute me- Na, sodium; K, potassium; Cl, chloride; CO2, carbon dioxide; BUN, blood urea nitrogen; Cr, chromium; Ca, calcium; WBC, ningococcemia or meningitis.1 PMA is defined as white blood cell; HGB, hemoglobin; HCT, hematocrit; Plt, acute septic arthritis without meningitis or the clas- platelet; CRP, C-reactive protein; PT, prothrombin time; PTT, partial thromboplastin time; ESR, erythrocyte sedimentation sical syndrome of meningococcemia (defined as the rate. combination fever, rash, and hemodynamic insta- bility).7 Giamerellis-Bourbolis et al8 reported 34 total cases of PMA in the literature from 1980 to http://www.jabfm.org/ intense outpatient therapy. One month after dis- 2002. The authors identified 3 additional cases in charge the patient regained full range of motion of non-English language journals.9–11 her knee and shoulder without pain and was with- Septic arthritis is a medical emergency that out any sequelae. Close contacts with the patient needs prompt recognition and treatment to prevent were treated with 1 dose of ciprofloxacin 500 mg by local destruction of the joint and peripheral circu- mouth. lation of infection. Initial diagnosis of septic arthri- tis is often apparent. The patient will present with on 1 October 2021 by guest. Protected copyright. Discussion fever, rigors, and a warm, swollen, and painful 2 Bacterial arthritis has many causative organisms. joint. The knee is the most common joint in- 12 Staphylococcus aureus is the most likely causative volved. Further evaluation of septic arthritis in- agent, occurring in 44% of cases.2 Streptococcal cludes arthrocentesis of the affected joint, complete and other Staphylococcal species are the next most blood cell count, and peripheral blood cultures. likely organisms to cause septic arthritis.2 Gram- The synovial fluid should be cultured, Gram negative enteric species, such as Escherichia coli and stained, and analyzed for cell count to help with Pseudomonads, are much less common and affect initial management. The synovium is positive for neonates and people with immunodeficiencies. N. meningococcus in 90% of PMA cases; the blood gonorrhea is the most common cause in young cultures are positive in 40% of cases.13 This infor- adults.2 Despite a 64% decline of all gonococcal mation can help to differentiate bacteria that disease from 1985 to 1997, emerging fluoroquino- present similarly. doi: 10.3122/jabfm.2008.01.060145 Primary Meningococcal Arthritis 67 J Am Board Fam Med: first published as 10.3122/jabfm.2008.01.060145 on 4 January 2008. Downloaded from Schaad (n=25), 1980 ative coverage can be considered. Intravenous pen- Wells (n=23), 1997 icillin is the antibiotic of choice for PMA and other forms of meningococcal infection. In this patient, 100 90 ceftriaxone was initiated for presumed gonococcal 80 infection. Blood cultures revealed sensitivity to 70 60 ceftriaxone, and it was continued at a dose of 1 g 50 40 intravenously daily to complete a 14-day course. 30 Antibiotic therapy should be targeted toward the 20 10 offending organism when synovial cultures and/or 0 Male URI > 1 joint Maculo- Positive Positive blood cultures are available. preceding papular Synovial Blood Cx Removal of the infected synovial fluid from the arthrtis rash Fluid Cx joint cavity by either repeated daily arthrocentesis Figure 1.
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