Maj. M. P. Vora, M.B.B.S., D.V.D.
Hon. Senior Venereologist,
St. George’s Hospital, Bombay.
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine & Surgery etc.
Volume No- LXXXVI, Number. 8 of August 1966
This article was solely contributed to Indian Medical Record
The gonococcal infection can cause diverse clinical manifestations depending on the locations in the body affected. Gonococcal arthritis constitutes the most common form of gonococcal infection. It develops secondary to the urogenital tract infection in about 5% cases of gonorrhoea, usually from 3 to 4 weeks after the initial infection. However, the infection of the joints may occur anytime subsequent to the primary gonococcal infection. It is more common in the male than in the female. It may follow ophthalmia neonatorum or vulvo-vaginitis in children. Chronic or complicated gonorrhoea often leads to either an acute or chronic gonococcal arthritis. An acute arthritis may pass on into subacute or chronic form. Though larger joints are more commonly affected, any joint may be involved. The knee joint is the most frequently affected; in order of frequency other joints which can be involved are:- ankle, wrist, elbow, small joints of hand and foot, sterno-clavicular, tempero-mandibular, sacro-iliac, hip and shoulder.
Clinically, gonococcal arthritis may be divided into two large groups:- (1) Acute and (2) subacute or chronic.
Acute arthritis - In general, acute arthritis occurs during the acute or subacute stages of gonorrhoea or an acute exacerbation on the top of chronic gonorrhoea. The onset is sudden with immense pain and moderate degree of fever usually of intermittent type. Although it is often mono-articular in nature, it can be polyarticular. The skin over the joint is red, hot and hyperaemic. The joint is swollen and tender. Pain is a prominent symptom. Synovial effusion is not uncommon. The total and differential W.B.C. count shows polymorphonuclear leucocytosis varying from 10 to 15 thousand per cmm. Since the ligaments, fasciae and tendon sheaths are often involved, peri-articular swelling is often detected. The fluid aspirated from the joint shows polymorphonuclear and gonococci either on staining the smears or on culture of the fluid. Suppuration is rare and surgical interference is seldom called for. Most cases respond to treatment and complete recovery is possible if proper treatment is instituted early. Attacks os arthritis vary in severity. When the attack is polyarticular, the inflammation spreads from joint to joint, and the first involved joint does not get better as the next becomes involved. There is rise in temperature. Administration of salicylates does not give ant relief. If neglected, extensive adhesions and distortions are not uncommon, crippling the person.
An acute gonococcal arthritis may take the form of (a) diffuse arthralgia in which there are no actual clinical signs of the joint involvement and pain tends to move from joint to joint. The skin over the joint is hyperaemic. (b) acute arthritis usually mono-articular involving a single large joint, severe pain and tenderness, red overlying skin, swelling of the joint, peri-articular thickening, fluid, in the joint, fever etc. are common. However, suppuration is rare. Occasionally, it may suppurate causing ankylosis. (c) acute polyarthritis where smaller joints of hand and foot are chiefly affected. There is pain on movement but no swelling of the joints. Suppuration is rare. In long-standing cases, fusiform swellings of the joints are seen.
Subacute or chronic gonococcal arthritis usually occurs in association with chronic or complicated gonorrhoea or so called gleet. It comes on insidiously and is often subjected to exacerbations which tend to subside in the course of time. The affected joint becomes stiff and tender. Pain is not severe. The body temperature may not show rise. Some wasting of the muscles of the joint is visible. Tenderness extends in the tissues beyond the joint. Periarticular thickening is present. Pain in the Tendo-achillis is the most common feature.
Subacute or chronic gonococcal arthritis may take the form of (a) hydrops articuli where a single large joint is usually affected, the knee-joint being the commonest. It is swollen and tender however, pain and redness are absent; the movements are limited. Periarticular thickening is obvious. (b) polyarticular involving number of smaller joints. There is sero-fibrinous exudate into the joints and a marked tendency to form adhesions and limit movements. Ankylosis or immobilization is common.
Diagnosis - Arthritis occurs either in acute or chronic form due to different aetiologic agents. A critical point to determine is to find out and confirm scientifically its aetiology, before the institution of specific therapy. It is possible that gonococcal origin or aetiology may be overlooked in many cases of rheumatism especially in children and young adults, if the physician fails to maintain a high index of suspicion. The difficulty can be minimised if he remembers the importance of adequate inquiry about the recent attack of acute urethritis and the examination of the urogenital tract, in every case of arthritis.
The tests suggested for the diagnosis of gonococcal arthritis are:-
The other tests which have to be carried out are:-
Although no one test is applicable in all instances, the gonococcal aetiology can be established by demonstration of gonococci or its antibodies. However, the demonstration of gonococci may be difficult or unsuccessful, at times, even after repeated tests where penicillin or sulpha drugs have been used recently. Under such circumstances one has to depend on clinical and circumstantial evidence.
Differential diagnosis - The following types of arthritis need to be considered: - Syphilitic, suppurative, acute rheumatic, rheumatoid, osteoarthritic either hypertropic or degenerative infectious diseases, Reiter’s disease, dysgenic, gout etc.
Treatment : - In every case of gonococcal arthritis, treatment must be applied to the affected joint or joints and to the original focus of infection. However, it is often noticed, one regrets to say - that no attempt is made either to confirm the aetiologic agent to treat the primary focus of infection, the real culprit.
The treatment of the joint - The first consideration is to relieve the acute pain by giving absolute rest to the joint by means of a splint or sand bags. However, it is essential not to fix the affected joint any longer than is necessary; otherwise there will be danger of adhesions and subsequent limitation of movements. Various preparations are used locally. Daily application of glycerine-belladonna, ichthyol 10 to 20% glycerine or hot antiphlogestine may be prescribed. An ointment containing Acid salicylates grs 40 to an oz of Ung. Capsici BP. Is spread thinly on a piece of lint and applied to the joint daily for an hour. Ung. Hydrag Co. or Scott’s dressing is spread on the lint and applied to the joint for about 24 hours on alternate days. Besides, use of diathermy, infra-red or radiant heat to the affected joints is made. In addition, fever therapy has a definite though limited place in the treatment of arthritis. In some cases it brings about a rapid and complete cessation of symptoms. A course of T.A.B vaccine intravenously can be given. The first dose should be 25 million organisms. It is desirable to double the dose at each subsequent injection in order to obtain good reaction. The maximum benefit is obtained by the first 3 or 4 injections. This therapy must be used with caution in elderly patients. It is contraindicated in cardiac diseases and acute tuberculosis. Artificial fever produced by hot baths, high frequency diathermy current or electrically heated cabinets has been used successfully where these facilities are available. All these measures help to relieve pain and swelling, reduce inflammation and promote quick recovery. Once the pain has subsided it is necessary to introduce as early as possible, passive movements and then voluntary movement and massage. Rapid recovery and good function is the result.
Treatment of the primary focus of infection - In treating gonococcal arthritis, special care must be taken to eradicate all foci of gonococcal infection from the body. The prostate, Cowper’s gland, epididymis, urethra and vesicles in the male and the cervix, Bartholin’s glands, uterus and tubes in the female need to be attended carefully. In these cases, chemotherapy alone will not be effective unless it is accompanied by local therapeutic measures. The primary focus of infection must be located, its extend determined and dealt with methodically so as to procure permanent and lasting benefits.
An acute fresh gonococcal infection in the male needs at least 1.2 M.U. of aqueous procain penicillin. G or Sulphadiazine one gm, four or five times a day orally for five to six days. As a general rule, the amount of treatment of gonorrhoea in the female is double of that in the male. And the amount of treatment for chronic or complicated gonorrhoea is three times of what is considered adequate for an acute fresh infection. Accordingly, the male and the female will need at lest 3.6 and 6 to 7 M.U. of aqueous procain penicillin-G respectively, in addition to local and supportive therapy. In some cases, one may have to give an additional course of tetracycline 250mg, four times a day for 5 to 7 days. Local therapeutic measures consist of prostatic massage and urethral dilatations weekly, urethral irrigations and instillations in the male and daily application of 1-2% acraflavin or picric acid in glycerine to the cervix, electric cauterization and diathermy in the female. It is necessary that the chemotherapy and local therapy are pursued energetically till the last trace of infection is eradicated. The importance of adequate vitamin intake and balanced diet could not be minimised. Of late, judicious use of steroids such as prednisone, prednisolone, dexamethasone in acute arthritis, has considerably helped to cut short the course of illness.