Bacterial Arthritides

Gonococcal arthritis. Gonococcal infection is the leading cause of bacterial arthritis in adults. Patients typically present with polyarthritis, tenosynovitis, and dermatitis caused by the gramnegative diplococcus Neisseria gonorrhoeae or, rarely, Neisseria meningitidis.¹

Characteristics of the initial bacteremic phase include migratory polyarthritis; tenosynovitis; and maculopapular, vesicular, or pustular skin lesions usually located on the hands and feet. Because cultures of synovial fluid samples are often negative, the diagnosis of gonococcal arthritis often depends on the combination of this clinical presentation and a history of sexual activity.

Lyme disease. This disorder is caused by the spirochete Borrelia burgdorferi and is transmitted by a bite from an ixodid tick. Patients in the earliest phase of disease typically present with erythema chronicum migrans a few days to 1 month (average, 7 days) after being bitten by an infected tick. The rash originates at the bite site as an erythematous papule and slowly expands into an annular, sharply demarcated “bull's-eye” lesion (A). It is flat, warm, and no more than minimally tender. Lesions may show central clearing. Other secondary lesions that resemble erythema chronicum migrans may erupt anywhere on the body.

Even without antibiotic treatment, lesions tend to resolve in about 1 month. Nonetheless, recurrent crops of lesions may occur. It is important to recognize the sentinel rash because early treatment can prevent cardiac, joint, and neurologic complications of Lyme disease.

Acute rheumatic fever. This is a delayed nonsuppurative sequela of a pharyngeal infection with group A β-hemolytic streptococci. The disease may be classified according to the Jones criteria:

• Major manifestations: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.
• Minor manifestations: arthralgia (usually transient), fever, elevated levels of acute-phase reactants (erythrocyte sedimentation rate, C-reactive protein), prolonged P-R interval. These features must occur in the setting of a positive throat culture, rapid streptococcal antigen test, or elevated or rising streptococcal antibody titer.

Erythema marginatum usually occurs during the early phase of disease and accompanies carditis. It presents as evanescent, nonpruritic, pink or faint red papules and macules distributed on the trunk (B) and sometimes on the proximal parts of the limbs, but not on the face. The lesions extend centrifugally, but the centers return to normal. An individual lesion may appear and disappear in a matter of hours.

References:

REFERENCE:1. Watts RA, Scott DG. ABC of rheumatology: rashes and vasculitis. BMJ. 1995;310:1128-1132.