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Primary meningococcal polyarthritis
Journal of Infection (I986) x3, 281-283
CASE REPORT Primary meningococcal polyarthritis C. Salmeron*, M. MartyT, H. Richet*, M. C. Escande*, F. Besancont and H. P. H. Lagrange* * Laboratoire Central de Microbiologie and t Service de M~decine Interne et Gastro-ent~rologie, HOpital HOtel Dieu, I, Place du Parvis Notre Dame, 75181 Paris Cedex 04 - France Accepted for publication
II
April I986
Summary We report a case of primary meningococcal polyarthritis simulating bacteraemic gonococcal infection. The clinical similarity between extragenital gonococcal and meningococcal infections is well illustrated. If the clinical features of meningococcal and gonococcal infections are usually different, they may sometimes be indistinguishable. Both gonococcal pharyngitis l, 2 and meningococcal urethritis 3 have been recorded. The onset of acute polyarthritis, fever and skin lesions is typical of gonococcal infection but these clinical features may also indicate infection due to Neisseria meningitidis. In the case we report, the correct diagnosis ofmeningococcal arthritis was established only after N. meningitidis group C had been identified in synovial fluid from the knee.
Case Report A 4o-year-old m a n was admitted to hospital because of fever and polyarthritis. At the age of I8 years he had had recurrent throat infections which led to tonsillectomy. W h e n he was 3o years o f age he had suffered from gonococcal urethritis. After that, he was well until 15 days before admission to hospital, w h e n he d e v e l o p e d a mild sore throat which resolved w i t h o u t antibiotics. T h e day before admission he suddenly developed fever, chills, myalgia and headache. W i t h i n I2 h his condition deteriorated with nausea, vomiting, diarrhoea and arthalgia all of which led to his admission to the e m e r g e n c y w a r d at the H 6 t e l - D i e u hospital. Physical examination revealed an e r y t h e m a t o u s m a c u l o - p a p u l a r skin rash, w i t h o u t any petechial or necrotic lesions, on the chest and arms as well as polyarthritis involving the knees and ankles. T h e r e was tenderness with swelling and redness of these joints. Fluid was f o u n d in b o t h knees. T h e rectal t e m p e r a t u r e was 4o °C and blood pressure was I2O/8O m m H g . T h e r e were no signs o f meningitis and otherwise physical examination was unremarkable. In particular, the external genitalia, the rectum, the prostate and p h a r y n x were normal. O n the second day after admission, the left wrist b e c a m e painful and swollen and a pustular lesion a p p e a r e d on the patient's left t h u m b . O n the third day, the rash disappeared. Haematological, biochemical and bacteriological tests gave the following results: white blood cell count I2"3 x io9/1 with 95 % neutrophils, h a e m o g l o b i n I3 g / d l , platelet c o u n t 6oo x io9/1. Results of coagulation tests were normal. oi63-4453/86/o6o281 "~03 $02.00/0
~) I986 The British Society for the Study of Infection
282
C. S A L M E R O N E T A L .
T h e erythrocyte sedimentation rate was i25 m m / h . T h e r e was proteinuria 2 g / d a y without haematuria or pyuria. Urea nitrogen concentration was 5"9 mmol/1, creatinine Ioo #mol/1, glucose 6.I mmol/1, calcium 2"5 mmol/1, phosphorus I "5 mmol/1 and serum protein 6o g/1, all of which were normal. R h e u m a t o i d factor, circulating i m m u n e complexes and antinuclear antibodies were not detected. Serum c o m p l e m e n t (CHs0) and antistreptolysin titres were normal. Serological studies for salmonellosis, brucellosis, leptospirosis and hepatitis B were all negative as was the T P H A test. X-rays of the chest, knees and ankles were normal. Repeated blood cultures were all negative having been systemically subcultured on 'chocolate' agar and incubated in an atmosphere of carbon dioxide. Arthrocentesis was performed on the left knee. T h e synovial fluid contained 34 g/1 protein. A Gram-stained smear showed many neutrophils and Gramnegative intra- and extra-cellular diplococci. T h e throat culture was negative. A urethral culture was not performed. Following these results, we suspected gonococcal polyarthritis and started intravenous (IV) benzyl-penicillin therapy (I6.6 g per day) together with indomethacin. T h e joints were immobilised. T w o days later the patient still had fever, without any i m p r o v e m e n t of his joints. T h i s led to substitution of penicillin by cefotaxime (4g IV per day) in the belief that the Gram-negative diplococci might be a beta-lactamase producing strain of Neisseria gonorrhoeae. On the 5th day after admission the synovial cultures yielded N. meningitidis group C. Fever subsided on the sixth day and tenderness of the joints disappeared within a week. T h e patient was kept on the same treatment for 4 weeks and was discharged symptom-free a m o n t h after admission. Neisseria meningitidis was identified according to the following data: Gram-negative diplococcus, oxidase positive, grown o n ' chocolate' agar incubated in an atmosphere of Io % carbon dioxide and giving transparent n o n - p i g m e n t e d colonies. Acid was produced from glucose and maltose but not from sucrose or lactose. Indole and hydrogen sulphide were not formed. T h e antigenic structure was determined by seroagglutination. All these features were confirmed by Dr J. Y. Riou (Neisseria Laboratory, Institut Pasteur, Paris). Discussion
T h e patient was a previously healthy m a n who developed primary acute polyarthritis due to N. meningitidis without signs of meningitis or detectable meningococci in sthe blood. Although arthritis has been observed in approximately 7 % of meningococcal infections% primary meningococcal arthritis is rare, less than 3o cases having been reported. T h e articular manifestations of the disease have some characteristics which may help in making an early diagnosis. In 50 % of cases, meningococcal arthritis is preceded by an infection of the u p p e r respiratory tract. Often (3o % of cases) it is associated with a skin rash and in 70 % of reports the arthritis involves only-one joint, usually one of the large joints such as the knee (6o % of cases). Meningococci of any one of the serological groups are isolated from synovial fluid in 8o-9o °/o of cases. Since similar clinical features are observed in the gonococcal arthritis-dermatitis syndrome 5, this is probably the first diagnosis to consider in terms of
Primary Meningococcal Polyarthritis
283
f r e q u e n c y because absence o f u r e t h r i t i s does n o t exclude N . gonorhoaeae as the causal agent. Identification o f N . meningitidis is essential for c o r r e c t diagnosis. W h i c h e v e r is the or ga ni s m , the first line o f t r e a t m e n t shoul d be penicillin t h e r a p y . S o m e a u t h o r s have r e c o m m e n d e d p r o l o n g e d t r e a t m e n t w h e n arthritis is d u e to N . meningitidis 6. (The authors thank MC Chantoiseau for secretarial assistance.) References
I. Fiumara NJ. Pharyngeal infections with Neisseria gonorrhoeae. Sex Transm Dis 1979; 6: 264-266. 2. Tice AW, Rodriguez VL. Pharyngeal Neisseriagonorrhoeae. JAMA 1981; 246:2717-2719. 3- Kanolus JJ, et al. Urethritis caused by Neisseria meningitidis. J Clin Microbiol 198o; 12: 284-285
.
4. Schaad UB. Arthritis in disease due to Neisseria meningitidis. Rev Infect Dis 198o; 2 : 88o-888. 5. Ducan WC. Gonorrhea I983, Dermatol Clin 1983. x: 43-516. Byeff PP, Suskiewicz L. Meningococcal arthritis. JAMA 1976; 235: 2752.
CASE REPORT Primary meningococcal polyarthritis C. Salmeron*, M. MartyT, H. Richet*, M. C. Escande*, F. Besancont and H. P. H. Lagrange* * Laboratoire Central de Microbiologie and t Service de M~decine Interne et Gastro-ent~rologie, HOpital HOtel Dieu, I, Place du Parvis Notre Dame, 75181 Paris Cedex 04 - France Accepted for publication
II
April I986
Summary We report a case of primary meningococcal polyarthritis simulating bacteraemic gonococcal infection. The clinical similarity between extragenital gonococcal and meningococcal infections is well illustrated. If the clinical features of meningococcal and gonococcal infections are usually different, they may sometimes be indistinguishable. Both gonococcal pharyngitis l, 2 and meningococcal urethritis 3 have been recorded. The onset of acute polyarthritis, fever and skin lesions is typical of gonococcal infection but these clinical features may also indicate infection due to Neisseria meningitidis. In the case we report, the correct diagnosis ofmeningococcal arthritis was established only after N. meningitidis group C had been identified in synovial fluid from the knee.
Case Report A 4o-year-old m a n was admitted to hospital because of fever and polyarthritis. At the age of I8 years he had had recurrent throat infections which led to tonsillectomy. W h e n he was 3o years o f age he had suffered from gonococcal urethritis. After that, he was well until 15 days before admission to hospital, w h e n he d e v e l o p e d a mild sore throat which resolved w i t h o u t antibiotics. T h e day before admission he suddenly developed fever, chills, myalgia and headache. W i t h i n I2 h his condition deteriorated with nausea, vomiting, diarrhoea and arthalgia all of which led to his admission to the e m e r g e n c y w a r d at the H 6 t e l - D i e u hospital. Physical examination revealed an e r y t h e m a t o u s m a c u l o - p a p u l a r skin rash, w i t h o u t any petechial or necrotic lesions, on the chest and arms as well as polyarthritis involving the knees and ankles. T h e r e was tenderness with swelling and redness of these joints. Fluid was f o u n d in b o t h knees. T h e rectal t e m p e r a t u r e was 4o °C and blood pressure was I2O/8O m m H g . T h e r e were no signs o f meningitis and otherwise physical examination was unremarkable. In particular, the external genitalia, the rectum, the prostate and p h a r y n x were normal. O n the second day after admission, the left wrist b e c a m e painful and swollen and a pustular lesion a p p e a r e d on the patient's left t h u m b . O n the third day, the rash disappeared. Haematological, biochemical and bacteriological tests gave the following results: white blood cell count I2"3 x io9/1 with 95 % neutrophils, h a e m o g l o b i n I3 g / d l , platelet c o u n t 6oo x io9/1. Results of coagulation tests were normal. oi63-4453/86/o6o281 "~03 $02.00/0
~) I986 The British Society for the Study of Infection
282
C. S A L M E R O N E T A L .
T h e erythrocyte sedimentation rate was i25 m m / h . T h e r e was proteinuria 2 g / d a y without haematuria or pyuria. Urea nitrogen concentration was 5"9 mmol/1, creatinine Ioo #mol/1, glucose 6.I mmol/1, calcium 2"5 mmol/1, phosphorus I "5 mmol/1 and serum protein 6o g/1, all of which were normal. R h e u m a t o i d factor, circulating i m m u n e complexes and antinuclear antibodies were not detected. Serum c o m p l e m e n t (CHs0) and antistreptolysin titres were normal. Serological studies for salmonellosis, brucellosis, leptospirosis and hepatitis B were all negative as was the T P H A test. X-rays of the chest, knees and ankles were normal. Repeated blood cultures were all negative having been systemically subcultured on 'chocolate' agar and incubated in an atmosphere of carbon dioxide. Arthrocentesis was performed on the left knee. T h e synovial fluid contained 34 g/1 protein. A Gram-stained smear showed many neutrophils and Gramnegative intra- and extra-cellular diplococci. T h e throat culture was negative. A urethral culture was not performed. Following these results, we suspected gonococcal polyarthritis and started intravenous (IV) benzyl-penicillin therapy (I6.6 g per day) together with indomethacin. T h e joints were immobilised. T w o days later the patient still had fever, without any i m p r o v e m e n t of his joints. T h i s led to substitution of penicillin by cefotaxime (4g IV per day) in the belief that the Gram-negative diplococci might be a beta-lactamase producing strain of Neisseria gonorrhoeae. On the 5th day after admission the synovial cultures yielded N. meningitidis group C. Fever subsided on the sixth day and tenderness of the joints disappeared within a week. T h e patient was kept on the same treatment for 4 weeks and was discharged symptom-free a m o n t h after admission. Neisseria meningitidis was identified according to the following data: Gram-negative diplococcus, oxidase positive, grown o n ' chocolate' agar incubated in an atmosphere of Io % carbon dioxide and giving transparent n o n - p i g m e n t e d colonies. Acid was produced from glucose and maltose but not from sucrose or lactose. Indole and hydrogen sulphide were not formed. T h e antigenic structure was determined by seroagglutination. All these features were confirmed by Dr J. Y. Riou (Neisseria Laboratory, Institut Pasteur, Paris). Discussion
T h e patient was a previously healthy m a n who developed primary acute polyarthritis due to N. meningitidis without signs of meningitis or detectable meningococci in sthe blood. Although arthritis has been observed in approximately 7 % of meningococcal infections% primary meningococcal arthritis is rare, less than 3o cases having been reported. T h e articular manifestations of the disease have some characteristics which may help in making an early diagnosis. In 50 % of cases, meningococcal arthritis is preceded by an infection of the u p p e r respiratory tract. Often (3o % of cases) it is associated with a skin rash and in 70 % of reports the arthritis involves only-one joint, usually one of the large joints such as the knee (6o % of cases). Meningococci of any one of the serological groups are isolated from synovial fluid in 8o-9o °/o of cases. Since similar clinical features are observed in the gonococcal arthritis-dermatitis syndrome 5, this is probably the first diagnosis to consider in terms of
Primary Meningococcal Polyarthritis
283
f r e q u e n c y because absence o f u r e t h r i t i s does n o t exclude N . gonorhoaeae as the causal agent. Identification o f N . meningitidis is essential for c o r r e c t diagnosis. W h i c h e v e r is the or ga ni s m , the first line o f t r e a t m e n t shoul d be penicillin t h e r a p y . S o m e a u t h o r s have r e c o m m e n d e d p r o l o n g e d t r e a t m e n t w h e n arthritis is d u e to N . meningitidis 6. (The authors thank MC Chantoiseau for secretarial assistance.) References
I. Fiumara NJ. Pharyngeal infections with Neisseria gonorrhoeae. Sex Transm Dis 1979; 6: 264-266. 2. Tice AW, Rodriguez VL. Pharyngeal Neisseriagonorrhoeae. JAMA 1981; 246:2717-2719. 3- Kanolus JJ, et al. Urethritis caused by Neisseria meningitidis. J Clin Microbiol 198o; 12: 284-285
.
4. Schaad UB. Arthritis in disease due to Neisseria meningitidis. Rev Infect Dis 198o; 2 : 88o-888. 5. Ducan WC. Gonorrhea I983, Dermatol Clin 1983. x: 43-516. Byeff PP, Suskiewicz L. Meningococcal arthritis. JAMA 1976; 235: 2752.