A 32 year old white woman presents to the emergency departme

A 32 year old white woman presents to the emergency department with sudden onset of a painful right knee. The pain is associated with fever, chills and immobility of the knee. She is sexually active. A knee joint aspiration reveals the following:

Turbid, yellowish-red fluid. WBC=105,000 with N90 L10, Glucose=10 mg/dL, Protein=150 mg/dL.

You would give this patient:


1. A 10 day course of Doxycycline
2. A course of IV Ceftriaxone with an optional 10 day course of Doxycycline
3. A 10 day course of Bactrim
4. Oral NSAID's and a heating pack
5. Intraarticular steroid shot with p.o. steroids and or colchicine

ANS: course of IV Ceftriaxone with an optional 10 day course of Doxycycline

The patient described in the question has a good history for infectious monoarthritis. Analysis of the fluid is supportive with a large white cell count and a left shift. The gram stain fortunately gives us the diagnosis of Gonococcal arthritis as evidenced by the gram negative diplococci. By far the most common agent are gram positive aerobes (approximately 80%) with Staphylcoccus aureus accounting for 60%, non-group A �-hemolytic streptococci 15% and Streptococcus pneumoniae 3%. Gram negative bacteria account for 18% and anaerobes are increasingly frequent causes in IVDA and immunocompromised hosts. Gonococcal arthritis affects women 2-3 times often and is often preceeded by a migratory tendinitis or arthritis. Though usually chronic arthritides, tuberculosis, atypical mycobacterial, fungal, herpes and other viruses have been described in the literature as presenting acutely.

Doxycline is a good choice for associated Chlamydia infections. Given the single organism seen on the gram stain, one is obligated to treat with IV ceftriaxone. However, one could not fault some one for empirically treating for the often associated Chlamydia infection. One would need to do a pelvic exam and GC/Chlamydia probe to lend more support to just treating this patient with IV ceftriaxone. One could also use a fluoroquinolone to treat Neisseria. Bactrim has variably poor effective killing power against Neisseria and would not be a good choice. Though NSAID's, heating packs and steroids may help the inflammatory process these would not treat the underlying infectious cause and actually might masquerade ongoing joint cartilage damage.