Working Diagnosis:
Gonococcal Septic Monoarthritis of the Left Ankle

Treatment:
Patient underwent successful left ankle washout in the operating room with Orthopedics. He completed one week of intravenous Ceftriaxone as well as oral Doxycycline to treat known co-infection with Chlamydia.

Outcome:
Patient completed inpatient physical therapy and was discharged one week after surgery. Weight bearing was permitted as tolerated and he was cleared for light activity. At the three week clinic follow-up, he was cleared to return to football under close guidance of his athletic trainer, and returned to full play with no restrictions.

Author's Comments:
Gonorrhea is the second most common sexually transmitted infection in the United States (1). Half of new cases reported affect the 15- to 24-year-old demographic.2 Dissemination of infection beyond the primary site occurs in 0.5-3% of patients and typically presents as septic arthritis, polyarthritis, tenosynovitis, pustular rash, or bacteremia. In cases of gonococcal septic arthritis, a distal large joint such as the knee, ankle, elbow, or wrist is usually affected. Gonococcal septic arthritis can be difficult to diagnose because the affected population is often young, healthy, without stereotypical septic arthritis risk factors, and not systemically ill (3). It is even more difficult to diagnose in the athlete because of the many alternative and benign explanations for nonspecific joint pain in this population. Missed or delayed diagnosis risks permanent joint damage that can end a sports career. The use of musculoskeletal ultrasound is critical in the evaluation of any nonspecific joint complaint due to its ability to identify effusion. Arthrocentesis of any identified effusion should be performed to further evaluate for septic arthritis.
Suspected gonococcal septic arthritis should be evaluated with CBC, inflammatory markers, urinalysis, gonococcal antigen testing, X-ray, point-of-care ultrasound of the affected joint, and synovial fluid analysis. Once diagnosed, patients require orthopedic consultation for washout and hospital admission for intravenous antibiotics. Patients should be evaluated for coexisting sexually transmitted infection such as chlamydia, HIV, syphilis, hepatitis B, and HSV.3 All sexual partners within the last 60 days must be notified and treated prophylactically with a single dose of 500mg intramuscular Ceftriaxone (4).
Return-to-play for gonococcal septic arthritis has not been studied extensively. The patient in this case followed a typical post-joint surgery return-to-play sequence. He started with inpatient physical therapy and then was allowed to perform light activity. After tolerating light activity, he was permitted to return to sport under the close watch of his athletic trainer. Eventually he was given full return to play privileges.

Editor's Comments:
This is an informative case that identifies gonococcal septic arthritis as a less common source of ankle pain in an athlete. It highlights the importance of a good history and physical exam, but also creates awareness that the history taking may provide distractors (i.e., the patient denying sexual history). This case does a great job of identifying the appropriate workup, treatment, and proposed return to play protocol for a patient with ankle gonococcal septic arthritis.

References:
1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance. https://www.cdc.gov/std/statistics/2022/default.htm. Accessed 3/20/24.
2. Centers for Disease Control and Prevention. Gonorrhea Detailed Fact Sheet. https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea-detailed.htm. Accessed 3/20/24.
3. Li R, Hatcher JD. Gonococcal Arthritis. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470439
4. Centers for Disease Control and Prevention. Health Alert Template for Disseminated Gonococcal Infection. https://www.cdc.gov/std/program/outbreakresources/HANtemplate-dgi.htm. Accessed 3/20/24.

Return To The Case Studies List.