This week in Morning Report we discussed an approach and differential diagnosis for tenosynovitis. We then discussed an approach to one of the diagnoses on the differential, disseminated gonococcal infection. See below for a summary of Morning Report:
1. Approach to Tenosynovitis
- Infectious causes (secondary to trauma or hematogenous spread)
- Pathogens include bacterial causes (Staphylococcus aureus, Streptococcus, Pasteurella multocida (after a cat bite), Mycobacterium, Neisseria gonorrhoeae (part of disseminated gonococcal infection)
- Connective tissue disease – related to seropositive arthropathy such as rheumatoid arthritis or systemic lupus erythematosus, scleroderma
- Sarcoidosis
- Diabetes mellitus
- Related to trauma or overuse such as de Quervian’s tenodinopathy which affects the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first extensor compartment at the styloid process of the radius; characterized by pain or tenderness at the radial side of the wrist
- Crystalline deposition disease
- Psoriatic arthritis (seronegative arthropathy)
- Amyloidosis
- Consider drug side effect (tendonitis or tendinopathy) from fluoroquinolone
We discussed the triad of disseminated gonococcal infection (DGI) which includes: tenosynovitis, dermatitis, and arthralgias. There can be other systemic manifestations of DGI which would include endocarditis or meningitis.
2. Gonorrheal Infections
In terms of gonorrheal infections, the incubation period is 2-7 days. Rectal and pharyngeal infections are more likely to be asymptomatic than urethral infections.
In males, 10% of cases are asymptomatic. If symptomatic, symptoms can include urethritis, purulent urethral discharge, pyuria, dysuria, urethral pruritis, and epdidymitis. In females, 50% of cases are asymptomatic. If symptomatic, this includes purulent endocervical discharge, pyuria, dysuria, pelvic pain, vaginal bleeding, bartholinitis, perihepatitis, and urethral infection.
In both males and females, symptoms can include disseminated gonococcal infection, pharyngeal infection, conjunctivitis, and proctitis. Sequelae can include pelvis inflammatory disease (PID), ectopic pregnancy, Fitz-Hugh-Curtis syndrome, reactive arthritis, and meningitis, among others.
In disseminated gonococcal infection, the rash described looks as follows:
3. Investigations and Treatment
- Urine NAAT most sensitive and specific for detecting N. gonorrhoeae
- Culture is strongly recommended to provide antimicrobial susceptibility information
- Cultures that are obtained within 48 hours after exposure may give a false negative result
- One should obtain culture/swab from any suspected site of infection (blood cultures, fluid culture if concerned about septic arthritis/joint, pharyngeal swab, rectal swabs)
- Due to high rates of co-infection, testing should be done for both gonorrhea and chlamydia
Treatment
- In terms of localized anogenital infection, treatment for gonorrhea includes:
- Ceftriaxone 250 mg IM x 1 AND Azithromycin 1 g PO x 1
- Azithromycin is added both to cover undiagnosed chlamydia AND to ensure treatment for gonorrhea is completed
- Ceftriaxone 250 mg IM x 1 AND Azithromycin 1 g PO x 1
- See table below for disseminated infections in adults and youth age >= 9 years
| Infection | Initial therapy while awaiting consultation with specialist |
| Arthritis | Ceftriaxone 2 g IV/IM daily x 7 days Plus azithromycin 1 g po x 1 |
| Meningitis | Ceftriaxone 2 g IV/IM daily x 10-14 days Plus azithromycin 1 g po x 1 |
| Endocarditis | Ceftriaxone 2 g IV/IM daily x 28 days Plus azithromycin 1 g po x 1 |
| Ophthalmia | Ceftriaxone 2 g IV/IM daily x single dose Plus azithromycin 1 g po x 1 |
See references below for alternative options if drug allergies/contraindications.
All cases should be discussed with an infectious diseases expert.
4. Follow Up and Test of Cure
- Test of cure should be done for ALL gonococcal infections (due to increasing resistance), especially if treatment failure, suspect drug resistance, suboptimal compliance, unresolved symptoms, alternative therapy used, pregnancy or pre-puberty, or pharyngeal infection
- Health care practitioners should instruct patients to refer partners with whom they have had sexual contact in the past 60 days for evaluation, testing, and presumptive treatment for gonorrhoeae without waiting for test results
- Positive gonorrhea results should be reported to local public health
- Obtain cultures for test of cure (TOC) three to seven days after treatment is complete
- If culture is not available and NAAT is used as a test of cure, it should be performed two to three weeks after completion of treatment.
- Repeat screening is recommended six months post-treatment for all people with N. gonorrhoeae infection.
5. Treatment Failure
Treatment failure is defined as one of these three entities:
- Positive Gram Stain > 72 hours after treatment
- Positive culture > 72 hours after treatment
- Positive NAAT 2-3 weeks after treatment
If treatment failure is identified in cases of cephalosporin combination therapies, local public health should be notified.
6. References
- https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/gonorrhea.html
- https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections/canadian-guidelines-sexually-transmitted-infections-34.html#toc361210442
- Singh, A. P. (Date Unknown). Tenosynovitis Causes, Symptoms, and Treatment. Accessed at https://boneandspine.com/tenosynovitis-causes-symptoms-treatment/ Accessed on December 24, 2021.
- Newman, C. R., Joshi, K., Brucks, E., & Ferreira, J. P. (2021). Disseminated Gonococcal Infection in an Immunosuppressed Patient. The American journal of medicine, 134(2), e123–e124. https://doi.org/10.1016/j.amjmed.2020.06.048
Please do not hesitate to reach out if you have any questions or comments, to cmr@wchospital.ca! 🙂