Surgical Management of Gonococcal Septic Arthritis: A Case Series and Literature Review

Introduction: Purulent gonococcal septic arthritis (GSA) is a rare but clinically significant manifestation of disseminated gonococcal infection (DGI) with Neisseria gonorrhoeae (NG). Presenting distinctly from the arthritis-dermatitis syndrome associated with DGI, GSA poses a unique diagnostic challenge as it presents as monoarthritis or oligoarthritis without systemic features. Current guidelines do not distinguish between these presentations of gonococcal arthritis, and there are no existing recommendations on the surgical management of purulent GSA. Case Report: We present a single-institution case series of three patients aged 33-51 with five joints confirmed to have GSA by Biofire joint panel polymerase chain reaction (PCR) and were treated with surgical incision and drainage (I&D). In this case series, four of five joints yielded no growth with standard cultures methods, underscoring the diagnostic difficulty of isolating NG. One patient experienced deterioration of symptoms despite broad-spectrum antibiosis. Two patients received intravenous (IV) ceftriaxone for 14 days following I&D, and one received IV ceftriaxone while inpatient, followed by cefixime oral therapy for 21 days after discharge. All patients were co-managed with infectious disease and had clinical improvement with improved range of motion and downtrending inflammatory markers at follow-up. Conclusion: This case series supports the role of I&D in combination with parenteral antibiosis in treating purulent GSA. Molecular testing, such as Biofire joint panel PCR, is useful in detecting NG due to superior sensitivity in identifying the fastidious organism. Multicenter prospective trials are needed to establish evidence-based surgical guidelines and antibiotic management in the face of emerging resistance.