Vol. 6 Issue 25
Knee Pain = STD?
Unilateral knee pain results in diagnosis of gonococcal arthritis
A 44-year-old male has been experiencing swelling and pain in his left knee leading to problems with ambulation for the past 4 days. He has been walking with crutches for 2 days and describes his knee pain as a 10 on a 1-10 scale or as a "continuous dull ache." He has had occasional left foot pain that is diffuse for the past 3 days; and a day after pain onset in the left knee, he developed pain in the right knee, although not as severe.
He denied any injury to his knee or aggravating factors. He admitted to low-grade temperatures up to 99.5¡ F orally in the evenings. He has missed the past 4 days of work due to the increasing pain in his knee and a general feeling of fatigue. He uses a heating pad and an ice pack, alternating them to help relieve the pain.
Additionally, he complained he is unable to sleep due to the severity of the knee pain. He also said his knee has become more swollen and reddened in the past day or so. His prior medical history is unremarkable to his current symptoms. He has no allergies and has been using ibuprofen every 4-6 hours with no relief of pain.
The patient lives alone and has been divorced for several years. He has two grown children living out of state. He works as a machinist at a local factory. He doesn't smoke, drink alcohol, use tobacco products or use illegal drugs. He does report working sometimes 12-15 hours a day, 5 days a week on a regular basis.
He admitted he doesn't have time for dating at this point in his life. His mother and his grown children as well as his co-workers have been his social support systems. He also regularly attends church and visits his children. He eats a healthy diet and usually has no problems sleeping. He was exercising on his treadmill in the mornings 3-4 times a week before his knee became problematic. He has no family history of gout or rheumatoid arthritis.
He answered negatively to these additional questions: Is the pain worse during certain times of the day? Is there any crepitus or swelling in other joints? Is there always pain with the edema? Is the joint always hot and edematous? Has he traveled recently to tick-infested areas? Has he noticed any joint stiffness or nodules over any of his other joints? Has he noticed urinary discharge, burning or frequency?
We discussed urinary function as well as his sexual activity, hoping it may give us further clues to diagnosis.1 He reported that he currently does not have a partner and is heterosexual. He denied ever contracting an STD and denied any past or present sexual practices placing him at risk for an STD. In reviewing his urinary habits, he denied the use of caffeine, urination frequency and burning, bladder spasms, incontinence and penile discharge.
The patient was new to our practice and seemed uneasy about answering questions regarding his sexual practices. Our male physician asked to see him privately. After repeatedly explaining how important it was for us to know about STDs and his risk factors for these conditions, the physician received the same responses.
His physical exam was unremarkable with the exceptions of a temperature of 99.6º F and his left knee being hot and edematous with crepitus and a large joint effusion. He displayed guarding upon palpation, was unable to effectively exhibit range of motion exercises, was unable to walk on the extremity without aid of crutches and had no pedal edema. All pulses were present and he was able to plantarflex and dorsiflex bilateral feet.
Homan's sign on both left and right were negative. No muscle flaccidity, subluxation or spasticity were seen in this left extremity. He had negative findings of tophi or joint nodules in all bilateral extremities. Lachman's, Ober's and McMurray's tests were all deferred. The use of these tests would have been beneficial if there were a history of an injury. Further, pain prevented the tests from being performed.2
Preliminary lab work was unremarkable with the exception of an elevated sedimentation rate of 61. He refused an MRI, X-rays and an STD culture, fearing his insurance would not cover these tests.
Differential diagnosis included gout, due to the quick onset, fever and presenting symptoms of joint edema, crepitus, effusion, severe pain and heat, although there is no evidence of tophi, back pain or nausea that usually accompanies chronic gout.1 Blood work for gout also was negative. Rheumatoid arthritis was another consideration, although the history the patient provided did not indicate gonococcal arthritis.3
Epstein Barr-induced arthritis was something to rule out as well, but the patient had no history of recent streptococcal infection. Tick-borne illness (arthritis) was not a consideration due to the lack of spending time in an endemic area.4
As he refused to have a joint aspiration for culture, the plan was to treat the patient as if he had gout. He was treated immediately with colchicine 0.6 mg every hour while awake and Indocin® (indomethacin) 75 mg twice daily with instructions to return if there is no improvement in 24 hours.5
He returned with no change in his symptoms and we again asked him about his sexual practices. He was more forthcoming and admitted that he had unprotected sex with a woman one time. He denied seeing the woman since. He explained he was embarrassed to mention it as he had never had an experience like this before. He said he was in denial and did not want to accept that unprotected sex could cause problems with his knee or joints, despite all the risks we had explained to him the day before. He also said he had just started having a penile discharge that morning, leading him to realize he needed to be honest about his sexual history.
Joint aspiration of his left knee tested positive for Neisseria gonorrhoeae culture and, along with the urethral drainage and burning, confirmed a diagnosis of gonococcal arthritis. Another classic rationale for this condition was the unilateral knee pain and edema at the onset that spread to his right knee within a day, although the pain was not as severe as the left knee at that point.
Management of Gonococcal Arthritis
Management for his gonococcal arthritis and Reiter's syndrome, which usually occur together rather than as separate entities, was injections of Rocephin® (ceftriaxone) 1 g daily for 10 days and Cipro® XR (ciprofloxacin) 500 mg bid for 14 days.6
Positive results were seen within 2 days. Within 3 weeks, he was able to return to work and perform the majority of his activities of daily living with no problems. He was instructed to call if he noticed any returning symptoms, and was instructed to return to the office in 2 weeks for a follow-up.
We kept a close follow-up on this patient and the treatment plan worked remarkably as he was very compliant.
This is a difficult case to manage as it requires multiple treatments and proper patient compliance. One of the main points to learn from this case is the patient must be made to feel as comfortable as possible when discussing sexual issues. Our goal should always be to provide quality care but also make the patient comfortable.
In this patient's scenario he was not ready to admit his sexual history, yet omitting this history could have caused severe consequences to his health.
1. Uphold, C., & Graham, M. (2003). Clinical guidelines in family practice. Gainesville, FL: Barramae Books.
2. Clarke, J. (2001). Organize the approach to musculoskeletal misuse syndrome. The Nurse Practitioner: The American Journal of Primary Health Care, 26(7), 11-27.
3. Cassidy, J., & Petty, R. (2001). Textbook of pediatric rheumatology. Philadelphia: W.B. Saunders.
4. Fell, E. (2000). An update on Lyme disease and other tick-borne illnesses. The Nurse Practitioner: The American Journal of Primary Health Care, 25(10), 38-51.
5. Crawther, C. (2003). Primary orthopedic care. St. Louis: Mosby.
6. Gilbert, D., Moellering, R. & Sande, M. (2003). The Sanford guide to antimicrobial therapy. Hyde Park, VT: Sanford Publishing.
Natalie Tesso Simmermacher is a nationally certified wound ostomy and continence advanced nurse specialist, professional speaker and author who works independently in various practice settings as a specialty nurse clinician.