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Meningococcal arthritis. report of two cases

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Meningococcal Arthritis
Report of Two Cases
Harvey L. Eichner and John J. Deller, Jr
Two cases of meningococcal arthritis are reported, 1 a n acute septic arthritis
resembling gonococcal arthritis following a transient bacteremia; the other, a
delayed arthritis with painless knee effusions following resolution of meningitis.
Arthritis is an occasional manifestation of meningococcemia with or without
meningitis. It may occur as a polyarthritis without effusion during acute septicemia, or as a subacute arthritis with effusion involving one or a few larger joints
while the generalized infection subsides. The pathogenesis of these two varieties
of meningococcal arthritis may be different. In rare instances, an isolated septic
arthritis without typical meningococcemia is found.
T h e occurrence of arthritis in meningococcal septicemia and meningitis was described by physicians treating meningitis, a
newly recognized disease, in the early part
of the nineteenth century. Articular complications were recognized with increased frequency when meningitis reached epidemic
proportions.
This report concerns 2 patients treated
for meningococcal arthritis within a 6month period. The first is a typical form
of presentation-painless effusions following meningococcemia and meningitis. T h e
second case is a more unusual varietyFrom the Department of Medicine, Letterman
General Hospital, San Francisco, Calif.
HARVEY
L. EICHNER,MAJ, MC, USA: Box 89,
Letterman General Hospital, San Francisco, Calif
94129. JOHNJ. DELLER,
JR, LTC, MC, USA, FACP:
Letterman General Hospital.
Reprint requests should be addressed to Major
Eichner.
Submitted for publication Aug 25, 1969; accepted
Dec 30, 1969.
272
meningococcal arthritis presenting as an
acute, septic joint, mimicking gonococcal
arthritis without classical meningococcemia.
CASE REPORTS
Care 1. A 19-year-old basic trainee was hospitalized with a 2-day history of fever, chills,
myalgias, sore throat, cough and headache. Physical
examination, which revealed an acutely ill Negro
man with a temperature of 102" F, was otherwise
unremarkable. On the night of admission, the
patient became restless and disoriented. Examination revealed nuchal rigidity; a positive Brudzinski's
sign; and petechiae on the chest, back and arms.
WBC count was 11,3OO/cu mm, with a marked left
shift. Cerebrospinal fluid contained 2122 WBC/cu
mm, primarily polymorphonuclear cells; gramnegative extracellular diplococci could be seen on
smear. A throat culture grew normal flora, but
blood and spinal fluid cultures yielded Neisscria
meningitidis ( N meningitidis) , Group C. The
patient was treated with intravenous penicillin, 20
million units/day. Although his sensorium cleared
rapidly, fever to 102°F and lethargy continued for 8
days. Aching in the legs persisted. On the sixth day,
Arthritis and Rheumatism, Vol. 13, No. 3 (May-lune 1970)
MENINGOCOCCAL ARTHRITIS
effusion of both knees was noted, the right showing
a greater degree than the left, but without pain,
heat, or erythema.
The patient gave a history of bilateral knee
effusions which had occurred in adolescence but
had subsided spontaneously without recurrence.
Arthrocentesis of the right knee revealed 100 ml
cloudy yellow fluid with 52,400 WBC/cu mm,
predominantly lymphocytes: a culture of this fluid
was sterile. A low grade fever, 99-looo F, persisted
for 10 days, and the effusions failed to resolve with
bed rest. On Day 16 of hospitalization, a synovial
biopsy was performed on the right knee (Fig 1 ) .
Histopathologic diagnosis was nonspecific synovitis.
Arthrocentesis of the right knee on Day 20 revealed a fluid with 31,150 WBC/cu mm; cultures
of this fluid were negative. The knee effusions
resolved gradually with bed rest over the next 10
days, and the patient was discharged.
Case 2. A 17-year-old high school student was
well until 1 day before admission when she developed cramping epigastric pain accompanied by
anorexia, nausea, vomiting, fever, and, later in the
day, left-sided neck pain. By the following morning.
these symptoms had subsided, but the patient noted
that her left knee was painful and swollen. This
condition progressed through the day, and she was
seen in the hospital emergency mom. Examination
revealed an acutely ill Caucasian girl with a
temperature of 104OF. There was marked tenderness over the midtrapezius and ,the left posterior
cervical triangle, but no inflammation of the upper
respiratory tract, lymphadenopathy or nuchal rigidity. The left knee, which was warm, swollen,
exquisitely tender to touch or motion, was held
flexed at 15" angle. The remainder of the examination, including the pelvic examination, was normal.
Approximately 15 ml grossly purulent fluid was
Fig 1. Case 1. Synovial biopsy of right knee showing nonspecific inflammation with primarily mononuclear cell infiltration (x 150).
Arthritis and Rheumatism, Vol. 13, No. 3 (May-lune 1970)
273
EICHNER & DELLER
symptoms in these joints; moreover, autop
sies may show involvement of joints where
meningococcal arthritis was not suspected
clinically (1-5) .
Although in most instances the initial
lesion resolves spontaneously, the process
may spread from deeper to more superficial
synovial tissue. At this point the effusion
begins and, in some cases, necrosis of synovial cells and destruction of cartilage may
be present (5). The effusion itself varies
from serous to grossly purulent. Meningococci are cultured from the joint fluid in
about one third of the cases, usually in the
earlier stages. The fact that the effusions
may appear a week after the acute meningococcal disease has subsided, and after
antibiotic treatment, leads to speculation
that effusion may be the result of some
mechanism other than progression of infection. A hypersensitivity reaction to the organism or to products of host tissue breakdown remains a distinctly possible explanation for this form of arthritis.
Patient 1 was typical of the meningococcal arthritic patients described in the literature. Although he had arthralgias shortly
DISCUSSION
after the meningitis appeared, knee
A spectrum of arthritic manifestations effusions were not noticed until Day 6 of
seems to be present in meningococcal dis- hospitalization. At that time, examination
ease. The more acutely inflamed joints of his knees did not reveal signs of acute
usually appear at the time the organisms inflammation, even though the aspirated
begin to disseminate; the lower grade effusion was of an inflammatory nature. It
inflammation and effusions tend to appear was not surprising that the synovial fluid
during the period of recovery and involve was sterile at such a late date in the face of
only one or a few joints. Perivascular adequate penicillin therapy.
In Patient 2, an acute septic arthritis was
inflammation and hemorrhage into periarticular' tissues are the causes of arthralgia, the presenting manifestation after a brief
erythema, and tenderness during the acute prodrome in a previously healthy individuillness. Arthralgia without the accompany- al. The presence of meningococcemia the
ing signs of inflammation is probably due day before the onset of arthritis can be
to the same processes. It is possible that this inferred from the history, although it was
stage of meningococcal arthritis is not no- not documented. This form of arthritis is
ticed at all because many patients who more typical of gonococcal arthritis, and
later develop effusions have not had earlier was indeed mistaken for this infection ini-
aspirated from the joint; an accurate cell count was
impossible due to necrotic debris, and no organisms
were seen on gram stain. WBC count was 20,45O/cu
mm with 90% polymorphonuclear cells. Although
no gram-negative diplococci were seen on cervical
smear, gonococcal arthritis was suspected and treatment with intravenous penicillin was initiated. The
patient continued to spike fevers to 103°F. and on
Day 2, a repeat aspiration of the left knee! produced
30 ml of sanguinopurulent fluid. Gram-negative
intracellular diplococci were seen on gram stain,
This was thought to confirm the initial clinical
impression, and treatment with 5 million units of
penicillin by the intermittent intravenous route
every 6 hr and immobilization of the joint were
continued. T h e knee, however, remained markedly
swollen, tender and warm, and the patient's fever
spiked to 101OF daily. On Day 8, N rneningitidis,
Group C, as well as rare Staphylococcus aureus
were identified from the culture of the first aspiration. Meningococci were not grown on subsequent
cultures of knee aspirates, nor o n throat or numerous blood cultures. Arthrocentesis was performed
twice more, and penicillin was instilled into the
joint because of persistent, purulent effusion and
fever. After 12 days, the patient became afebrile and
the knee was only slightly tender. The effusion
gradually disappeared and after physical therapy,
the patient recovered without residual disability.
She was discharged on Day 29.
274
Arthritis and Rheumatism, Vol. 13, No. 3 (May-June 1970)
MENINGOCOCeAL ARTHRITIS
tially. The occurrence of meningococcal arthritis presenting as an acute septic arthritis is rare. Of the 8 case reports (6-11),
all but those of Sainton (3 cases) were of
arthritis in infants. Serologic types were not
mentioned. Localization to one joint does
not necessarily indicate a different pathophysiologic mechanism; it probably r e p
resents either a small inoculum or increased host resistance as a moderating
factor in the septicemia.
Although antibiotic therapy is essential
in the treatment of meningococcemia, the
course of the delayed variety of meningqcoccal arthritis may be little affected by it.
As exemplified by Case 1, many cases of
arthritis become manifest after the septicemia has been adequately treated. I n the
acute variety described in Case 2, the organism is found in the synovial fluid. Antibiotic therapy apparently sterilizes the joint
although both the fever and the arthritis
may persist for some time.
The presence of leukocytes in the joint
fluid appears to be the cause of persistent
fever. Many patients with purulent
effusions remain febrile after the cultures
become negative, while lysis of the fever
coincides with clearing of the purulent
effusion. Frequent arthrocentesis is associated with a reduction in the WBC count in
the joint and is recommended in the treatment of the suppurative arthritis; intraarticular antibiotics are not indicated.
Atthritis and Rheumatism, Vol. 13, No. 3 (May-lune 1970)
REFERENCES
1. PINALSRS, ROPESMW: Meningococcal
arthritis. Arthritis Rheum 7241, 1964
2. BOCERWP: Purulent meningococcal arthritis. Amer J Med Sci 208:708, 1944
3. Fox MJ, GILBERTJ: Meningococcus infections with articular complications. Amer J Med
Sci 208:63, 1944
4. JAEGER HW: Meningocosis del aparato
locomotor (Meningococcal arthritis) R e v Chile
Pediat I4:414, 1943
5. KEEFER CS, PARKER
F, MYERSWK: Histologic changes in the knee joint in various
infections. Arch Path (Chicago) 28:199, 1934
G: Multiple puru6. BASSMH, NORTHMAN
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W, GREENFIELD
EC: Meningococcal suppurative arthritis of crytogenic origin.
S Afr Med J 10:545, 1966
8. LONGPH, BLISS EA: Observations upon
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Canad Med Ass J 37:457, 1937
9. KOBAYASHIM: Ein Fall von Meningokokken-polyarthritis des Sauglings (Case of
meningococcal polyarthritis in an infant) . Oriental J Dis Infants 16:22, 1934
10. SAINTONP: Meningococcal rheumatism
and arthritis. Lancet 1:1081, 1919
11. WEILL E, DUFOURT A, BOCCA C.
Meningococcemie sans meningities mais avec
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275
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