Rodríguez, Cristina López MD; Octavio, Juan Gómez MD; Isea, Carolina MD; Petkova, Elisabeth MD; Pernaute, Olga Sánchez MD; Fernández Guerrero, Manuel L. MD
From the Division of Infectious Diseases and Rheumatology, Department of Medicine, Instituto de Investigaciones Sanitarias Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain.
The authors declare no conflict of interest.
Correspondence: Manuel L. Fernández Guerrero, MD, Department of Internal Medicine, Fundación Jiménez Díaz, Avda Reyes Católicos, 2, Madrid 28040, Spain. E-mail: firstname.lastname@example.org.
Despite our improved understanding of the epidemiologic features of meningococcal infections and advances in diagnosis and treatment, the disease remains an important cause of morbidity and mortality.1 Neisseria meningitidis infections are distributed worldwide and are endemic in Europe and North America. Although meningitis and sepsis are the most common and severe manifestations, pneumonia, eye infections, otitis, epiglottitis, and pericarditis are occasionally observed.1
Arthritis has been noticed in the course of meningococcemia in a small number of patients, mostly children younger than 5 years.2 Most patients presented with sepsis and meningitis and developed monoarthritis involving large joints such as the knee, wrist, or ankle within the first days of admission.3 Rarely, patients develop polyarthritis without meningitis, and then, rheumatoid arthritis and other collagen vascular diseases are considered in the diagnosis.4
We report 2 patients who presented with acute meningococcal polyarthritis mimicking other inflammatory conditions.
A previously healthy 60-year-old man was admitted because of fever and polyarthritis. A week before, he had low-grade fever, general malaise, backache, pain in the hip, and swelling of the hand and wrists with severe pain that worsened with minor activity.
Physical examination showed fever (38.5°C) and swelling of both wrists and the proximal interphalangeal and metacarpophalangeal joints of the left hand. The motion of the hip was severely impaired by pain. The general examination was normal.
The leukocyte count was 20,500/μL with 88% granulocytes; hemoglobin was 11.7 g/dL. C-reactive protein was 25.3 mg/dL. Rheumatoid factor was negative. Three blood cultures yielded N. meningitidis serogroup B, clonal complex VR1:12-1. Susceptibility in vitro tests showed the following minimal inhibitory concentration values: ceftriaxone, 0.001 μg/mL; rifampin, 0.01 μg/mL; ciprofloxacin, 0.007 μg/mL; and penicillin, 0.25 μg/mL.
The patient was treated with ceftriaxone. Fever and rheumatologic manifestation rapidly subsided, and he was discharged doing well. In a follow-up visit, no residual joint damage was observed.
An 88-year-old woman with type 2 diabetes mellitus was admitted because of pain and swelling in the hands and ankles for the last 5 days. On admission, temperature was 37.8°C. Examination showed arthritis of the proximal interphalangeal joints in both hands and severe painful swelling of both wrists and ankles.
The leukocyte count was 16,500/μL with 91% granulocytes, and hemoglobin was 9.4 g/dL. The sedimentation rate was 120 mm/hr, and C-reactive protein was 42.9 mg/dL. Glucose was 404 mg/dL, and serum creatinine was 1.6 mg/dL. Immunoelectrophoresis showed a monoclonal immunoglobulin M, lambda type in small amount. Serology for Brucella, Borrelia, Coxiella, and HIV were negative. Rheumatoid factor and antinuclear and anti-DNA antibodies were negative, and serum levels of complement were within reference range. Blood cultures were negative. Aspiration of the right ankle showed a purulent exudate. Neisseria meningitidis susceptible to penicillin, ceftriaxone, ciprofloxacin, and rifampin was isolated.
Antimicrobial therapy with intravenous ceftriaxone was started. Fever and joint swelling rapidly subsided, and she was dismissed from hospital. Three weeks later, she was doing well without any functional residual damage.
Meningococcal arthritis is a rare infection. Although most cases occurred in children and immunocompetent adults, patients with conditions that suppress normal antibody synthesis such as multiple myeloma or Waldenström disease, on occasion, may present with primary meningococcal arthritis.5–7 Association between strains of serogroup W135, mostly of the clonal complex ET-37, and meningococcal arthritis has been found.2,5
Traditionally, meningococcal arthritis has been thought to occur in 2 different ways: as a primary septic arthritis, mainly monoarthritis occurring at the onset of the disease in which case meningococci are isolated from the joint, and as a reactive arthritis at the end of the first or second week after initiation of antimicrobial therapy in which case no bacteria are isolated from synovial fluid and arthritis is likely due to an immune complex reactions.5,8,9 The present report of 2 patients who developed very acute polyarthritis with involvement of the small joints of the hands, wrists, and ankles shows the limitations of this traditional view of early-onset meningococcal arthritis as a monoarticular infection. In addition, it is a good remainder that multiple joint involvement does not necessarily imply a noninfectious etiology.10
In our patients, diagnosis of meningococcal arthritis in the absence of meningitis and the typical rash of disseminated infection was unexpected. They did not have exposure to patients with meningitis, and infection occurred in the absence of meningococcal outbreak. We believe that leukocytosis and granulocytosis were important diagnostic clues that suggested the diagnosis of infectious arthritis and the need to take blood and synovial fluid for cultures.
In opposition to arthritis caused by Staphylococcus aureus, the functional outcome of meningococcal arthritis is good, and the majority of patients have uneventful recovery.3 Once antimicrobial therapy was started, fever and joint inflammation rapidly subsided, and patients were dismissed from hospital without any functional loss.
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