Identification of neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction

Objective. To analyze synovial fluid (SF) for the presence of Neisseria gonorrhoeae DNA using the polymerase chain reaction (PCR). Methods. We used a modified, nested PCR to detect the presence of N gonorrhoeae DNA in 41 samples of SF obtained from 10 patients with clinical gonococcal arthritis whose SF samples were sterile by culture and from 27 controls, including 11 patients with Reiter's syndrome. Results obtained using this method were compared with those obtained using the GEN-PROBE system, an RNA–DNA hybridization technique. Results. With nested PCR, N gonorrhoeae DNA was detected in 11 of 14 SF samples obtained from patients with culture-negative clinical gonococcal arthritis but in none of the 11 SF samples from Reiter's syndrome patients. The specificity of this technique was 96.4%, with a sensitivity of 78.6%. The rate of false-positive results was 3.6%. The GEN-PROBE technique was unable to detect N gonorrhoeae ribosomal RNA in any of the samples. Conclusion. These findings demonstrate the potential utility of the PCR in confirming the clinical diagnosis of gonococcal arthritis as well as providing insight into the pathogenesis of this disorder in patients whose SF are sterile by standard culture techniques. PCR may also prove helpful in differentiating N gonorrhoeae arthritis from acute Reiter's syndrome.     

Use of the polymerase chain reaction to study arthritis due to neisseria gonorrhoeae

Objective. To explore the utility of the polymerase chain reaction (PCR) in the diagnosis, management, and investigation of arthritis due to Neisseria gonorrhoeae. Methods. The PCR was used to detect DNA from N gonorrhoeae in model systems and in extracts of synovial fluid (SF) from patients with systemic gonococcal infections and objective evidence of arthritis. Results. One N gonorrhoeae organism or its equivalent was detectable in human SF from inflamed joints. Five of 8 patients with systemic N gonorrhoeae infection and arthritis had N gonorrhoeae DNA demonstrated by PCR in at least 1 pretreatment SF specimen that was N gonorrhoeae culture positive. Thirty-seven of 38 control specimens were negative, the exception probably being due to cross-contamination from a positive specimen. All specimens that were positive for N gonorrhoeae by other methods were also positive by PCR. Two others were positive by PCR but negative by other methods. Four pretreatment specimens were negative by all methods, including PCR. This suggests that, for these patients, negative cultures reflected true absence of N gonorrhoeae, and not the presence of unculturable organisms. This group also had a significantly shorter duration of disease than did the patients with N gonorrhoeae DNA found in their SF. All patients had a prompt response to antibiotic treatment. Two of 3 patients whose specimens were previously positive showed marked decreases in SF N gonorrhoeae DNA after treatment. Conclusion. The PCR using these or similar oligonucleotide primers can be a useful adjunct in the diagnosis of gonococcal arthritis and can be of value in assessing its response to therapy. In some N gonorrhoeae–associated arthritides, there appears to be a lack of both viable and nonviable N gonorrhoeae organisms in the SF. These observations may have implications regarding the pathogenesis of this form of arthritis.     

Monoarthrite septique à gonocoque : difficultés diagnostiques et intérêt de la PCR dans le liquide articulaire

Introduction

The incidence of Neisseria gonorrhoeae septic arthritis remains low in the general population. Its clinical and microbiological diagnostic remains difficult.

Arthritis confined to knee joints synovial lymphocyte responses to microbial antigens correlate with distribution of HLA

The responses of synovial lymphocytes to Chlamydia/Ureaplasma and to enteric antigens were studied in 31 patients with arthritis confined to knee joints, 15 patients with sexually-transmitted Reiter's syndrome, 9 with enteric Reiter's syndrome, and 24 with rheumatoid arthritis. The frequency of HLA antigens was studied in 28 patients with knee joint arthritis; this group was characterized by elevated frequencies of HLA–A2 and DR1. A subgroup of 8 responders to Chlamydia/Ureaplasma was characterized by an increase of HLA–Bw44 and DR7 or 8, while a subgroup of 8 responders to enteric antigens was characterized by increases of HLA–A1 and DR5. The frequency of HLA–B27 in the groups responding to antigens was 25–30%, less than half the frequency in patients with Reiter's syndrome.     

Clinical studies on gonococcal arthritis and reiter's syndrome and measurement of gonococcal and bedsonia antibodies

Clinical and serologic studies on 94 patients suspected of having gonococcal arthritis or Reiter's syndrome are reported. Twenty-eight patients had arthritis due to a Neisserian organism. Causative organisms were identified as gonococci in 19 instances. The species of the remaining 9 organisms was not identified. Seven patients exhibited the complete Reiter's syndrome. Neither clinical features nor measurement of gonococcal or Bedsonia antibodies were sufficient to establish a diagnosis in those cases that had sterile blood and synovial fluid cultures and lacked the Reiter's triad.     

Comparison of synovial tissue and synovial fluid as the source of nucleic acids for detection of Chlamydia trachomatis by polymerase chain reaction

Objective. Difficulties in detecting Chlamydia trachomatis in human joints by polymerase chain reaction (PCR) may be related to whether synovial tissue or synovial fluid (SF) is used as the source of DNA in PCR amplification. In this study, a new PCR assay was developed and used to compare chlamydial DNA in paired samples of SF and synovial tissue from patients with arthritis. Methods. The PCR assay targeted the ribosomal RNA operons, which are present in 2 copies on the C trachomatis chromosome. DNA from several relevant bacteria and chlamydial serovars was used for testing this screening system. The detection of chlamydial DNA in nucleic acid preparations from matched samples of SF and synovial tissue was compared by PCR assay. Samples were obtained from 55 patients, including patients with reactive arthritis, Reiter's syndrome, and other arthropathies. Results. Testing of the PCR screening system confirmed it to be highly specific and sensitive. Use of this assay to screen DNA from SF and synovial tissue samples showed that 29 (53%) of 55 synovial tissue preparations were positive for chlamydial DNA, but only 16 (29%) of the matched SF samples from these 29 patients were similarly positive. Five (9%) of 55 SF samples, but not their tissue counterparts, were positive for chlamydial DNA by PCR. Conclusion. Detection of chlamydial DNA in the joints of patients by PCR gives positive results more often when synovial tissue rather than SF is the source of target nucleic acids. Although synovial tissue is the source of choice for the most reliable determination of chlamydia in the joint, both synovial tissue and SF should be assayed if possible.     

Lower prevalence of Chlamydia pneumoniae DNA compared with Chlamydia trachomatis DNA in synovial tissue of arthritis patients.

OBJECTIVE: To assess the presence of Chlamydia pneumoniae DNA in the joints of patients with reactive arthritis (ReA) and other arthritides. METHODS: DNA was prepared from synovial tissue (ST) and several synovial fluid (SF) samples from 188 patients with either ReA, undifferentiated oligoarthritis, or other forms of arthritis, and from 24 normal (non-arthritis) individuals. Preparations were screened using polymerase chain reaction (PCR) assays that independently targeted the C. pneumoniae 16S ribosomal RNA and major outer membrane protein genes. RESULTS: Twenty-seven of 212 ST samples (12.7%) were PCR positive for C. pneumoniae DNA; 10 SF samples from these 27 patients were similarly positive. Among the PCR-positive patients, 3 had ReA, 2 had Reiter's syndrome, 7 had undifferentiated oligoarthritis, 4 had undifferentiated monarthritis, 6 had rheumatoid arthritis, and 5 had other forms of arthritis. No samples from normal control individuals were PCR positive. CONCLUSION: DNA of C pneumoniae is present in synovial specimens from some arthritis patients. The prevalence of this organism in the joints was lower than that of C trachomatis, and synovial presence of the organism was not associated with any distinct clinical syndrome. Widely disseminated nucleic acids such as those of C. pneumoniae might have some role in the pathogenesis of several arthritides, since the organism was not found in the ST from normal control individuals.     

Mycoplasma infection and rheumatoid arthritis. Analysis of their relationship using immunoblotting and an ultrasensitive polymerase chain reaction detection method

Objective. To examine the relationship between infection with Mycoplasma and the development of rheumatoid arthritis (RA) and juvenile rheumatoid arthritis (JRA). Methods. Immunoblotting of patient synovial fluid and sera on detergent-phase membrane protein extracts of various Mycoplasma species was carried out to learn whether patients exhibited serologic evidence of previous exposure to mycoplasmas. Moreover, an ultrasensitive polymerase chain reaction (PCR) method was developed for assessing whether Mycoplasma DNA could be detected in synovial fluid from patients and controls. Results. Immunoblotting provided serologic evidence of previous Mycoplasma exposure in patients and controls. The genus-specific PCR detected known human Mycoplasma species and could reliably detect <5 copies of Mycoplasma hominis, Mycoplasma fermentans, or a molecular mimic control in synovial fluid. Repeat testing revealed no evidence of Mycoplasma DNA in patient synovial samples. Conclusion. This study provided serologic evidence suggesting that, while previous exposure to Mycoplasma was common, there was no detectable persistence of Mycoplasma DNA in the synovial fluid or tissue of patients with RA or JRA.     

Light and electron microscopic studies on the synovial membrane in reiter's syndrome.

Studies by light microscopy on synovium obtained from 11 patients with Reiter's syndrome during the first month of an episode showed proliferation of synovial lining cells, polymorphonuclear neutrophils among the synovial lining cells, increased surface fibrin, and vascular congestion. Biopsy specimens taken later showed vascular congestion and still proliferated synovial lining cells, fewer polymorphonuclear neutrophils in some, and a tendency toward increased infiltration with lymphocytes and plasma cells. Electron microscopy of samples from 8 patients during the first month of disease activity showed occlusion of vessels by platelets in 4, and fibrin or dense granular material in the vessel walls in 4. Five of the patients with arthritis of less than 4 weeks duration had unidentified intracellular and extracellular particles; some of these were highly suggestive of Chlamydia. No such particles were noted in samples from patients with more chronic cases. Using an antibody to Chlamydia trachomatis and the peroxidase-antiperoxidase technique, immunocytochemistry showed reaction product in synovial macrophages in 2 patients with arthritis of less than 4 weeks duration, but not in the 1 patient studied who had more chronic disease. These studies provide support for dramatic synovial vascular injury consistent with that caused by endotoxin and the presence of chlamydial antigen in synovial macrophages, at least in the early phases of synovitis.     

Chronic gonococcal arthritis with C5 deficiency presenting with brief flare-ups: case study and literature review

Gonococcal arthritis is typically acute and appears within 3 weeks after initial infection. Chronic gonococcal arthritis is now exceptionally rare, since the advent of the antibiotic era. Numerous host factors are involved in gonococcal dissemination, such as complement deficiency, HIV and gonococcus strain characteristics. Gonococcal arthritis shares the same risk factors. In this instance, our patient was a 16-year-old girl suffering from persistent polyarthralgia with joint swelling presenting with brief flare-ups for a period of 1 year. She disclosed a single episode of unprotected sexual intercourse 1 year ago, i.e. just before developing her first rheumatological symptoms. Therefore, we performed a joint aspiration (arthrocentesis), and synovial fluid was inoculated directly into aerobic and anaerobic blood culture bottles, which tested positive for Neisseria gonorrhoeae within 24 h. Clinical presentation was consistent with previous reports of chronic gonococcal arthritis. Further investigation revealed a C5 complement deficiency, which might explain the chronic Neisseria process. A favourable outcome was reached after a ten-day course of IV ceftriaxone, with no apparent sequelae found during follow-up 6 weeks later. This case demonstrates an unusual gonococcal arthritis with brief flare-ups for the course of a year, followed by a subacute form. N. meningitidis infections, similar to N. gonorrhoeae, are typically acute and may sometimes be involved in chronic processes. However, this characteristic appears to be rare in the case of N. gonorrhoeae. Risk factors for this chronic process will be discussed with a review of the literature.     

Artritis gonocócica y déficit de C2

Disseminated gonococcal infection is a rare presentation of the sexually transmitted pathogen, Neisseria gonorrhoeae. Here, we report the case of a 64-year-old woman with disseminated gonococcal infection, which started with symptoms of oligoarthritis and malaise. Neisseria gonorrhoeae was identified in the carpal synovial fluid. The follow-up study revealed an absence of total hemolytic complement and complement C2 was not detected. Being relatively common, C2 deficiency has been associated with disseminated gonococcal infection in a few cases. We present a new case and discuss those previously published.     

Seltene Ursache für rezidivierende Monarthritis

Isolated monarthritis caused by Tropheryma whipplei without involvement of the gastrointestinal tract is rare but is nowadays often described as an early manifestation of the disease. In a male patient with recurrent knee joint arthritis for several years, we could ultimately diagnose Whipple’s disease based on PCR positive biopsies of synovial tissue and fluid. Furthermore, the patient was found to be an asymptomatic T. whipplei carrier. With adequate antibiotic therapy the patient has meanwhile fully recovered.     

Molecular diagnosis of ureaplasma urealyticum in an immunocompetent patient with destructive reactive polyarthritis

Polymerase chain reaction (PCR) amplification, which is a useful method for detecting infectious agents in joints, has potential utility in the molecular diagnosis of venereal-associated arthritis. Among pathogens detected by this technique, Ureaplasma urealyticum, which is primarily associated with reactive arthritis (ReA), is also implicated in septic arthritis in immunocompromised patients. We report here a case of destructive polyarthritis, initially suggestive of septic arthritis, in an immunocompetent patient whose PCR positivity for U urealyticum DNA in one joint, in conjunction with the disease outcome and histologic findings, led to the diagnosis of destructive ReA.     

Chromosomal DNA from a variety of bacterial species is present in synovial tissue from patients with various forms of arthritis

OBJECTIVE: We and others have reported the presence of Chlamydia and other bacterial species in joint specimens from patients with reactive arthritis (ReA). The present study was conducted to investigate whether bacteria other than those specified by diagnostic criteria for ReA could be identified in synovial fluid (SF) or tissue from patients with various arthritides, and whether the presence of such organisms corresponds to particular clinical characteristics in any patient set or subset. METHODS: DNA in synovial biopsy samples and SF obtained from 237 patients with various arthritides, including ReA, rheumatoid arthritis, and undifferentiated oligoarthritis, was assayed by polymerase chain reaction (PCR) using "panbacterial" primers; we chose only samples known to be PCR negative for Chlamydia, Borrelia, and Mycoplasma species. PCR products were cloned, and cloned amplicons from each sample were sequenced; DNA sequences were compared against all others in GenBank for identification of bacterial species involved. RESULTS: Ten percent of patient samples were PCR positive in panbacterial screening assays. Bacterial species identified belonged to the genera Neisseria, Acinetobacter, Moraxella, Salmonella, Pseudomonas, and others. Thirty-five percent of PCR-positive patients showed the presence of DNA from more than a single bacterial species in synovium; overall, however, we could identify no clear relationship between specific single or multiple bacterial species in the synovium and any general clinical characteristics of any individual or group of patients. CONCLUSION: This analysis provides the first systematic attempt to relate bacterial nucleic acids in the synovium to clinical characteristics, joint findings, and outcomes. Many patients with arthritis have bacterial DNA in the joint, and, in some cases, DNA from more than a single species is present. However, except for 1 case of a control patient with staphylococcal septic arthritis, it is not clear from the present study whether the synovial presence of such organisms is related to disease pathogenesis or evolution in any or all cases.     

Detection of Borrelia burgdorferi by polymerase chain reaction in synovial membrane, but not in synovial fluid from patients with persisting Lyme arthritis after antibiotic therapy

OBJECTIVES—To identify possible sites of bacterial persistence in patients with treatment resistant Lyme arthritis. It was determined whether Borrelia burgdorferi DNA may be detectable by polymerase chain reaction (PCR) in synovial membrane (SM) when PCR results from synovial fluid (SF) had become negative after antibiotic therapy.
METHODS—Paired SF and SM specimens and urine samples from four patients with ongoing or recurring Lyme arthritis despite previous antibiotic therapy were investigated. A PCR for the detection of B burgdorferi DNA was carried out using primer sets specific for the ospA gene and a p66 gene of B burgdorferi.
RESULTS—In all four cases, PCR with either primer set was negative in SF and urine, but was positive with at least one primer pair in the SM specimens. In all patients arthritis completely resolved after additional antibiotic treatment.
CONCLUSIONS—These data suggest that in patients with treatment resistant Lyme arthritis negative PCR results in SF after antibiotic therapy do not rule out the intraarticular persistence of B burgdorferi DNA. Therefore, in these patients both SF and SM should be analysed for borrelial DNA by PCR as positive results in SM are strongly suggestive of ongoing infection.

Keywords: Lyme arthritis; polymerase chain reaction; synovial membrane; synovial fluid     

PROMINENCE OF PENICILLINASE-PRODUCING STRAINS OF NEISSERIA GONORRHOEAE IN GONOCOCCAL ARTHRITIS--EXPERIENCE IN DURBAN, SOUTH AFRICA

Penicillin resistance amongst gonococcal strains causing disseminatedgonococcal infection (DGI) has been infrequently reported worldwide.The clinical records of 34 patients with gonococcal arthritisseen over a 53-month period were reviewed. The study populationconsisted of 32 blacks and two Indians with a mean age of 23.5yr (range 14–46 yr) and a female to male ratio of 2.8:1.The diagnosis of gonococcal arthritis was made on the basisof isolation of Neisseria gonorrhoeae from the SF alone in 20patients, SF and genital site in nine genital site alone intwo and genital site and synovial tissue in one patient andsynovial tissue alone in two patients. Eighteen of the 32 (56%)synovial isolates were penicillinase-producing strains of N.gonorrhoeae (PPNG). Monoarthritis was the commonest mode ofpresentation and seen in 73% of patients. The joints most frequentlyinvolved were the wrist (44%), knee (41%), ankle (15%) and shoulder(12%). None of the patients had cutaneous lesions. The occurrenceof DGI is usually associated with protein 1-A serotype and arginine,hypoxanthine and uracil requiring auxotype, but all isolatesavailable for auxotyping in this study were prototrophic. Thisstudy shows a very high prevalence of PPNG strains causing DGI,an observation which has important therapeutic implications. KEY WORDS: Gonococcal arthritis, Septic arthritis, Disseminated gonococcal infection, Penicillinase-producing Neisseria gonorrhoeae Present address: S. A. Institute of Medical Research, P O Box1038, Johannesburg 2000, South Africa.     

Arthritis due to a penicillinase-producingNeisseria gonorrhoeae from Saudi Arabia

Summary A case of arthritis due to a penicillinase-producingNeisseria gonorrhoeae in a 29-year-old lady is reported. The organism was isolated from the synovial fluid of the affected joint. Isolation of penicillinase-producingN. gonorrhoeae from such fluid has only rarely been reported. However, this is probably the first reported case from the Middle East and surrounding areas.

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Arthritis durch pencillinasebildendeNeisseria gonorrhoeae. Fallbericht aus Saudi-Arabien

Zusammenfassung Eine 29jährige Frau erkrankte an einer Arthritis durch penicillinasebildendeNeisseria gonorrhoeae. Der Erreger wurde aus der Synovialflüssigkeit des betroffenen Gelenkes isoliert. Über die Isolation von penicillinasebildendenN. gonorrhoeae aus solchen Flüssigkeiten liegen nur wenig Berichte vor. Aus dem Mittleren Osten und umgebenden Regionen ist dies wahrscheinlich der erste Fallbericht.

     

Chronic destructive oligoarthritis associated with Propionibacterium acnes in a female patient with acne vulgaris: Septic‐reactive arthritis?

Propionibacterium acnes is an anaerobic bacillus implicated in certain chronic arthritides. This report describes an HLA–B27+ 17‐year‐old woman with acne vulgaris who presented with rapidly destructive arthritis in the left shoulder as well as an evolving left subclavicular adenopathy. One year later, arthritis was detected in the left knee; the inflammatory synovial fluid was sterile. Growth of P acnes was observed in cultures of the shoulder synovium and lymph nodes, but polymerase chain reaction was negative for Borrelia, Chlamydia, and Ureaplasma DNA. Three months of treatment with amoxicillin and rifampicin led to clinical disappearance of the oligoarthritis, but arthritis recurred in the left knee after discontinuation of therapy. On biopsy, bacteria were undetectable in the knee synovium, but chronic arthritis was evident histologically. Antibiotics were reintroduced for 12 months and were again effective against the clinical symptoms. Although the asymmetry, histologic features, arthritis–acne association, and genetic predisposition of this chronic destructive oligoarthritis would seem to indicate a reactive arthropathy, the isolation of P acnes from 2 distinct specimens prompted us to propose calling this a case of septic‐reactive arthritis, which is further supported by the absence of progression after antibiotic therapy and the persistence of the rheumatism. To our knowledge, this is the first demonstration of the efficacy of prolonged antibiotic therapy on the joint manifestations of chronic rheumatism associated with acne.     

Chlamydia and Borrelia DNA in synovial fluid of patients with early undifferentiated oligoarthritis: Results of a prospective study

Objective

More than 50% of patients with synovitis involving 1–4 joints remain classified as having undifferentiated oligoarthritis (UOA) after 1 year of disease. The clinical presentation is often similar to that of reactive arthritis (ReA) and other spondylarthropathies or to Lyme arthritis. We therefore determined how often Chlamydia trachomatis (Ct) and Borrelia burgdorferi (Bb) can be identified in patients with UOA, by using an extensive laboratory approach.

Methods

We prospectively studied 52 patients with UOA who presented at an early synovitis clinic in a region highly endemic for Lyme disease. Patients were examined by standardized clinical and immunoserologic procedures. Synovial fluid was screened for the presence of Ct and Bb DNA by polymerase chain reaction (PCR). Urine was tested for Ct DNA by ligase chain reaction, and serum was tested for Ct antibodies by enzyme‐linked immunosorbent assay and Bb antibodies by hemagglutination test and Western blotting. PCR results in the UOA patients were compared with the results in cohorts of patients with definite rheumatoid arthritis (RA), Lyme arthritis, and Chlamydia‐induced arthritis (CIA).

Results

In the synovial fluid of 9 of 52 patients with UOA (17%), we found Ct DNA, and in 6 of the 52 patients (12%), Bb DNA was found. The frequency of bacteria‐specific DNA was 50% (7 of 14) in CIA patients and 69% (11 of 16) in patients with Lyme arthritis. No Bb or Ct DNA was found in the synovial fluid of the 31 RA patients.

Conclusion

With optimized PCR protocols, it is possible to detect considerable levels of Bb and Ct DNA in the synovial fluid of patients with UOA. Although the presence of bacterial DNA does not unequivocally prove its etiologic significance, we suggest that at least one‐third of patients with UOA may have a form of ReA that involves asymptomatic primary infection.