[Question #1151] Possible DGI infection-need guidance

48 months ago
Dear Dr Hook or Dr. HHH

A little over a week ago my right knee started to swell, become red, hot and limit my range of movement and give me a lot of pain. This was not something new, I have suffered from Gout from some time.  The pain got worse and 2 days ago I saw my orthopedic who took 5ml of synovial fluid from my knee and injected cortisone believing it was gout again.  Yesterday he called to tell me no uric acid crystals were found and the wbc count was 13,000 in the synovial fluid which was not indicating a septic joint.  He did have the sample cultured but are waiting for the result.

The reason for my concern is about a month and half ago I saw an escort and had protected oral and vaginal sex. She was extremely careful about the condom and in my mind seemed like a safe experience. Since the the aspiration and cortisone my knee has improved minimally. It is still swollen and red. The fact that they did not detect any crystals (which to be honest, has happend before...where I have what seems to be an obvious gout attack and no crystals are found in the sample other times they have been detected)  and the fact that I read the gonnoccal arthritis normally has a synovial wbc count that is much lower then other septic joints has me concerned. The fact that there has been little improvement has me also concerned.

I did not tell him about this experience given it was protected? Should I of? Should I be worried? Is my synovial wbc count worrisome for gonnoccal infection? Will the culture even indicate this infection.

Thanks in advance
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
Welcome back to the forum.

For sure this isn't DGI. Clearly you have some sort of recurrent arthritis of the knee -- probably gout, given the previous documentation of crystals in the joint fluid. Arthritis due to DGI has two basic forms:  multiple joint involvement, usually with typical skin rash, and with fever; or septic arthritis of a single joint. Most cases of the latter are preceded by the former:  i.e. a single joint persists with pain and swelling as the other joints are improving. Septic gonococcal arthritis usually has fever. And you have to realize that the coincidence of having two different kinds of (gonococcal, gout) involving the same joint is extraordinarily unlikely. Further, there is little chance you acquired gonorrhea from the exposure described:  condoms work, and lack of symptoms of urethritis (penile discharge, painful urination) also is pretty good evidence you weren't infected. Neither lack of crystals nor failure to improve promply argues strongly for a cause other than gout.

You have misunderstood something you read about synovial fluid WBC counts. In the early, polyarthritis form of DGI, fluid WBC counts typically are low (and synovial fluid cultures negative). However, in the septic arthritis form, WBC counts just as high as in any other septic arthritis, e.g. caused by staph and similar bacteria. So the relatively low count in your case also argues against an infectious cause of any kind. And finally, the answer to your closing question is yes:  if your arthritis were gonococcal, standard culture procedures would detect it.

So my advice is to follow your doctor's advice about arthritis management. No worries about DGI. 

This is your 5th question on the forum, all of which have tones that imply inflated worries about STDs in general. Although I didn't re-read all of those discussions in detail, they all involved very low risk scenarios. Don't assume that every new symptom following a new sexual exposure is somehow connected to that event. It sounds like you always have safe sex (congratulations!) and thus you can disregard symptoms that are not typical for STDs.

Let me know if anything isn't clear. Best wishes and stay safe--   HHH, MD

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48 months ago
Thank you so much for the reply. It is true that I have a history of anxiety around STD and is actually something I have found rather difficult to deal with. At the time of an encounter I am confident with safe sex practices, it isn't till weeks after when some medical issue arises do I have anxiety...I digress, that is an issue for my psychologist.

I have a couple of follow up questions for peace of mind.

1) in addition to the encounter described in my previous post, I had a an encounter with a massage worker 3 month ago where I received oral sex with a condom on.  She put the condom on with her mouth. I'm assuming that was no risk for std as well?

2) In terms of the arthritis. In the weeks prior to this attack I did have pain and sought attention for pain and swelling in my wrist and even before that my elbow. All presumed to be related to gout none of these attacks overlapped and none nearly as severe as my current knee issue. I never had fever or skin rash. I'm assuming this does not change your assessment about having DGI? From what I understand of gout it is unusual for two joints to be effected at the same time and that is possibly why it seems like I may have migratory arthritis. It is just my body to get my uric acid under control possibly?

3)I am confused on one issue. I have read that DGI is usually a result of  an asymptomatic infection that spreads. Do most people with DGI also have penile burning and discharge? 


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
1) No risk at all. Even unprotected, oral sex should be considered safe sex -- not completely free of STD risk, but much lower chance than for vaginal or anal sex. And virtually no risk at all for some STDs, such as HIV, chlamydia, and HSV2. And saliva is generally non-infectious. For example, it kills HIV and probably other pathogens as well.

2) Correct:  this information does not change my assessment about DGI.

3) Only partly right. The strains of gonorrhea most likely to disseminate are also more likely to cause asymptomatic genital infection. However, "more likely" only means a trend. The large majority of urethral infections with such strains cause overt symptoms you would not miss. That includes the large majority of those with DGI that originated with urethral gonorrhea.

We're talking about two areas in which I am legitimately among the world's top few experts. Even though that work is 30-40 years old, little research on these topics has been done more recently:  http://www.ncbi.nlm.nih.gov/pubmed/4202519, http://www.ncbi.nlm.nih.gov/pubmed/820229, http://www.ncbi.nlm.nih.gov/pubmed/6771877

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48 months ago
Thank you for all your responses.  I am certainly less concerned now.  

I have one last question.  The other gout attacks where I have had the fluid aspirated  and there have been crystals found have been in my left knee. The knee aspirated the other day where no crystals were found was my right knee. Does the fact that I normally get attacks in the other knee make a difference in your assessment of it potentially being DGI as opposed to gout?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
This doesn't make any significant difference in my opinion or advice. Once someone has gout, any joint can be affected. While absence of crystals is somewhat atypical, it's not rare in gout. And if it weren't gout, DGI would be low on the list of possibilities; I could list at least 10 conditions that would be more likely. In any case, gout is the best bet, and the chance of any kind of infectious cause (DGI or any other) is low. I imagine your doctor has said pretty much the same. But recheck with him or her if the problem continues or is otherwise unclear. Or see a rheumatologist, if that's not your doctor's specialty already.

That completes the two follow-up comments and replies included with each question, ending this thread. Take care and stay safe.

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