ANSWER 66
The patient has acute gonorrhoea and gonococcal arthritis. The X-ray of the knee is nor-
mal. The diagnosis is made by microscopy of the discharge, which should show Gram-
positive diplococci, and culture of an urethral swab. The swab should be inoculated onto
fresh appropriate medium straight away and kept at 37°C until arrival at the laboratory.
Immediate treatment on clinical grounds with ciprofloxacin is indicated; penicillin should
be reserved for gonorrhoea with known penicillin sensitivity, to prevent the development
of resistant strains. Septic monoarthritis is a complication of gonorrhoea; other metastatic
infectious complications are skin lesions and, rarely, perihepatitis, bacterial endocarditis
and meningitis.
The patient disclosed that he had had unprotected sexual intercourse with prostitutes in
Thailand and Singapore; he had had no intercourse following return to the UK so no fol-
low-up of contacts was necessary. For advice on precautions and investigation for other
sexually transmitted diseases he was referred to the sexually transmitted diseases (STD)
clinic.
- All students and doctors should be confident in eliciting a sexual history.
- Accurate sexual histories are more likely when the patient feels confidence and empathy
with the interviewer. - Contact tracing is an important element of management of sexually transmitted disease.