A disseminated infection is one in which a localized infection spreads (disseminates) from one area of the body to other organ systems. Once pain subsides, more active exercises, with stretching and muscle strengthening, should begin. Examination detects a purulent, yellow-green urethral discharge, and the meatus may be inflamed. Currently, for gonorrhea infection hasacquired a number of features:•reduced sensitivity of the gonococcus to traditional antibacterialagents,•uncontrolled use of antibiotics leads to the appearance … There are no history or physical exam features that can distinguish between chlamydia and gonorrhea infection except for disseminated infection, which is unique to gonorrhea. It causes the sexually transmitted genitourinary infection gonorrhea as well as other forms of gonococcal disease including disseminated gonococcemia, septic … The most common presentation of disseminated gonococcal infection (DGI) is acute arthritis, tenosyovitis, and dermatitis (Arthritis-Dermatitis Syndrome). Neisseria gonorrhoeae, also known as gonococcus (singular), or gonococci (plural) is a species of Gram-negative diplococci bacteria isolated by Albert Neisser in 1879. , MD, MPH, University of California San Diego, (See also Overview of Sexually Transmitted Diseases.). In some patients, pain develops and tendons (eg, at the wrist or ankle) redden or swell. 2017 Jan 15;23(1) Metcalfe R, Reed M, Winter A. Examination with a proctoscope may detect erythema or mucopurulent exudate on the rectal wall. Tenosynovitis … Required fields are marked *. Disseminated gonococcal infection results from the spread of the bacteria to the joints and other tissues. There are a few groups we especially want to remind to seek STD screening. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. Onset is often acute, usually with fever, severe joint pain, and limitation of movement. Gonorrhea is an infection caused by a sexually transmitted bacterium that infects both males and females. amzn_assoc_marketplace = "amazon"; Disseminated Gonorrhea Infections occur when the sexually transmitted pathogen Neisseria gonorrhoeae spreads beyond the site of infection and … A spectrum of symptoms include: Tenosynovitis; Skin lesions; Polyarthralgia and oligoarthralgia, or purulent arthritis; Constitutional symptoms … Stephanie Florez-Pollack, B.S., and Melissa M. Mauskar, M.D. PID may include salpingitis, pelvic peritonitis, and pelvic abscesses and may cause lower abdominal discomfort (typically bilateral), dyspareunia, and marked tenderness on palpation of the abdomen, adnexa, or cervix. This topic will discuss the epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of DGI. Neisseria gonorrhoeae, also known as gonococcus (singular), or gonococci (plural) is a species of Gram-negative diplococci bacteria isolated by Albert Neisser in 1879. Gonococcal arthritis is inflammation of the joints caused by a disseminated … We do not control or have responsibility for the content of any third-party site. Heterosexually active men are not routinely screened unless they are considered at high risk (eg, those with multiple sex partners, patients at adolescent or STD clinics, men entering correctional facilities). Centers for Disease Control and Prevention: 2015 Sexually Transmitted Diseases Treatment Guidelines: Gonococcal Infections. Over 95% of patients treated for gonococcal arthritis recover complete joint function. The lower incidence of DGI is caused by a lower prevalence of gonococcal strains able to enter the bloodstream and survive, going on to seed joint, tendon sheath, skin, and other tissues. Symptoms range from mild to severe and include dysuria and vaginal discharge. Skin lesions occur typically on the arms or legs, have a red base, and are small, slightly painful, and often pustular. Due to increasing drug resistance, experts no longer recommend monotherapy for gonococcal infection. This severe type of gonorrhea takes place when “the sexually transmitted pathogen Neisseria gonerhoeae spreads beyond the site of infection and invades the … About 25% of men have minimal symptoms. Please confirm that you are a health care professional. DGI typically affects the skin, tendon sheaths, and joints. While there are systemic infections that can affect the entire body at once, doctors will reserve the term for those infections that are normally constrained to a specific site. In some patients, pain develops and tendons (eg, at the wrist or ankle) redden or swell. Disseminated gonococcal infection (DGI) results from bacteremic spread of the sexually transmitted pathogen, Neisseria gonorrhoeae, which can lead to a variety of clinical symptoms and signs, such as arthritis or arthralgias, tenosynovitis, and multiple skin lesions. Gonorrhea is a commonly caused … Suspected disseminated gonococcal infection (DGI) DGI occurs when infection with N gonorrhoeae is left untreated. amzn_assoc_asins = "B009LRVC0K,B07B2VYWBJ,B07GFRG49Y,B005IG9SW2"; Your email address will not be published. Some patients present with or have a history of skin lesions of DGI. In patients who have an azithromycin allergy or who immediately vomit the drug, doxycycline 100 mg orally twice a day for 7 days is an alternative to azithromycin as a second antimicrobial. In a small fraction of men, ascending urethritis progresses to epididymitis. A cervical swab should be sent for culture or NAAT. Given the high proportion of patients in the series with disseminated infection, and the concern for life-threatening outcomes due to DGI, healthcare professionals are encouraged to evaluate all patients receiving eculizumab who … A limp with an unusual cause. This can lead to  joint pain and swelling from infected joints; small, painless red based skin lesions that have clear fluid or pus in them; infection in the blood; or, on rare occasions, infections of the heart valves or fluid around the brain. BMJ. However, for patients with symptoms for > 7 days, specimens should be obtained, cultured, and tested for antimicrobial sensitivity. 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Gonorrhea is a sexually transmitted disease. Urethritis may occur concurrently; pus may be expressed from the urethra when the symphysis pubis is pressed or from Skene ducts or Bartholin glands. The infection is spread through the columnar or transitional epithelium; therefore, this organism can affect the urethra, rectum, cervical canal, pharynx, upper female … Serologic tests for syphilis (STS) and HIV and NAAT to screen for chlamydial infection should also be done. Steven J. Schweon is an infection prevention consultant in Saylorsburg, Pa. Gonococcal infections caused by the bacterium Neisseria gonorrhoeae are the second most commonly reported notifiable condition in the United States [ … Recent menstruation. The link you have selected will take you to a third-party website. Abstract Septic arthritis caused by N gonorrhoeae is monoarticular or pauciarticular, and is more commonly associated with positive synovial fluid cultures and negative blood cultures. Nucleic acid amplification tests (NAATs) may be done on genital, rectal, or oral swabs. Culture is sensitive and specific, but because gonococci are fragile and fastidious, samples taken using a swab need to be rapidly plated on an appropriate medium (eg, modified Thayer-Martin) and transported to the laboratory in a carbon dioxide–containing environment. Alerts and Notices Synopsis Tenosynovitis, Dermatitis, Polyarthralgia Syndrome Gonococcemia refers to the presence of Neisseria gonorrhoeae in the bloodstream, often leading to disseminated gonococcal infection (DGI). Gonorrhea is a purulent infection of the mucous membrane surfaces caused by Neisseria gonorrhoeae. Skin lesions occur typically … Pericarditis, endocarditis, meningitis, and perihepatitis occur rarely. Gonorrhea is a commonly caused sexually transmitted infection. Anyone showing symptoms should immediately reach out to their health care provider. Sex Transm Dis. Genital gonorrhea, the usual source of disseminated infection, may be asymptomatic. Screen asymptomatic, high-risk patients using NAAT. Asymptomatic patients considered at high risk of sexually transmitted diseases (STDs) can be screened by NAAT of urine samples, thus not requiring invasive procedures to collect samples from genital sites. When gonorrhea infection spreads to other organs and sites in the body, the disease is referred as disseminated gonococcal infection. DGI with gonococcal arthritis is initially treated with IM or IV antibiotics (eg, ceftriaxone 1 g IM or IV every 24 hours, ceftizoxime 1 g IV every 8 hours, cefotaxime 1 g IV every 8 hours) continued for 24 to 48 hours once symptoms lessen, followed by 4 to 7 days of oral therapy. CDC has created the DGI Case Report Form and REDCap Survey, which state and local health departments may use to collect … EPT may enhance partner adherence and reduce treatment failure due to reinfection. Sometimes gonorrhea spreads to the adnexa, causing salpingitis, or disseminates to skin and/or joints, causing skin lesions or septic arthritis. N. gonorrhoeae must be distinguished from N. meningitidis and other closely related organisms that are often present in the throat without causing symptoms or harm. After an episode of vaginal intercourse, likelihood of transmission from women to men is about 20%, but from men to women, it may be higher. Disseminated gonococcal infection results from the spread of the bacteria to the joints and other tissues. Chlamydiae or intestinal bacteria may also cause PID. Gonorrheal cervicitis is commonly accompanied by dysuria or inflammation of Skene ducts and Bartholin glands. About 10 to 20% of infected women and very few infected men are asymptomatic. Epididymitis usually causes unilateral scrotal pain, tenderness, and swelling. In 10 to 20% of women, cervical infection ascends via the endometrium to the fallopian tubes (salpingitis) and pelvic peritoneum, causing pelvic inflammatory disease (PID). ), For uncomplicated infection, a single dose of ceftriaxone plus azithromycin, For DGI with arthritis, a longer course of parenteral antibiotics, Concomitant treatment for chlamydial infection. If gonorrhea isn’t treated it can also spread to the blood and cause disseminated gonococcal infection (DGI). eculizumab, gonorrhea, disseminated gonococcal infection (See the Editorial Commentary by McQuillen and Ram on pages 601–3 .) Because nucleic acid amplification tests have replaced culture in most laboratories, finding a laboratory that can provide culture and sensitivity testing may be difficult and require consultation with a public health or infectious disease specialist. Disseminated gonococcal infection complicated 0.4%–3% of gonococcal infections during the 1970–80s.1, 2 Although rates declined thereafter,1, 2 a recent resurgence has been attributed to oral–genital sexual practices among men who have sex with men (MSM).2 The classic presentation is a triad of … Definition: Gonococcal arthritis is inflammation of a joint due to a gonorrhea infection.. Gonococcal arthritis is a type of septic arthritis.This is inflammation of a joint due to a bacterial or fungal infection. amzn_assoc_region = "US"; 2015 Apr 21;350:h1985 In both male and female, arthritis is the most common manifestation of DGI. Urethral and cervical swabs should be submitted for culture and DNA probe for N. gonorrhea and Chlamydia trachomatis. The process usually settles in one or two … Your email address will not be published. Save my name, email, and website in this browser for the next time I comment. Disseminated gonococcal infection. Disseminated gonorrhea: a health risk associated with untreated oral gonorrhea. It occurs in 0.5–3% of infected individuals. Approximately 70% of all cervical cancers are caused by which of the following types of human papilloma virus (HPV)? In females, gonorrhea can also infect the cervix.Gonorrhea is most commonly spread during sex. Gram stain is sensitive and specific for gonorrhea in men with urethral discharge; gram-negative intracellular diplococci typically are seen. If gonococcal infection is confirmed, and as is the case with any other sexually transmitted disease, the patient should be tested for syphillis using a rapid plasma reagin (RPR) test, and for human immunodeficiency virus (HIV). In a news release, the department said that disseminated gonococcal infections (DGI), a severe form of gonorrhea, has gone mostly untreated. The trusted provider of medical information since 1899, Overview of Sexually Transmitted Diseases, Chlamydial, Mycoplasmal, and Ureaplasmal Mucosal Infections. 2013 Feb 5;158(3):ITC2-1, correction can be found in Ann Intern Med 2013 Mar 19;158(6):504; Mayor MT, Roett MA, Uduhiri KA. Disseminated Gonococcal Infection List of authors. Patients who are allergic to cephalosporins are treated with one of the following: Gemifloxacin 320 mg orally plus azithromycin 2 g orally once, Gentamicin 240 mg IM plus azithromycin 2 g orally once. Disseminated infection is one of the major threats of gonococcal infection. California gonorrhea: Increase in disseminated gonococcal infections reported. California state health officials are reporting an increase in disseminated gonococcal infections (DGI), which is an uncommon, but significant complication of untreated gonorrhea. “As an infectious disease and public health physician, I am very concerned that we are seeing completely preventable complications of sexually transmitted disease (STD) infections that went undiagnosed and untreated, likely due to people not seeking care or getting routine testing during the COVID-19 pandemic,” said Dr. Erica Pan, Acting State Public Health Officer. With gonococcal arthritis, blood cultures are less often positive, but cultures of joint fluids are usually positive. Disseminated gonococcal infection. Therapeutic considerations today have to take antibiotic-resistant or even multi-resistant Neisseria gonorrhoeaestrains into account. This website uses cookies so that we can provide you with the best user experience possible. A spectrum of symptoms include: Tenosynovitis; Skin lesions The author has disclosed no financial relationships related to this article. Gonococcal arthritis is a complication of gonorrhea, a sexually transmitted infection that results in inflammation and pain in the tissues and joints. Dissemination to skin and joints, which is uncommon, causes sores on the skin, fever, and migratory polyarthritis or pauciarticular septic arthritis. It occurs in <3% of gonorrhoea infections. Gonococcal arthritis. Urinary frequency and urgency may develop as the infection spreads to the posterior urethra. Male urethritis has an incubation period from 2 to 14 days. An affected joint should be aspirated, and fluid should be sent for culture and routine analysis (see arthrocentesis). Pelvic inflammatory disease occurs in 10 to 20% of infected women. While there are systemic infections that can affect the entire body at once, doctors will reserve the term for those infections that … Patients with skin lesions, systemic symptoms, or both should have blood, urethral, cervical, and rectal cultures or NAAT. It occurs when the infection spreads through the bloodstream to other parts of the body, especially the skin and joints. 2006 Jan. 33(1):36-51. . Most of the cases in California have presented with joint pain and infected joints. Gonorrhea is most commonly spread during vaginal, oral or anal sex. Beatrous SV, Grisoli SB, Riahi RR, Matherne RJ, Matherne RJ. Treatment for gonorrhea is effective and available, but many cases go untreated. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Conjunctival gonococcal infection can result in scarring, permanent visual impairment and blindness. Disseminated gonococcal infection (DGI), also called the arthritis-dermatitis syndrome, reflects bacteremia and typically manifests with fever, migratory pain or joint swelling (polyarthritis), and pustular skin lesions. Disseminated Gonorrhea Infections occur when the sexually transmitted pathogen Neisseria gonorrhoeae spreads beyond the site of infection and invades the bloodstream traveling to distant sites in the body. Blood and joint fluid samples should be sent to the laboratory with notification that gonococcal infection is suspected. It occurs in 0.5–3% of infected individuals. Definition: Gonococcal arthritis is inflammation of a joint due to a gonorrhea infection.. Gonococcal arthritis is a type of septic arthritis.This is inflammation of a joint due … Disseminated gonococcal infection. Over time, the bacteria that causes gonorrhea can spread to the bloodstream and other parts of the body… Gonorrhea, colloquially known as the clap, is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. Gonococcal arthritis is a rare disorder. Disseminated gonorrhea infections occur when a sexually transmitted pathogen, Neisseria gonorrhoeae, spreads beyond the site of infection and … Gonorrhea most often affects the urethra, rectum or throat. Gonorrhea is an infection caused by a sexually transmitted bacterium that can infect both males and females. In disseminated infection, it is important to evaluate for evidence of meningitis and endocarditis. Other articles where Disseminated gonococcal infection is discussed: gonorrhea: Symptoms: …sometimes enter the bloodstream, causing disseminated gonococcal infection (DGI) in virtually any organ system. All sex partners who have had sexual contact with the patient within 60 days should be tested for gonorrhea and other STDs and treated if results are positive. When gonorrhea spreads in this way, it’s referred to as a disseminated gonococcal infection (DGI) or … Infection may involve the genitals, mouth, and/or rectum. Infected men may experience pain or burning with urination, discharge from the penis, or testicular pain. Learn more about our commitment to Global Medical Knowledge. Test of cure is recommended only for patients treated with an alternative regimen for pharyngeal infections. Fitz-Hugh-Curtis syndrome is gonococcal (or chlamydial) perihepatitis that occurs predominantly in women and causes right upper quadrant abdominal pain, fever, nausea, and vomiting, often mimicking biliary or hepatic disease. The classic triad of features consists of dermatitis, tenosynovitis and migratory polyarthritis. Neonates can acquire conjunctival infection during passage through the birth canal, and children may acquire gonorrhea as a result of sexual abuse. Gonococcal arthritis is a complication of gonorrhea, a sexually transmitted infection that results in inflammation and pain in the tissues and joints. The legacy of this great resource continues as the Merck Manual in the US and Canada and the MSD Manual outside of North America. During pelvic examination, clinicians may note a mucopurulent or purulent cervical discharge, and the cervical os may be red and bleed easily when touched with the speculum. Posttreatment cultures are unnecessary if symptomatic response is adequate. Patients with disseminated gonorrhea usually have no urogenital symptoms. Rectal gonorrhea is usually asymptomatic. However, a health care visit is preferable to ascertain histories of drug allergies and to screen for other STDs. Inpatient management and consultation with an infectious disease specialist to decide upon initial regimen are recommended, especially in patients who may be noncompliant … It is caused by gram negative gonococcus bacteria. amzn_assoc_linkid = "9b27718be6cb179e82542d17d7861c3e"; Dermatol Online J. Merck & Co., Inc., Kenilworth, NJ, USA is a global healthcare leader working to help the world be well. Gonorrhea is diagnosed when gonococci are detected via microscopic examination using Gram stain, culture, or a nucleic acid–based test of genital fluids, blood, or joint fluids (obtained by needle aspiration). “STD risk has not gone away. Disseminated gonorrhea infections occur when a sexually transmitted pathogen, Neisseria gonorrhoeae, spreads beyond the site of infection and into the bloodstream to distant sites in the body. Due to increasing drug resistance, experts no longer recommend... © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Disseminated Gonococcal Infection (Skin Lesions), Musculoskeletal and Connective Tissue Disorders, Pharyngeal or rectal exposures (either sex), Centers for Disease Control and Prevention. The Merck Manual was first published in 1899 as a service to the community. verify here. This site complies with the HONcode standard for trustworthy health information:   Coinfection with Chlamydia trachomatis occurs in 15 to 25% of infected heterosexual men and 35 to 50% of women. The outcome is potentially fatal. In babies, gonorrhea most commonly affects the eyes.Gonorrhea is a common infection that, in many cases, causes no symptoms. Disseminated gonococcal infection (DGI) is seen in about 0.5 – 3% of patients with Neisseria gonorrhoeae. Gram stain does not identify chlamydiae, so urine or swab samples for NAAT are obtained. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful. Rarely, men develop abscesses of Tyson and Littre glands, periurethral abscesses, or infection of Cowper glands, the prostate, or the seminal vesicles. Joints become swollen, tender, and extremely painful, limiting movement. Cervicitis usually has an incubation period of > 10 days. N. gonorrhoeae can spread through the bloodstream and infect other parts of the body, including the joints, resulting in disseminated gonococcal infection (DGI), which occurs in 0.5% to 3% of patients infected with N. gonorrhoeae. Gonococcal purulent arthritis usually requires repeated synovial fluid drainage either with repeated arthrocentesis or arthroscopically. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Chlamydia is around 10 times more common than gonorrhea in young populations. Disseminated gonorrhea infections happen when the sexually transmitted pathogen called Neisseria gonorrhoeae spreads beyond the site of infection … Joint fluid is usually cloudy to purulent because of large numbers of WBCs (typically > 20,000/microliter). amzn_assoc_placement = "adunit0"; Chlamydia infection. Gonococcal arthritis is a rare disorder. amzn_assoc_search_bar = "true"; amzn_assoc_ad_mode = "manual"; Men who have sex with men are screened if they have been sexually active within the previous year (for insertive intercourse, urine screen; for receptive intercourse, rectal swab; and for oral intercourse, pharyngeal swab). Recent menstruation in a woman who has a Neisseria gonorrhoeae infection … Passive range-of-motion exercises should be started as soon as patients can tolerate them. This can lead to joint pain and swelling from infected joints; small, painless red based skin lesions … According to WHO, the incidence of gonorrhea is about200 million cases per year. Men with obvious discharge may be treated presumptively if likelihood of follow-up is questionable or if clinic-based diagnostic tools are not available. They tend to occur in the extremities and occasionally on the trunk. Alternative names: Disseminated gonococcal infection (DGI); Disseminated gonococcemia; Septic arthritis — gonococcal arthritis. If you disable this cookie, we will not be able to save your preferences. Schweon, Steven J. MPH, MSN, RN, CIC, FSHEA, FAPIC. Symptoms include rectal itching, a cloudy rectal discharge, bleeding, and constipation—all of varying severity. In about 30 to 40% of patients with DGI, blood cultures are positive during the first week of illness. But babies of infected mothers can be … The skin lesions can be macular, maculopapular, or pustular (Figure 1). Herein, we reported atypical presentation of DGI with subcutaneous abscess of right knee, pyomyositis … 2012 Nov 15;86(10):931-8 full-text, correction can be found in Am Fam Physician 2013 … Drinking hand sanitizer, vodka eyeballing and vodka tampons?. ... Disseminated gonococcal infection. Initially, the joint is immobilized in a functional position. In the US, confirmed cases of gonorrhea, chlamydial infection, and syphilis must be reported to the public health system. Infected men may experience pain or burning with urination, discharge from the penis, or testicular pain. Alerts and Notices Synopsis Tenosynovitis, Dermatitis, Polyarthralgia Syndrome Gonococcemia (also called arthritis-dermatosis syndrome) refers to the presence of Neisseria gonorrhoeae in the bloodstream, often leading to disseminated gonococcal infection. In females, gonorrhea can also infect the cervix. Examination of the eyes with a slit lamp is recommended so that infection of the cornea can be excluded. (See also the US Preventive Services Task Force’s summary of recommendations regarding screening for gonorrhea. Uncomplicated gonococcal infection of the urethra, cervix, rectum, and pharynx is treated with the following: Preferred: A single dose of ceftriaxone 250 mg IM plus azithromycin 1 g orally, Alternative: A single dose of cefixime 400 mg orally plus azithromycin 1 g orally. Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae that leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease and epididymitis.The disease primarily affects individuals between 15–24 years of age and has an incubation period of 2–7 days.Gonorrhea … In classic disseminated gonococcal infection (DGI), the patient presents with the triad of skin lesions, polyarthralgias, and tenosynovitis. If a pelvic examination is not possible, NAAT of a urine sample or self-collected vaginal swab can detect gonococcal (and chlamydial) infections rapidly and reliably. Samples for Gram staining can be obtained by touching a swab or slide to the end of the penis to collect discharge. Disseminated gonorrhea Gonococcemia refers to the presence of Neisseria gonorrhoeae in the bloodstream, often leading to disseminated gonococcal infection (DGI). Treat uncomplicated infection with a single dose of ceftriaxone 250 mg IM plus azithromycin 1 g orally once. Last full review/revision Jul 2019| Content last modified Jul 2019. Disseminated gonococcal infection (DGI) is a common cause of acute polyarthralgias, polyarthritis, or oligoarthritis in healthy young patients. Nonpregnant women (including women who have sex with women) are screened annually if they, Engage in high-risk sexual behavior (eg, have a new sex partner or multiple sex partners, engage in sex work, use condoms inconsistently), Have a partner who engages in high-risk behavior. Disseminated Gonococcal Infection (DGI) This results from gonococcal bacteremia and only occurs in up to 3% of those with gonorrhea. The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis. If it isn’t treated promptly, oral gonorrhea may eventually spread to the bloodstream, where it can then infect other parts of the body. Gonococcal bacteremia is more likely to be associated with polyarthralgias and skin lesions. 1. Expedited partner therapy (EPT) involves giving patients a prescription or drugs to deliver to their partner. It causes the sexually transmitted genitourinary infection gonorrhea as well as other forms of gonococcal disease including disseminated gonococcemia, septic arthritis, and gonococcal ophthalmia neonatorum. But babies can be infected during childbirth if their mothers are infected. Gonococcal septic arthritis is a more localized form of DGI that results in a painful arthritis with effusion, usually of 1 or 2 large joints such as the knees, ankles, wrists, or elbows.
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