Review Question - QID 107605

This patient has a disseminated gonococcal infection manifesting with fevers, arthralgias, tenosynovitis and skin lesions. Treatment should intravenous (IV) third generation cephalosporin therapy followed by oral antibiotics for a total of 7 days of treatment.

Disseminated gonococcal infections (DGIs) can be diagnosed using clinical suspicion with cervical or urethral cultures acting as the confirmatory test. Diagnosis may be difficult as patients may not have a history of genitourinary symptoms or may not endorse a history a sexual activity. Cultures of the cervix in women and urethra in men yield the highest diagnostic sensitivity and specificity. Infections typically respond very well to antibiotic treatment.

Happe et al. discuss, in detail, the presentation of DGIs. One to three percent of patients with gonorrhea develop a disseminated infection. Once disseminated, the infection can present in a "bacteremic" or "suppurative" form. Those who present with the "bacteremic" form demonstrate fever, chills, asymmetric tenosynovitis, dermatitis and arthralgias without non-purulent arthritis. In the second "suppurative" form patients are typically afebrile, have no skin lesions but have purulent arthritis.

Garcia-Arias et al. review diagnosis and treatment of DGIs. Patients will present with leukocytosis and elevated erythrocyte sedimentation rate. In patients with the bacteremic form of disseminated infection (as in the patient described), blood cultures will almost always be negative and culture of joint aspirate will be positive about 50% of the time. Culture of genitourinary samples has a sensitivity and specificity of 50-70% and 90-95%, respectively. Treatment should include IV third generation cephalosporin therapy for 24-48 hours (spectinomycin if penicillin allergic) followed by oral therapy. Doxycycline or azithromycin should be added if the patient is suspected to be co-infected with Chlamydia.

Figure A: Demonstrates a small pustular lesion on an erythematous base on the dorsum of the patient's right hand.

Incorrect Answers:
Answer 1: Patients with acute meningococcemia may present with arthritis, but are typically more toxic and have concurrent septicemia or meningitis.
Answer 2: Reiter's syndrome presents with uveitis, urethritis and arthritis. Chlamydia trachomatis is an organism that is commonly implicated in Reiter's syndrome.
Answer 3: Acute bacterial endocarditis may present with arthritis and skin lesions. Blood cultures are typically positive with patients also usually having additional cardiac abnormalities.
Answer 5: Sweet's syndrome presents with reddish plaques or nodules, neutrophilia and fever. It may be associated with an underlying malignancy.