Obgyn · Year 3 · from Obgyn

Case 2: Disseminated Gonococcal Infection

Patient Demographics

  • Age: 19 years
  • Sex: Female
  • Occupation: Retail worker

Chief Complaint

"I have painful joints in my hands and a rash on my legs for the past week."

History of Present Illness

The patient presents with a 7-day history of migratory joint pain that began in her right knee, then moved to her left wrist, and is now affecting multiple small joints of her hands. She developed a rash on her lower extremities 4 days ago consisting of scattered painful bumps, some of which have developed central pustules. She reports low-grade fever, malaise, and fatigue. Upon specific questioning, she recalls having a mild vaginal discharge approximately 3 weeks ago that resolved spontaneously without treatment. Her last menstrual period was 10 days ago and was heavier than usual. She is sexually active with three partners over the past 3 months and uses condoms inconsistently.

Past Medical History

  • No significant medical history
  • No prior STIs diagnosed
  • Menarche at age 12, regular cycles

Physical Examination Findings

  • Vital Signs: Temperature 38.2 degrees Celsius, HR 92 bpm, BP 118/72 mmHg
  • General: Alert young woman appearing mildly ill
  • Skin: Multiple scattered pustular lesions on an erythematous base on the lower extremities and dorsum of hands, some with central necrosis, approximately 15 lesions total
  • Musculoskeletal: Tenosynovitis of right wrist extensors with pain on passive extension, tenderness and mild swelling of the second and third MCP joints bilaterally, no frank effusion in large joints
  • Pelvic Examination: Minimal mucopurulent cervical discharge, no cervical motion tenderness, no adnexal tenderness or masses

Diagnostic Workup

  • Urine Pregnancy Test: Negative
  • Complete Blood Count: WBC 12,800/microL with 78% neutrophils
  • ESR: 45 mm/hr (elevated)
  • CRP: 68 mg/L (elevated)
  • Blood Cultures: Pending (ultimately negative)
  • Cervical NAAT: Positive for Neisseria gonorrhoeae, negative for Chlamydia trachomatis
  • Pharyngeal NAAT: Positive for Neisseria gonorrhoeae
  • Rectal NAAT: Negative
  • Skin Lesion Gram Stain: Gram-negative diplococci identified
  • Joint Fluid (right wrist aspiration): WBC 28,000/microL with 90% neutrophils, no crystals, Gram stain with gram-negative diplococci, culture pending

Diagnosis

Disseminated Gonococcal Infection (DGI) presenting with the classic triad of:

  1. Dermatitis (pustular skin lesions)
  2. Tenosynovitis (wrist extensor involvement)
  3. Migratory polyarthralgia with septic arthritis

Management Plan

Hospitalization for IV Therapy:

  1. Admit for parenteral antibiotic therapy and joint monitoring
  2. Orthopedic consultation for possible joint washout if large joint septic arthritis develops

Antibiotic Regimen:

  1. Ceftriaxone 1 gram IV every 24 hours (weight-based dosing for DGI)
  2. Continue parenteral therapy for 24 to 48 hours after clinical improvement
  3. Transition to oral therapy: cefixime 400 mg twice daily to complete at least 7 days total therapy (some experts recommend 10 to 14 days for DGI)
  4. Add azithromycin 1 gram orally single dose for presumptive chlamydia co-treatment (even with negative chlamydia NAAT given high co-infection rates)

Supportive Care:

  1. NSAIDs for pain and inflammation
  2. Rest and immobilization of affected joints
  3. Serial joint examinations

Partner Notification:

  1. All sexual partners from preceding 60 days should be evaluated and treated presumptively
  2. Expedited partner therapy where legally permissible

Additional Testing:

  1. HIV testing (DGI is an AIDS-defining illness consideration)
  2. Syphilis serology (RPR)
  3. Hepatitis B and C serologies

Follow-up:

  1. Test of cure NAAT at 7 to 14 days (particularly for pharyngeal infection which has higher treatment failure rates)
  2. Repeat NAAT for gonorrhea and chlamydia at 3 months
  3. Counseling on consistent condom use and STI prevention

Prognosis

With appropriate antibiotic therapy, disseminated gonococcal infection carries an excellent prognosis. The dermatitis and tenosynovitis typically resolve within days of starting treatment. Joint damage is uncommon with early treatment.

Clinical Image

Image Description: Clinical photograph demonstrating the characteristic pustular skin lesions of disseminated gonococcal infection. The lesions appear as papules and pustules on an erythematous base, with some showing central necrosis or hemorrhagic centers. These lesions are typically few in number (less than 40), distributed on the extremities, and may be painful.

Attribution: Image from Wikimedia Commons, Category: Neisseria gonorrhoeae (https://commons.wikimedia.org/wiki/Category:Neisseria_gonorrhoeae). Licensed under Creative Commons.

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