Case Description:
A 42-year-old woman with a history of asthma and diet-controlled type 2
diabetes presented to the hospital with fever, skin rash, knee, and
ankle pain for four days. Prior to admission, the patient developed a
fever of 103.9 followed by the development of a generalized non-pruritic
rash and subsequently developed polyarticular swelling and erythema in
her right foot and bilateral knees. The patient reported unprotected
sexual intercourse with a new partner a week prior to the presentation.
Vitals on admission were blood pressure of 137/80 mmHg, pulse 88 beats
per minute, temperature 36.6 degrees Celsius, respirations 18 breaths
per minute, and oxygen saturation of 99% on room air. On examination,
the skin showed the presence of diffuse vesiculopustular, non-tender,
non-pruritic rashes (Figure 1). The right foot was erythematous and
associated with ankle edema, and the left knee exhibited mild swelling
with a reduced range of motion due to tenderness. Labs on admission
showed a white count of 21,000/microL. HIV antigen and antibody testing
was negative. Two sets of blood cultures were negative. The urine NAAT
was indeterminate. She was started empirically on intravenous vancomycin
and ceftriaxone. Right knee swelling confirmed joint effusion on imaging
which was aspirated, revealing monosodium urate crystals in synovial
fluid analysis and the culture growing gram-negative diplococci. No
cervical motion tenderness was noted. Disseminated gonococcal infection
was suspected and the patient underwent recurrent synovial joint
washouts due to persistent symptoms of pain and reduced range of motion.
The patient’s symptoms improved over the 5-day hospital course and
ultimately discharged home to continue ceftriaxone for a total of 7 days
post-final joint washout.