Discussion:
Gonorrhea is a sexually transmitted infection caused by N.
gonorrhoeae with resultant genital infections, and rarely, pharyngeal
and anorectal infections
(6). Bacteremia
resulting in DGI is found to be more common during pregnancy,
menstruation, and with the use of intra-uterine devices (IUDs)
(7) and seen in about
0.5-3% of the cases
(8). Other risk
factors predisposing for dissemination include homosexual or bisexual
men, infection with resistant strains, and complement deficiencies
(9). Eculizumab, a
monoclonal antibody to complement protein 5, used for treatment of
complement mediated conditions like hemolytic-uremic syndromes has been
associated with an increased risk of meningococcal disease
(10). DGI is more
common among females than males; this is likely due to a higher
percentage of women remaining asymptomatic, hence delaying treatment,
along with subsequent endometrial exposure of submucosal vessels to the
bacteria, leading to the dissemination of infection
(11).
Blood cultures are found to be positive in less than one-third of
disseminated gonorrhea cases. Positive blood cultures are more often
seen in patients that present with cutaneous involvement as well as
gonococcal polyarthritis. Cutaneous manifestations in DGI along with
polyarthritis can also be accompanied by tenosynovitis. Cutaneous
findings are predmonantly noted on the trunk and extremities. Our
patient was found to have a generalized maculopapular, non-tender, and
petechial rash. Joint involvement in DGI is manifested by polyarthralgia
but never as suppurative arthritis
(12).
Polyarthralgia is typically asymmetric and can affect all joints, large
and small. Our patient was also a newly diagnosed diabetic which likely
led to worsening of the underlying infection and presentation of
cutaneous manifestations. A study of 55 patients with disseminated
infections from Neisseria gonorrhoeae revealed that this complication
occurs in young adults, with a predominance in women (80%) with
arthritis being the most common manifestation
(13).
N. gonorrhoeae is isolated in about 25% of the synovial fluid
obtained by arthrocentesis. Synovial cultures are less sensitive in
gonococcal arthritis compared to NAAT in the detection of N.
gonorrhoeae . Whenever feasible, NAAT is recommended as the initial test
for patients, including asymptomatic patients, with a suspicion of
gonorrhea. One case study concluded that when DGI is considered as part
of the differential diagnosis, the gonococcal infection cannot be
excluded solely on negative urine NAAT. A thorough history, which
includes sexual history, testing of appropriate sites (rectal,
oropharyngeal) along with, NAAT of the joint aspirate should be
considered when suspicion is high
(5). Cautious
interpretation of a negative NAAT must be done since some N.
gonorrhoeae subtypes can have variations in the targeted sequences
tested by NAAT resulting in a false-negative test
(14).
DGI has been reported in patients with SLE; likely mechanisms include
complement depletion, use of immunosuppressive medications, and an
association between SLE and inherited complement disorders
(15). Given the
overlap of symptoms between DGI and SLE, a high degree of suspicion is
warranted to diagnose DGI in patients with SLE
(16).
Conclusion: Early detection and appropriate treatment of disseminated gonorrhea
with cutaneous and joint involvement is the key to the prevention of
lifelong disability. Given its rare presentation, low threshold must be
held for prompt testing of gonorrhea and initiation of treatment,
especially in patients with SLE and immunosuppressed states. A detailed
sexual history is indicated in all the patients when DGI is considered a
possible diagnosis to avoid delays in the diagnosis and treatment. If
DGI is suspected and considered a likely differential, a negative urine
NAAT should not dissuade the clinicians from pursuing further diagnostic
tests.