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.