Gonococcal tenosynovitis in two HIV-infected heterosexual men: delayed diagnoses following negative urine nucleic acid amplification testing

Abstract

With recent increases in annual gonorrhoea incidence and disproportionately high infection rates amongst men who have sex with men, the clinical picture of disseminated gonococcal infection is changing. We present two cases where consideration of, and investigation for, disseminated Neisseria gonorrhoeae infection provided the answer when routine inpatient diagnostics had been unsuccessful.

Cutaneous manifestations of disseminated gonococcemia

“…The cutaneous lesions are usually confined to the extremities and described as tender, sparse papulo-pustules on a hemorrhagic base. Other reported skin manifestations include abscesses, cellulitis, petechiae, purpuric macules, necrotizing fasciitis, and vasculitis ( [2,6,13,16,[20][21][22], Table 1). Immune impairment should be considered when patients present with severe skin lesions and the clinician should investigate for underlying conditions such as diabetes mellitus, chronic steroid use, and HIV infection [2].…”

“…Abscesses Submucous periurethral abscess or multiple synchronous distant abscesses (usually in immunocompromised) [2,22] Cellulitis Multifocal cellulitis that has yet to organize into distinct abscesses [6] Macules Round ill-defined, pink macule with central pinpoint vesiculation [16] Necrotizing fasciitis…”

“…Usually sparse and found on extremities [13,16] Table 1. Cutaneous Lesions Described in Disseminated Gonococcal Infections [2,6,13,16,[20][21][22] [2,15]. Even so, when DGI is clinically suspected, cultures should be obtained from mucosal sites including the cervix, pharynx, rectum, and urethra [14].…”

“…Additional findings include a dense neutrophilic infiltrate with leukocytoclasis and possibly bacterial invasion [14,19]. Another option for patients with negative cultures is the Neisseria gonorrhoeae/Chlamydia trachomatis nucleic acid amplification testing assay and urine polymerase chain reaction test which provide greater sensitivity [2,5,6,15,22].…”

Septic arthritis in a previously healthy man with pan-negative infectious and rheumatologic work-up

“…Despite the overall strength of the urine gonorrhoea NAAT, there are instances when it fails. A previous case reported two HIV-positive, MSM men with septic arthritis with negative initial urine NAAT who later had joint cultures with N. gonorrhoeae 10. To the authors’ knowledge, our case report is the first to report of urine NAAT-negative, joint culture-positive gonococcal arthritis in an immunocompetent, presumably heterosexual male.…”