A 32-year-old previously healthywoman presents to the emergencydepartment with skin lesions, suprapubicpain, and generalized myalgia of1 week’s duration. Trimethoprim-sulfamethoxazolefor a presumed urinarytract infection is prescribed, and thepatient is discharged. The symptomspersist; she is hospitalized 2 days later.
1. Erythematous lesions, suprapubic pain, and myalgia
A 32-year-old previously healthy woman presents to the emergency department with skin lesions, suprapubic pain, and generalized myalgia of 1 week’s duration. Trimethoprim-sulfamethoxazole for a presumed urinary tract infection is prescribed, and the patient is discharged. The symptoms persist; she is hospitalized 2 days later.
The patient denies diarrhea, dysuria, vaginal discharge, chills, or rigors. Her last menstrual period was 10 days earlier. Temperature is 37.4oC (99.4oF); other vital signs are normal.
Mild suprapubic tenderness is noted; there are no masses or signs of peritonitis. Several tender maculopapular erythematous lesions with several vesicles and scabs are scattered over the extremities and trunk (A). The right first metacarpophalangeal and right elbow joints are erythematous, tender, and slightly swollen (B).
What condition is the likely cause of this woman’s symptoms?
(Answer on next page.)
1. Erythematous lesions, suprapubic pain, and myalgia: The differential diagnosis includes reactive arthritis, Reiter syndrome, septic arthritis, disseminated gonococcal arthritis, acute rheumatic fever, bacterial endocarditis, Lyme disease, secondary syphilis, and hepatitis B. Disseminated gonococcal infection was suspected; empiric therapy with intravenous ceftriaxone was initiated. The complete blood cell count was normal. Microscopic examination of the urine revealed 2 white blood cells, 3 red blood cells, and a few bacteria.
Neisseria gonorrhoeae DNA was detected by polymerase chain reaction (PCR) analysis in a cervical specimen; this finding confirmed the diagnosis of disseminated gonococcal infection. A PCR test was negative for chlamydiae. Results of blood and urine cultures and a rapid plasma reagin test ruled out syphilis and Chlamydia infection. Intravenous ceftriaxone was given for 48 hours; the patient’s symptoms improved within 24 hours. The patient was given a 7-day prescription of an oral cephalosporin and discharged. A follow-up appointment with her primary care physician was scheduled.
Disseminated gonococcal disease occurs in between 0.3% and 5% of persons with N gonorrhoeae infection. Adults between the ages of 16 and 24 years are most commonly affected. Risk factors for disseminated gonococcal infection include multiple sex partners, inherited complement (C5 to C8) deficiency, systemic lupus erythematosus, HIV infection, homosexuality, pregnancy, menstruation, and puerperium. Gonococcal virulence is increased by bacterial factors such as pili, protein 1a, proteoglycan, IgA protease, and the absence of protein A and protein III.
Tenosynovitis, arthritis, and dermatitis make up the classic clinical triad of the disease. Tenosynovitis occurs in 65% of patients and typically involves the wrists, hands, fingers, ankles, and toes. Between 30% and 40% of patients are affected by arthritis-usually a migratory polyarthritis of the wrists, fingers, knees, elbows, and ankles. A macular, maculopapular, vesicular, or pustular dermatitis erupts on the extremities and, rarely, on the trunk of 50% to 75% of patients. Less common clinical findings are pericarditis, endocarditis, meningitis, perihepatitis (Fitz-Hugh–Curtis syndrome), pyomyositis, osteomyelitis, and glomerulonephritis.
Diagnosis is made by PCR analysis, which detects N gonorrhoeae DNA in mucosal specimens of the cervix, rectum, pharynx, and urethra. Blood cultures and synovial cultures are positive in 50% of patients. Skin culture yield is less than 5%.
Culture on selective media, such as Thayer-Martin agar with 5% carbon dioxide, has a sensitivity of 95% or more for urethral specimens from men with symptomatic urethritis and 80% to 90% sensitivity for endocervical infections in women.
Treatment usually involves parenteral infusion of a third-generation cephalosporin until improvement is noted, followed by a 7-day course of an oral cephalosporin. Hospitalized patients who are allergic to β-lactam antibiotics can be given ciprofloxacin, ofloxacin, or spectinomycin. Quinolones, amoxicillin-clavulanate, and cefuroxime are prescribed for outpatients. Because 50% of patients have concurrent Chlamydia trachomatis infection, doxycycline, 100 mg bid for 7 days, is recommended.
Order serologic tests for Chlamydia infection, syphilis, and HIV infection in patients with gonorrhea. Strongly recommend screening for all sex partners of affected patients.
FOR MORE INFORMATION:
•Angulo JM, Espinoza LR. Gonococcal arthritis. Compr Ther., 1999;25:155-162.
•Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51(RR-6):36-42.
•Cohen M. Gonococcal arthritis. Bull Rheum Dis. 1998;47:4-6.
•Kerle KK, Mascola JR, Miller TA. Disseminated gonococcal infection. Am Fam Physician. 1992;45:209-214.
•Liebling MR, Arkfeld DG, Michelini GA, et al. Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. Arthritis Rheum.1994;37:702-709.
•Rompalo AM, Hook EW 3rd, Roberts PL, et al. The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis. Arch Intern Med. 1987;147:281-283.
•Shapira O, Bar-On E, Sagiv S, Malkin C. Disseminated gonococcal infection. J Am Geriatr Soc. 1990;38:678-679.
•Smith KR, Ching S, Lee H, et al. Evaluation of ligase chain reaction for use with urine for identification of Neisseria gonorrhoeae in females attending a sexually transmitted disease clinic. J Clin Microbiol. 1995;33:455-457.
•Stewart K, Carlson M, Segal AM, White CS. Gonococcal arthritis caused by penicillinase-producing strains of Neisseria gonorrhoeae. Arthritis Rheum. 1991;34: 245-246.
•Woods GL, Garza DM. Use of gen-probe competition assay as a supplement to probes for direct detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urogenital specimens. J Clin Microbiol. 1996;34:177-178.
2. Palmar and plantar rash
For several weeks, a 29-year-old woman has had a rash on her palms and soles. Topical over-the-counter therapies have failed to resolve the condition. She offers no history that suggests an irritant or contactant; contact dermatitis is not suspected.
Small, discrete, scaly papules are noted on the patient’s palms, feet, and soles.
To what do you attribute these lesions?
(Answer on next page.)
2. Palmar and plantar rash: Results of a reactive plasma reagin test and a fluorescent treponemal antibody absorption test confirmed the suspected diagnosis of secondary syphilis. Primary syphilis is characterized by a chancre that arises at the site of inoculation; 3 to 12 weeks later, the signs of secondary syphilis, including the eruption of lesions on the palms and soles, begin to appear. These papulosquamous lesions of secondary disease regress within 4 to 12 weeks.
The patient was given 2.4 million units of benzathine penicillin G intramuscularly. A second reactive plasma reagin test performed 3 months after therapy showed a 4-fold drop in titer that represented a cure.
3. Mildly tender penile ulcer
A 40-year-old homosexual man, who is seropositive for HIV, is concerned about a worsening lesion on his penis. The patient reports that the wound occurred 1 week earlier when he lacerated his genitals with the zipper of his pants. The lesion progressed and began to ulcerate despite applications of a topical antibiotic.
The patient has no fever; he complains of moderate pain in the inguinal region. He denies a history of sexually transmitted diseases other than HIV infection. His partner has outbreaks of genital herpes several times a year.
A 2- to 3-cm indurated papule with central ulceration is noted. The lesion is mildly tender to palpation. There is no discharge or surrounding inflammation. Significant lymphadenopathy and warmth are present in the inguinal region.
What do you suspect is responsible for the ulcer?
(Answer on next page.)
3. Mildly tender penile ulcer: Bacterial superinfection of a traumatic laceration, herpes simplex, syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale are in the differential. Empiric amoxicillin-clavulanate therapy was initiated for possible bacterial superinfection. A viral culture ruled out herpes simplex.
The lesion’s presentation strongly suggested a syphilis chancre; the relatively painless lesion with little to no exudate erupted as a raised papule that quickly ulcerated. Significant painful, bilateral, inguinal lymphadenopathy was present. A positive reactive plasma reagin test and a follow-up fluorescent treponemal antibody test that detected antibodies directed against Treponema pallidum confirmed the diagnosis of primary syphilis.
Because of the patient’s HIV status, the syphilis was treated with 7.2 million units of intramuscular benzathine penicillin G, administered as 2.4 million units once weekly for 3 weeks. Cerebrospinal fluid evaluation was postponed because of the absence of CNS involvement.
After starting therapy, the patient’s ulcer healed quickly and the results of follow-up reactive plasma reagin tests were normal. His partner was contacted and underwent serologic testing; his condition is being monitored.
4. Painless ulcer on foreskin
A 32-year-old man presents with an ulcer of acute onset on the foreskin. Two weeks earlier, he had unprotected sexual intercourse with a prostitute.
The painless ulcer demonstrates a rolled, indurated border and “dirty” base. The lesion is mildly friable when rubbed with a cotton swab. There is no regional lymphadenopathy.
Based on your clinical assessment, which conditions will you include in the differential?
(Answer on next page.)
4. Painless ulcer on foreskin: Syphilis was ruled out by a darkfield examination and serologic tests; culture on modified chocolate agar failed to grow Haemophilus ducreyi, the organism that causes chancroid. The diagnosis of granuloma inguinale, or donovanosis, was established by skin biopsy, which demonstrated innumerable silver stain–positive organisms within histiocytes following Warthin-Starry staining. Donovan bodies are the tissue form of the organism; they appear as bipolar-staining safety pin–shaped organisms. The causative organism is the gram-negative rod Calymmatobacterium granulomatis.
Double-strength trimethoprim-sulfamethoxazole tablets (trimethoprim, 160 mg; sulfamethoxazole, 800 mg) were given twice daily until the ulcer resolved. The results of HIV testing were negative. Although donovanosis occurs rarely in the United States, it needs to be considered in the differential diagnosis of all genital ulcers.
FOR MORE INFORMATION:
•Rosen T, Brown TJ. Genital ulcers: evaluation and treatment. Dermatol Clin. 1998;16:673-685.