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Christine Ahn MD
Carl Allen DDS, MSD
Brandon Ayres MD
Howard P. Baden MD
Robert Baran MD
Keira Barr MD
Gregory J. Basura MD, Ph.D
Donald Belsito MD
Jeffrey D. Bernhard MD
Jesse Berry MD
Victor Blanco MD
Benjamin R. Bohaty MD
William Bonnez MD
Sarah Brenner MD
Robert A. Briggaman MD
Robert Brodell MD
Roman Bronfenbrener MD
Walter Brooks MD
William Buckley MD
Philip Bulterys MD, PhD (candidate)
Susan Burgin MD
Sonya Burton MD
Sean P. Bush MD, FACEP
Jeffrey Callen MD
Scott Camazine MD
Michael Cardwell
Shelley D. Cathcart MD
Robert Chalmers MD, MRCP, FRCP
Chia-Yu Chu MD, PhD
Flavio Ciferri MD
Maria Rosa Cordisco MD
Noah Craft MD, PhD
John T. Crissey MD
Harold E. Cross MD, PhD
Charles E. Crutchfield III MD
Adriana Cruz MD
Donna Culton MD, PhD
Bart J. Currie MBBS, FRACP, DTM&H
Chicky Dadlani MD
Alexander Dane DO
C. Ralph Daniel III MD
Thomas Darling MD, PhD
William Delaney MD
Damian P. DiCostanzo MD
Ncoza Dlova MD
James Earls MD
Libby Edwards MD
Melissa K. Egge MD
Charles N. Ellis MD
Rachel Ellis MD
David Elpern MD
Nancy Esterly MD
Stephen Estes MD
E. Dale Everett MD
Janet Fairley MD
David Feingold MD
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Organizations
Am. Journal of Trop. Med & Hygiene
Armed Forces Pest Management Board
Blackwell Publishing
Bugwood Network
Centers For Disease Control and Prevention
Centro Internacional de Entrenamiento e Investigaciones Mèdicas (CIDEIM)
Dermatology Online Journal
East Carolina University (ECU), Division of Dermatology
Tenosynovitis, Dermatitis, Polyarthralgia Syndrome
Gonococcemia refers to the presence of Neisseria gonorrhoeae in the bloodstream, often leading to disseminated gonococcal infection (DGI). Gonorrhea, caused by N. gonorrhoeae, a gram-negative diplococcus, is the second most commonly reported sexually transmitted disease in the United States after chlamydia. (See gonorrhea for further discussion of primary infection.) Gonococcemia occurs in approximately 1%-3% of patients with gonorrhea.
DGI occurs more commonly in females, due to their higher incidence of occult infection and the increased risk of gonococcemia posed by menstruation and pregnancy. Other risk factors include the presence of human immunodeficiency virus (HIV), lupus, or complement deficiencies; multiple sexual partners; low socioeconomic status; drug use; males who have sex with males (MSM); and a prior history of sexually transmitted infections (STIs). Gonococcemia is most prevalent in the adolescent and young adult populations.
Disseminated gonococcemia occurs in approximately 1%-3% of children and adolescents with untreated mucosal infection. Infection occurs 7-30 days after incubation and, in menstruating females, within 7 days of menstruation. Disseminated gonococcemia usually occurs after asymptomatic primary infection.
The onset of gonococcemia is often abrupt, with fever (usually 101°F-104°F [38.3°C-40°C]), skin lesions, and arthralgias and/or tenosynovitis. Successive crops of hemorrhagic pustules, papules, petechiae, or areas of necrosis may appear during febrile episodes. Arthralgias are asymmetric and migratory, involving at first the extensor tendons of wrists, fingers, knees, and ankles. Later, septic arthritis leads to pain and swelling in one or, occasionally, more joints. Only 25% of patients report skin pathology.
Septic arthritis may result in progressive joint destruction and osteomyelitis. Other complications include myocarditis, toxic hepatitis, and, less commonly, endocarditis and meningitis. Major embolic phenomena may occur.
Acute endocarditis is extremely uncommon; however, it is a fatal consequence of DGI leading to rapid destruction of the aortic valves.
Abdominal spread of gonococci may cause gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome) with abdominal pain, tenderness, and, occasionally, a hepatic friction rub.
Most patients deny genitourinary complaints; however, they may manifest with vaginitis, cervicitis, urethritis, pelvic inflammatory disease, pelvic abscesses, epididymitis, proctitis, or pharyngitis. MSM may develop proctitis, rectal discharge, and pharyngitis.
Note: Outside of the neonatal period, if N. gonorrhoeae is cultured from a non-sexually active child, sexual abuse must be ruled out. Childhood sexual abuse is a problem of epidemic proportions affecting children of all ages and economic and cultural backgrounds. There are few unambiguous diagnostic signs of sexual abuse, and they are present in only a minority of victims. They include objective evidence of characteristic genital trauma and the detection of specific STIs. The presence of semen, sperm, or acid phosphatase, or a positive culture for gonorrhea is considered absolute evidence of sexual abuse when congenital acquisition of the disease is excluded.
Special Considerations in Neonates: In neonates the occurrence of disseminated gonococcemia is 1% or less. Transmission is generally through perinatal exposure, ie, transmitted from the mother to the baby during childbirth. Neonates present with polyarticular septic arthritis, generally involving the wrists, hands, ankles, or feet. The neonate may display a low-grade fever, irritability, and pain with moving the affected joint.
It is difficult to differentiate gonococcal septic joint from other pathogens; thus a culture and synovial fluid analysis should be performed. If the neonate is demonstrating pseudoparesis of the hip, prompt drainage should be performed to avoid aseptic necrosis of the femoral head.
Bacteremia, sepsis, and meningitis are very rare complications. Sepsis is more common in premature infants. Bacteremia is generally clinically silent until sepsis manifests.
