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 infection (STI) 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 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 child who is not sexually active, 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.