32 year old man, presented to the ER with a 2 day history of skin lesions on his hands and feet. The lesions accompanied by fever(102.9F), malaise, diffuse arthralgias and 1 episode of vomiting.
Physical: 5-6 purpuric papules, each with a central area of necrosis or pustule formation, located on the palmar and dorsal aspects of his hands and feet, and a well defined plaque on his right ankle.
This patient claimed to be in monogamous relation.
Differential diagnosis of fever and skin lesions:
- Rocky Moutain Spotted fever
- Tick bite fever
- Tick-borne diseases
- Infective endocarditis
- Gonococcemia
- Vasculitis
Classical presenting picture of disseminated gonoccocemia: (with/without septic arthritis)
- Fever
- tenosynovitis
- skin lesions: 5-40 lesions on the extremities, macules-papules that may become hemorrhagic pustules (present mostly in the non septic arthritis form)
- purulent arthritis
Diagnosis:
- Blood cultures: 50% (form without septic arthritis)
- Synovial cultures:47% (form with septic arthritis)
- genital, anorectal, pharyngeal infection in 70-80%- all mucosa should be tested! These can be tested by Gram stain(94% positive in symptomatic men), PCR, culture on Thayer Martin media. For cultures, samples should be inoculated directly onto the culture medium.
Management:
- The only drugs currently recommended: Cephalosporins
- Quinolones are NOT recommended anymore because of rapidly spreading resistance.
Urogenital and anorectal gonorrhea:
- Ceftriaxone 125 mg IM x1 dose
- Cefixime(Suprax) 400 mg po x1 dose
- Others: Ceftizoxime 500 mg, cefoxiting 2 g with 1 g probenecid, cefotaxime 500 mg
Disseminated Gonococcal infection:
- Ceftriaxone 1 g daily - then switch to po cefixime to complete 7 days course.
- May use IV Cefotaxime, or Ceftizoxime 1 g IV q 8h as alternative
Do NOT forget the partner
Microbiology basics:
Nisseria Gonorrhea is a fastidious organism, aerobic, gram-negative cocci, typically arranged in pairs(diplococci) with adjacent sides flattened together. The bacteria are not mobile, and do not form endospores. Pathogenic strains are usually encapsulated.
The Nisseria genus has two species N. gonorhoeae and N. meningitidis. The others may cause opportunistic infections.
All species are oxidase positives, most catalase positive.
Virulence factors in N. gonorrhoeae:
Virulence factor________________Biological Effect
Capsule__________________________Antiphagocytic
Pilin____________________________Mediates initial attachment to epithelial cells
Por(Protein I)_____________________Porin protein-promotes intracellular survival
Opa(Protein II)____________________Mediates firm attachment to epithelial cells
Rmp(Protein III)___________________Protects other surface antigens from antibodies
Tbp1, Tbp2(Trasnferrin)_____________Mediates acquisition of iron for bacterial meabolism
Lbp(Lactoferrin)___________________Mediates acquisition of iron
LOS____________________________Endotoxin
Ig A1 protease_____________________Destroys Ig A1
Beta-lactamase____________________Hydrolyze beta-lactam ring in PCN
Special predisposing factors: Late complement deficiencies
