Case Presentation: A 24-year-old male with past medical history of sickle cell trait, bicytopenia (with a negative outpatient hematology and oncology workup) and diagnosed acute rheumatic fever 7 months earlier (on prophylactic penicillin BID) presents to the emergency department with 3 weeks of fevers, night sweats, migratory arthralgias and painful subcutaneous nodules involving primarily the lower extremities. Vitals showed a temperature of 102.7 F, blood pressure of 147/59, heart rate of 108 beats/min, respiratory rate of 18 and oxygen saturation of 99%. Initial labs and imaging were notable for leukocytosis of 11.73 K/uL, negative urinalysis, negative respiratory viral panel, and negative chest x-ray. Physical exam was notable for scattered skin nodules to the bilateral upper and lower extremities in different stages of healing. Dermatology, infectious disease (ID), and rheumatology were consulted. Blood cultures were collected, and the patient was started on IV Ceftriaxone. Jones Criteria was met by 2 major manifestations including migratory arthritis and subcutaneous nodules, and the patient’s overall presentation was thought to be a flare of rheumatic fever. The patient clinically improved on Ceftriaxone, and notably the blood cultures returned positive for Neisseria gonorrhoeae. After further discussion with the patient, he states that he did have an unprotected sexual encounter about one month prior to symptom onset along with a sore throat. Based on the history, culture results and further discussion with ID, it was concluded that the patients’ symptoms were likely the result of disseminated gonococcal infection.
Discussion: A disseminated gonococcal infection (DGI) is estimated to occur in around 1-2% of patients with a Neisseria gonorrhoaea infection . The signs and symptoms of DGI can include migratory polyarthralgia (in up to 70% of patients), tenosynovitis, dermatitis, fever, purulent arthritis, and genitourinary symptoms . An array of other infectious and noninfectious diseases can present similarly to DGI. One such example is acute rheumatic fever, which can present with polyarthralgia, fever and rash in young adults. This case was complicated by the fact that the patient had a prior diagnosis of rheumatic fever, and thus this was initially thought to be the cause of his symptoms, as infections can recur in up to 5% of patients on oral prophylaxis . It is possible that this patient’s initial presentation 7 months prior was also an episode of DGI, even though the patient had negative blood cultures at this time. It is estimated that only 50% of blood cultures are positive in patients with DGI, and thus diagnosis is often made on clinical suspicion and response to appropriate treatment .
Conclusions: DGI can present with an array of symptoms, many of which are similar to other infectious and non-infectious diseases. One such disease with similar manifestations is acute rheumatic fever. Patients with DGI will not always show positive blood cultures, and thus a proper history of illness and clinical suspicion is important for diagnosis.