Case Presentation: A 30-year-old woman was presented with two days progressive swelling and pain of her right hand after blunt trauma. The pain was associated with paresthesia of the right thumb and fever. There was no associated vaginal discharge, joint pain, sore throat or skin rash. Past medical history was significant for uncontrolled diabetes. The temperature on presentation was 98.9F. On physical examination, right thenar area and thumb with swelling and tenderness, no erythema or skin breakdown. The remainder of the exam was unremarkable. Laboratory revealed a white blood cell count of 17K/mcL HgbA1C9.6%. Incision and drainage of the affected area grew Neisseria gonorrhea(NG). Blood culture was negative for NG, Human Immunodeficiency Virus (HIV) test was negative, syphilis screen was nonreactive and nucleic acid amplification test of the cervix, urine and throat were all found to be negative for NG and chlamydia. On further questioning the patient, she reported working as a masseuse, she had two sexual partners during the last year with the inconsistent use of condoms. She was started initially on vancomycin 1 gram twice a day plus piperacillin-tazobactam 4.5g every 6 hours, which was switched to ceftriaxone 1g daily, and the total duration of antibiotics given was ten days. The patient had complete resolution of her symptoms with no recurrence.
Discussion: Gonorrhea is a common sexually transmitted disease affecting the genital tract, and more than 555,000 cases were reported to CDC in 2017. Extragenital manifestation for the disease affects approximately 1% of cases and caused by hematogenous spread. Skin abscess formation is a rare complication but mostly occur around genital areas. Primary skin infection with abscess formation was reported in areas like paraspinal area, thigh, and the calf; trauma was reported in some of these cases. Hand abscess formation is an extremely rare presentation, and to our knowledge, there were less than ten cases reported for hand abscess. Most of these cases were reported secondary to disseminated infection, and trauma commonly preceded the abscess fromation. There is a scarcity of evidence-based guidelines regarding the management of gonococcal skin abscesses due to the rarity of the presentation. However, most of the reported cases were treated with surgical incision of the area and antibiotics. A hospitalist should be aware of gonorrhea outside urogenital tract as a reemerging disease. A comprehensive assessment includes sexual history, occupational exposure, and history of trauma is needed for early identification and management of this disease, especially for the adolescents and young adult population.
Conclusions: Gonorrhea infection can be presented outside the genital tract as an abscess in the abscess of other systemic manifestations. Diagnosing this abscess usually requires surgical drainage of this abscess. In the setting of lacking evidence-based guidelines regarding the management of this condition, we suggest management with surgical drainage in addition to antibiotics treatment to help to diagnose the disease and guide antibiotic management.