Case Presentation: Our patient is a 27 y/o male with PMHx of HIV (CD4 count 740, HIV viral load 100 copies/mL), Type I Diabetes who presented to the emergency room for tachycardia and fever. ED vitals notable for temperature of 39.1° C and heart rate of 108. White blood cells notable to be 13.8 thousand/mcL. CT Chest/Abd/Pelvis with no significant findings. Patient had blood cultures drawn and received Ceftriaxone, Azithromycin and Doxycycline with concern for rectal chlamydia. On day 2, both aerobic blood cultures grew gram-positive cocci in pairs and clusters and vancomycin and cefepime were initiated. However, the cultures were addended to gram-negative cocci on day 4. These organisms were speciated as Neisseria gonorrhea with negative beta lactamase. Ceftriaxone was initiated at this time for antibiotic coverage. An initial transthoracic echocardiogram (TTE) was negative, but a transesophageal echocardiogram (TEE) revealed a mobile echo-density on the right coronary cusp of the aortic valve consistent with an aortic valve vegetation, measuring 1.2 x 0.8 cm, causing severe aortic insufficiency. Cardiac catheterization was negative. At this time, the patient was transferred to another hospital and underwent urgent aortic valve replacement. Intra-operatively, the right coronary leaflet of the aorta was found to be destroyed and a TEE also showed a gerbode ventriculo-atrial defect. Myectomy and debridement of the interventricular septum was completed, and the aortic valve was replaced with improvement to trace aortic insufficiency. Post-operative care was complicated by an atrioventricular block however patient self-converted prior to further intervention. The patient was discharged home on Ceftriaxone 2 grams every 12 hours for 6 weeks and the patient was followed in Infectious Disease clinic after hospital discharge for antibiotic compliance and completed therapy with no overt complications.
Discussion: Neisseria gonorrhea is a gram-negative diplococcus commonly seen as a sexually transmitted infection of the urogenital tract. If left untreated, these infections can disseminate affecting multiple organs. Disseminated Gonococcal infection (DGI) occurs in 1-3% of all gonococcal infections and gonococcal endocarditis (GE) can occur in 1-2% of all DGI patients (3). These cases are diagnosed with blood cultures and cardiac abnormalities are found through echocardiogram – most commonly affecting the aortic valve. Although GE is rare, the mortality is high with reported ranges from 19-23% (1,3).This case is unique as our patient had a Gerbode ventriculo-atrial defect secondary to his endocarditis. Gerbode’s defects are left ventricle to right atrial shunts and can be congenital or acquired (2). Endocarditis is a common cause however Nesseria gonorrhea endocarditis causing Gerbode’s has not been noted in the literature.
Conclusions: Our case highlights a rare presentation seen in a common diagnosis. Due to high mortality rates, GE must be considered in a septic individual. As gonorrhea infections continue to rise worldwide more of these cases will most likely be described in the literature.