Case Presentation: INTRODUCTION: Disseminated gonococcal infection presents as either purulent monoarticular arthritis or as tenosynovitis, migratory polyarthralgia and vesiculopustular rash in young sexually active adults. We present an unusual case of disseminated gonococcal infection presenting as petechial rash, tenosynovitis and polyarthralgia with hypocomplementemia in a middle woman.CASE PRESENTATION: 46 years old woman medical history of alcoholic cirrhosis presented with a 4-day history of fever, acute migratory polyarthritis and generalized petechial rash involving neck, trunk, extremities, palms, and soles; sparing face and oral mucosa. On presentation, the patient had leukocytosis with markedly elevated ESR & CRP and low complement C3, C4 levels. The patient denied sore throat, oral/mucosal ulcers, genital ulcers/discharge, high-risk sexual activity or previous history of STD. Initial workup for cutaneous vasculitis including ANCA, ANA, hepatitis viral panel and HIV was negative. Infectious workup including serologies for rocky mountain spotty fever, anaplasma, syphilis & coxsackie B were negative. Her skin biopsy was consistent with leukocytoclastic vasculitis with areas of red blood cell extravasation, fibrinoid necrosis with perivascular neutrophil rich infiltrate and nuclear dust (karyorrhexis), no IgA deposits were seen. Interestingly patient’s blood cultures grew Neisseria gonorrhea in both aerobic bottles and the urine NAAT test was positive for gonorrhea. The patient was started on IV ceftriaxone and arthritis and rash improved during the hospital stay.

Discussion: Disseminated gonococcal infection typically presents with tenosynovitis, polyarthralgia and vesiculopustular rash but can present with petechial rash as in our patient. Low complement levels from other etiologies can predispose a healthy patient to DGI. A variety of cutaneous manifestations of disseminated gonococcal infection have been reported including cellulitis, petechiae, abscesses, purpura, necrotizing fasciitis, urticaria erythema multiforme, and erythema nodosum. DGI should be considered while evaluating a young patient with tenosynovitis, polyarthralgia and any kind of rash.

Conclusions: Disseminated gonococcal infection can present with a myriad of cutaneous manifestations. DGI should be suspected in a patient with purpuric and petechial rash.

IMAGE 1: Petechial rash on foot of a patient with disseminated gonococcal infection.