3/20/18 Resident Morning Report – Right Foot and Hand Pain, Swelling, and Erythema; Vaginal Discharge; Septic Joint; Disseminated Gonococcal Infection

CC: Right foot and hand pain

HPI: This is a 40 year-old female with a history of intravenous drug use (last use 1 year prior to admission), who presented with a chief complaint of right foot and hand pain with accompanying swelling and erythema of both aforementioned extremities. The pain had begun approximately 1 month prior to admission and initially was localized to her right ankle, eventually migrating to include her right hand, again with accompanying swelling and erythema. She noticed no drainage from areas of involvement but did endorse subjective fevers and chills as well as incidentally noted suprapubic tenderness and vaginal discharge. Her past medical history was notable for gallstone pancreatitis for which she had had a cholecystectomy. She was sexually active with one partner and used barrier protection occasionally. Her vital signs on admission were within normal limits. Her right hand was noted to have erythema of the volar palm that extended to the 3rd digit and included a 2 cm x 3 cm area of fluctuance of the mid palm; she reported pain with active range of motion and passive extension. Her third digit was held in the flexed position. Her right ankle and dorsum of the right foot also demonstrated significant erythema and swelling, again with a 2.5 cm x 2.5 cm area of fluctuance to the dorsolateral midfoot with painful passive and active range of motion throughout the ankle and foot. Genitourinary exam was notable for moderate, thin, yellow discharge of the introitus but without cervical motion tenderness or cervix friability.

Labs/Diagnostics:

Cervical Swab:

  • Chlamydia RNA: negative
  • Gonorrhea RNA: positive
  • Wet mount: Trichomonas observed; no yeast cells or clue cells observed

Right Ankle Aspirate:

  • Nucleated cell count: 2700
  • Segmented neutrophils: 70%
  • Lymphocyte: 26%
  • Monocyte/histiocyte: 4%
  • No crystals observed

Right Foot and Right Hand Wound Cultures

  • 1+ Neisseria gonorrhea
  • Anaerobic culture negative

Patient undergoes joint aspirate and wound cultures from her pustular lesions. A diagnosis of disseminated gonococcal infection is made and supported by positive findings on her cervical swab. Patient was continued on antimicrobial therapy with a plan to treat for a full course of 7 days.


Morning Report Pearls:

  • Disseminated gonococcal infection is the most common cause of polyarthralgias in young, otherwise healthy patients who are sexually active
  • There are two classical forms of presentation in disseminated gonococcal patients:
    • Arthritis-dermatitis syndrome is a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis
    • Purulent arthritis is similar to a septic joint in presentation and laboratory findings
  • Joints involved can include both large and small joints with the migratory nature of the disease distinguishing it from other causes of septic arthritis
    • Symmetric joint involvement is uncommon
  • Skin findings are common, especially in arthritis-dermatitis syndrome and typically present as painless, pustular, or vesiculopustular, rarely resembling erythema nodosum or erythema multiforme
  • Isolation of the organisms can establish the diagnosis of disseminated infection; patients with risk factors or with suspected disseminated infection should be swabbed for evidence of urogenital, rectal, or pharyngeal involvement via nucleic acid amplification testing
    • Though positive in this case, testing of skin lesions is not typically part of the typical evaluation given their low yield
    • Synovial fluid may also only be positive in approximately 50% of cases but with positive mucosal site testing and suspicious clinical presentation, a presumptive diagnosis can be made
  • Treatment of susceptible organisms with third-generation cephalosporins for a total of 7 days (or 14 days if evidence of septic arthritis)

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