| Health Advisory -- November 11, 2006
Disseminated Gonorrhea in King County
Since March of 2006, clinicians in King County have reported 16 cases of disseminated gonococcal infection (DGI). Although DGI was relatively common in the 1970s, strains of Neisseria gonorrhoeæ prone to dissemination have been rare in recent decades, with only two cases of DGI reported to Public Health – Seattle & King County (Public Health) between 1991 and 2005.
The first case of DGI occurring in 2006 involved a man who presented with a septic knee after having sex with multiple partners while in Southeast Asia. Clinicians in Washington State have subsequently reported 15 additional cases of DGI, 11 in men and 4 in women. Most cases have required hospitalization and intravenous antibiotics, and many have undergone surgical procedures. At least 5 cases acknowledged using cocaine or crack cocaine, and one was homeless. Microorganisms were available for antimicrobial susceptibility testing in 9 cases, all of which were resistant to fluroquinolones.
DGI is a rare complication of gonorrhea. Patients can present with a monoarticular purulent arthritis, or the arthritis-dermatitis syndrome. The arthritis-dermatitis syndrome manifests as an asymmetric, oligoarticular or polyarticular arthritis, arthralgias or tenosynovitis which develops over several days and primarily involves the knees, elbows and distal joints. Approximately 75% of cases have dermatologic manifestations, most frequently discrete papules, pustules or vesicles, sometimes with a hemorrhagic or necrotic component. Most patients do not have concurrent symptoms of genital tract infection, though genital tract, rectal or pharyngeal cultures are usually positive. Meningitis, osteomyelitis, septic shock, endocarditis and acute respiratory distress syndrome are rare complications.
Clinicians should consider the diagnosis of DGI in adolescents and adults presenting with new symptoms of arthralgia or arthritis. Evaluation should include culture of the blood, genital tract, synovial fluid and unroofed skin lesions. If patients report having receptive oral or anal sex, clinicians should be culture these sites as well. Empiric therapy should include intravenous ceftriaxone or an alternative third generation cephalosporin. All cases should be reported immediately by telephone to Public Health at 206-731-2275.
In addition, Public Health recommends pharyngeal cultures for gonorrhea be included in routine STD evaluations of women who report having receptive oral sex in the preceding 60 days and who use cocaine or crack cocaine and/or who exchange sex for money or drugs.
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