A 36-year-old woman comes to the emergency department due to 12 hours of malaise and fever with chills. The patient also has pain in multiple joints. Her menstrual period started 3 days ago, and she is using 4-6 tampons per day. The patient is sexually active. Her 4-year-old son had a sore throat 2 weeks ago. Temperature is 39.3 C (102.7 F), blood pressure is 122/81 mm Hg, pulse is 104/min, and respirations are 14/min. Examination shows several pustules on the chest, forearms, palms, and fingers. Joint examination shows no swelling, but the right wrist and left ankle are tender on palpation, especially with active or passive joint movement. Heart sounds are normal. Funduscopic and oropharyngeal examinations are normal. There is no cervical, axillary, or inguinal lymphadenopathy. Which of the following is the most likely diagnosis in this patient?
Disseminated gonococcal infection | |
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This patient likely has disseminated gonococcal infection (DGI), which typically presents with purulent arthritis or the following triad:
Polyarthralgia: Asymmetric pain in multiple distal and proximal joints. Examination usually reveals pain with movement and palpation; multiarticular joint swelling, erythema, and warmth are uncommon.
Pustular rash: Most patients have 2-10 pustular or vesiculopustular lesions on the distal extremities; trunk lesions can also occur. The palms and soles may or may not be affected.
Tenosynovitis: Patients report pain over the flexor tendons of multiple distal joints (eg, wrists, ankles, fingers, toes) and/or pain with passive range of motion of the joint.
Systemic signs of infection (eg, fever, chills, malaise) are frequently present. Although examination (eg, mucopurulent discharge) or testing (nucleic acid amplification) often reveals urogenital infection, many patients have no urogenital symptoms.
The diagnosis of DGI requires cultures of blood and synovial fluid (when joint effusion is present) and nucleic acid amplification testing (NAAT) of samples from mucosal sites (eg, urethra, throat, rectum). Because Neisseria gonorrhoeae grows fastidiously, blood and synovial fluid cultures are frequently negative (fewer than one-third of patients had positive blood cultures in one study); therefore, the diagnosis is usually presumptively established by NAAT of urogenital sites.
(Choice B) Parvovirus B19 is associated with fever, rash, and arthritis. However, the rash is usually on the malar surface and is then followed by a lace-like rash on the trunk and extremities. Pustular lesions would be atypical.
(Choice C) Sore throat is quite common in young children. Although rheumatic fever can cause migratory polyarthritis and rash, the rash is subcutaneous nodules or erythema marginatum (evanescent, pinkish rash), not pustules.
(Choice D) Secondary syphilis can present with fever and rash. However, the rash is usually generalized, symmetric, and maculopapular and typically occurs on the trunk, extremities, palms, and soles. A few pustular lesions would be atypical. Most patients with secondary syphilis also have palpable lymphadenopathy.
(Choice E) Toxic shock syndrome caused by Staphylococcus aureus is associated with prolonged tampon use. It often presents with fever and rash. Although the rash often appears on the palms and soles, it is usually diffuse and sunburn-like; in addition, many patients develop rapid-onset hypotension and multiorgan dysfunction.
Educational objective:
Disseminated gonococcal infection causes purulent monoarthritis or the triad of tenosynovitis, polyarthralgia, and pustular lesions. Blood and synovial fluid cultures are often negative due to the fastidious nature of Neisseria gonorrhoeae, but urogenital mucosa testing (eg, nucleic acid amplification) is typically positive even in the absence of urogenital symptoms.