By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: Only 0.24% of patients with gonorrhea had disseminated infection, with septic arthritis occurring in approximately one-half.
SOURCE: Tang ET, Johnson KA, Alvarado L, et al. Characterizing the rise of disseminated gonococcal infections in California, July 2020-July 2021. Clin Infect Dis 2022; Oct. 3;ciac805. [Online ahead of print].
Tang and colleagues examined all cases of disseminated gonococcal infection (DGI) reported to the California Department of Public Health (CDPH) during July 1, 2020, to July 31, 2021, from the California Project Area. This area includes all of California except Los Angeles and San Francisco, which have separate surveillance systems.
Of the 53,338 cases of gonorrhea reported, 149 (0.24%) had DGI, 115 of which were confirmed and 34 were probable. The estimated incidence was 0.47 DGI cases per 100,000 population. The mean age of the cases was 40 years, but it was significantly lower in cisgender males (36 years), who accounted for half the cases, than in cisgender females (45 years).
More complete information was available for 111 cases. Illicit drug use, mostly methamphetamine, was reported in 36 of the 94 (36%) cases for which the information was available. Almost one-fourth had experienced homelessness in the previous 12 months. Diabetes mellitus was reported in 13 (12%), human immunodeficiency virus infection was reported in nine (8%), chronic hepatitis C virus infection was reported in six (5%), six (5%) were receiving immunosuppressive therapy, and two were pregnant. Two had previously had an episode of DGI, but none were recorded as having complement deficiency and none were receiving eculizumab.
The median interval from symptom onset to presentation was three days (interquartile range [IQR], 1-7). Urogenital, pharyngeal, and rectal symptoms were absent in the majority. Fever and polyarthralgia occurred in approximately one-third, and 59 (53%) were considered to have septic arthritis and one-fifth had tenosynovitis. Synovial fluid cultures were positive in 47/69 (68%). Petechial and/or pustular skin lesions were present in 13 (12%) cases.
Bacteremia was detected in one-third, and five cases (5%) had endocarditis. Blood cultures were positive in 40/97 (41%) samples. Two patients had osteomyelitis and one had a hepatic abscess. Of the total, 102 (92%) were hospitalized and 47 (46%) of 103 underwent a surgical procedure. Two patients died, but the reasons are not indicated.
Antimicrobial susceptibility data were available for 47 isolates and none were resistant to ceftriaxone, cefixime, or azithromycin, while resistance to penicillin, tetracyclines, and ciprofloxacin was detected in 9%, 16%, and 43%, respectively.
COMMENTARY
Although uncommonly encountered, Neisseria gonorrhoeae has been reported to be the most frequent cause of septic arthritis in sexually active adults, and this site of infection was identified in approximately one-half of cases in this series. The most characteristic (albeit not most frequent) presentation is the arthritis-dermatitis syndrome consisting of tenosynovitis and polyarthralgia with skin lesions (typical skin lesions can be seen at https://phil.cdc.gov/Details.aspx?pid=6384). Other rarer manifestations may include meningitis, endocarditis, myopericarditis, perihepatitis, osteomyelitis, and abscesses.
This report encompasses a time that was affected by the COVID-19 pandemic, which may have affected the results, since delays in seeking medical care potentially may increase the risk of dissemination of a mucosal gonococcal infection. Other factors in this series also likely had the potential to delay access to medical care, especially the frequency of illicit drug use and of homelessness. Furthermore, the majority of cases lacked pharyngeal, urogenital, or rectal symptoms that might have led to earlier presentation.
A variety of host factors have been reported to predispose to dissemination of N. gonorrhoeae infection, including, e.g., complement deficiencies. Investigators also have searched for microbial factors that may be associated with bloodstream invasion. However, a recent study using whole genome sequencing failed to find significant differences between disseminated and urogenital strains.1
This study by Tang et al confirms that ceftriaxone remains the antibiotic of choice and that cefixime is a good choice for transition to an oral regimen.
REFERENCE
- Cartee JC, Joseph SJ, Weston E, et al. Phylogenomic comparison of Neisseria gonorrhoeae causing disseminated gonococcal infections and uncomplicated gonorrhea in Georgia, United States. Open Forum Infect Dis 2022;9:ofac247.
