Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, its manifestation varies from a classic arthritis-dermatitis syndrome to uncommon pyogenic infections of several organs. Herein, we reported atypical presentation of DGI with subcutaneous abscess of right knee, pyomyositis of right lower extremity, and subsequently complicated by Escherichia coli pyomyositis. This infection responded to appropriate antimicrobial therapy and prompt surgical management with good clinical outcome. 1. Introduction Neisseria gonorrhoeae is a fastidious gram-negative diplococci. It is an important cause of cervicitis, urethritis, and pelvic inflammatory disease (PID) [1]. This organism also causes septic arthritis or a distinct syndrome of disseminated gonococcal infection (DGI), with tenosynovitis, skin lesions, and polyarthralgia [2]. The author reported a patient who had atypical manifestation of DGI complicated by Escherichia coli pyomyositis. 2. Case Presentation A 48-year-old woman with a poorly controlled diabetes mellitus for 12 years, presented with acute severe right knee pain and fever for 7 days. Three weeks before the onset, she fell on the ground accidentally and developed right knee pain. However, she was able to walk after the event and there was no open wound nor knee swelling. A physician provided a short slab for right knee immobilization, but her knee pain was progressive and she was unable to mobilize or leave her bed for one week before admission. She also complained of perianal pain during this illness. At Siriraj Hospital, body temperature was 38.2°C, pulse rate 102/minute, blood pressure and respiratory rate were normal. Her right knee was swollen, fluctuated on the lateral sides with diameter about 7 15 centimeters (cm), and marked tenderness and warmth. Anal examination found a draining abscess on the left side of perianal area, sized about 3 4？cm. Others were unremarkable. An aspiration of the right knee revealed frank pus. Plain radiography of the right knee was unremarkable. Blood sugar was 413？mg/dL, complete blood count showed hemoglobin of 7.5？g/dL, hematocrit 23.6%, white blood cell count of 23,180？cell/mm3 (neutrophil 88.2%, lymphocyte 4.3%, monocyte 4.4%), platelets count of 547,000？cell/mm3, ESR 102？mm/hr, and CRP 330？mg/L. Serum BUN and creatinine were within normal limits. She was admitted to the hospital and ceftriaxone 2？g/day with clindamycin 1,800？mg/day were empirically commenced. The surgeon performed incision and drainage (I&D) of the right knee abscess and perianal abscess on
References
[1]
L. M. Newman, J. S. Moran, and K. A. Workowski, “Update on the management of gonorrhea in adults in the United States,” Clinical Infectious Diseases, vol. 44, no. 3, pp. S84–S101, 2007.
[2]
P. A. Rice, “Gonococcal arthritis (disseminated gonococcal infection),” Infectious Disease Clinics of North America, vol. 19, no. 4, pp. 853–861, 2005.
[3]
P. H. Kilmarx, C. M. Black, K. Limpakarnjanarat et al., “Rapid assessment of sexually transmitted diseases in a sentinel population in Thailand: prevalence of chlamydial infection, gonorrhoea, and syphilis among pregnant women—1996,” Sexually Transmitted Infections, vol. 74, no. 3, pp. 189–193, 1998.
[4]
S. Srifeungfung, A. Roongpisuthipong, S. Asavapiriyanont et al., “Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in HIV-seropositive patients and gonococcal antimicrobial susceptibility: an update in Thailand,” Japanese Journal of Infectious Diseases, vol. 62, no. 6, pp. 467–470, 2009.
[5]
S. C. Kalichman, J. Pellowski, and C. Turner, “Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention,” Sexually Transmitted Infections, vol. 87, no. 3, pp. 183–190, 2011.
[6]
J. M. Marrazzo, Handsfiled, and P. F. Sparling, “Neisseria gonorrhoeae,” in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, G. L. Mandell, J. E. Bennett, and R. Dolin, Eds., pp. 2753–2770, Elsevier, 7th edition, 2010.
[7]
B. Newburger, “Metastatic intramuscular gonococcal abscess,” Annals of Surgery, vol. 84, pp. 879–885, 1926.
[8]
A. Leelarasamee, S. Pruksachatwuthi, P. Aswapokee, S. Kobwanthanakun, and S. Kongsamran, “Dermatitis-arthritis syndrome as a manifestation of disseminated gonococcal infection (DGI): report of a case,” Siriraj Medical Journal, vol. 34, no. 5, pp. 262–266, 1982.
[9]
L. Parivisutt, A. Leelarasamee, and S. Nilganuwonge, “Disseminated gonococcal infection (DGI) due to penicillin-resistant strain: report of two cases,” Siriraj Medical Journal, vol. 34, no. 11, pp. 873–878, 1982.
[10]
A. Suzaki, K. Hayashi, K. Kosuge, M. Soma, and S. Hayakawa, “Disseminated gonococcal infection in Japan: a case report and literature review,” Internal Medicine, vol. 50, pp. 2039–2043, 2011.
[11]
J. H. Linner, “Suppurative myositis and purulent arthritis complicating acute gonorrhea,” The Journal of the American Medical Association, vol. 123, pp. 757–759, 1943.
[12]
R. L. Swarts, L. A. Martinez, and H. G. Robson, “Gonococcal pyomyositis,” Journal of the American Medical Association, vol. 246, no. 3, p. 246, 1981.
[13]
S. G. Gurbani, C. T. Cho, K. R. Lee, and L. Powell, “Gonococcal abscess of the obturator internal muscle: use of new diagnostic tools may eliminate the need for surgical intervention,” Clinical Infectious Diseases, vol. 20, no. 5, pp. 1384–1386, 1995.
[14]
The WHO Western Pacific and South East Asian Gonococcal Antimicrobial Surveillance Programme, “Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific and South East Asian Regions, 2009,” Communicable Diseases Intelligence, vol. 35, no. 1, pp. 2–7, 2011.
[15]
M. R. Visser, I. M. Hoepelman, H. Beumer, M. Rozenberg-Arska, and J. Verhoef, “Comparative in vitro antibacterial activity of the new carbapenem meropenem (SM-7338),” European Journal of Clinical Microbiology and Infectious Diseases, vol. 8, no. 12, pp. 1061–1064, 1989.
[16]
L. Slaney, H. Chubb, Z. Mohammed, and A. Ronald, “In-vitro activity of meropenem against Neisseria gonorrhoea, Haemophilus influenzae and H. ducreyi from Canada and Kenya,” Journal of Antimicrobial Chemotherapy, vol. 24, pp. 183–186, 1989.
