A 44-year-old man at hands with pai...

A 44-year-old man at hands with pain in the muscles, right shoulder, and right wrist. Other symptoms include malaise, pharyngitis, febrile disease and chills. He denies intravenous medicine use, contact with ill bodily substances or recent travel. Wrist examination displays tenosynovitis, and shoulder examination reveals pain, warmth, and erythema without effusion. feminine hemorrhagic pustules ranging from 03 to 08 cm in diameter appear forward his hands (see accompanying figure) and feet His white life-blood cell count is 13,400 for [mm.sup.3] with a neutrophil predominance, and his erythrocyte sedimentation rate is 52 mm through hour. Blood cultures showed no growing Skin biopsy reveals leukocytoclastic vasculitis with intravascular thrombi and associated epidermal necrosis with perivascular inflammation. Gram stain is negative for bacterial organisms.

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Question

Based upon the above history, physical examination, and laboratory and biopsy rises which one of the following diagnoses best fits the etiology of this patient's condition?

[] A. Infective endocarditis.

[] B Reactive arthritis.

[] C Disseminated gonococcal infection.

[] D Acute human immunodeficiency virus (HIV) infection.

[] E Meningococcemia.

Discussion

The answer is C: Disseminated gonococcal infection. Neisseria gonorrhoeae infection typically furnishs urethral discharge and dysuria. (1) However, 1 to 3 percent of patients with gonorrhea evolve disseminated infection and present with common of two forms. (2)

The first form is an arthritis-dermatitis syndrome consisting of tenosynovitis, dermatitis, and polyarthralgias without feculent arthritis. (2) Acute illness is characterized at fever, chills, and malaise. The tenosynovitis oftentimes involves multiple tendons. Skin lesions (three to 20 in number) include painful erythematous macules les than 1 cm in diameter that unroll to hemorrhagic pustules within 24 to 48 hours and are ground near small joints of the hands and feet The pustular vasculitis, intravascular thrombi, arthralgias, and tenosynovitis issue from hematogenous dissemination of the gonococcus. (3)

The next to the first form is a purulent arthritis without associated skin lesions. chiefly patients are afebrile and at hand with an asymmetric polyarthritis. These strikingly different clinical presentations may overlap, with the dermatitis arthritis syndrome progressing to corrupt arthritis. (2,4) In rare septicemic forms, disseminated infection may lead to hepatitis, meningitis, endocarditis, or other systemic involvement. (5)

Diagnosis is based forward the characteristic clinical picture and clinical suspicion. Patients may not always admit to or know about their be in possession of or their partners' sexual position s For example, the patient in this case admitted and nothing else at follow-up to having sexual intercourse with prostitutes, rather than sharing this information at presentation. Disseminated gonococcal infection is three to four times more often met with in women than in men (24) and asymptomatic colonization of the oropharynx, urethra, anorectum, and endometrium is a primary predisposing factor. Other dissemination factors include menstruation, pregnancy, pelvic surgery insertion of intrauterine devices, and congenital or acquired completeness or immune deficiencies. (1,6)

Patients with disseminated gonorrhea are les likely to have positive line cultures but more likely to have positive agricultures of the urethra or cervix. (7) Thus, this infection is best confirmed from culturing gonococci from the primary infected mucosal site. (1) tillages are positive in 75 to 90 percent of cases. (8) It is imperative to obtain agricultures from all possible mucosal surfaces to increase diagnostic yield. Selective medium (i.e., Thayer Martin) that contain antibiotics (i.e., vancomycin) may inhibit the germination of some gonococci and should be avoided. (9) improvements of joints, skin lesions, and life-blood are less likely (positive in 25 to 50 percent of cases) to swell organisms8 and should be cultur forward antibiotic-free medium. (9) Direct fluorescent antibody testing forward skin biopsies is positive in more than 50 percent of cases. (1) Synovial fluid analysis, tillage and nested polymerase chain reaction may help identify organisms and establish the diagnosis. (8)

Treatment consists of parenteral antibiotics for 24 to 48 hours and, after clinical improvement, oral therapy for a total of seven days. Initial therapy should include ceftriaxone, cefotaxime, or ceftizoxime. Oral treatments include cefixime, ciprofloxacin, ofloxacin, or levofloxacin. Penicillin-resistant strains of N gonorrhoeae are widespread, (10) and quinolone resistance is becoming more prevalent. (11) Patients usually regain quickly and completely. Purulent arthritis, if instant may require joint drainage and a longer course of antibiotics. All patients should be treated presumptively for Chlamydia trachomatis. (1311)

Patients with infective endocarditis may quick in emergencies with myalgias, arthralgias, fever, and chills. Hemorrhagic skin lesions are caused from septic emboli. However, most patients with infective endocarditis have cardiac abnormalities and positive house cultures. (12)