eMedicine Specialties > Dermatology > Bacterial Infections
Gonococcemia: Differential Diagnoses & Workup
Updated: Jul 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
| Acanthosis Nigricans | Reactive Arthritis |
| Cutaneous Manifestations of Hepatitis C | Syphilis |
| Lyme Disease | |
| Meningococcemia | |
| Psoriatic Arthritis |
Other Problems to Be Considered
Other causes of arthritis and dermatitis may display a clinical picture similar to that of DGI, with some notable differences.
Reactive arthritis is a human leukocyte antigen B27 (HLA-B27)–associated condition that predominantly occurs in young men and has the clinical triad of urethritis, conjunctivitis, and arthritis. However, the distribution of the arthritis is different, occurring predominantly in the joints of the axial skeleton. The clinical picture is less acute, occurring over the course of weeks rather than days and with less severe fever. This syndrome does not respond to antibiotic therapy, and it does not have the associated dermatitis that occurs in gonococcemia.
Rheumatic fever is a rare illness in the modern era and can present with high fever, rash, arthritis, and endocarditis. This condition follows a streptococcal infection and requires long, emergent intravenous antibiotic therapy for endocarditis; it also responds well to anti-inflammatory medications.
Syphilis, an STD that commonly occurs in sexually active young adults, can also produce a rash, symptoms of arthritis, and genital lesions. However, genital involvement is usually in the form of an ulcer and not urethritis, and the rash can involve the palms and the soles. Laboratory tests, including rapid plasma reagin (RPR) titers, can aid in distinguishing syphilis from gonococcemia.
Nongonococcal septic arthritis can be caused by a variety of organisms, but it presents with an acute onset of joint swelling and pain. Culture of joint fluid commonly reveals organisms. This type of arthritis is a destructive form of arthritis that is usually monoarticular. It most frequently occurs in children and elderly persons. Immediate treatment with antibiotics is indicated.
Other conditions to consider in a patient with arthritis and skin lesions include the following: meningococcemia, hepatitis, bacterial endocarditis, SLE, tenosynovitis (eg, de Quervain disease, infectious), and other seronegative arthritides (eg, ankylosing spondylitis, Sweet syndrome, related dermal vasculitides).
Workup
Laboratory Studies
The diagnosis of DGI should be based on clinical findings and confirmed with laboratory investigations if possible.
- CBC count: Patients with gonococcemia may have an elevated WBC count, in the range of 10,000-15,000/µL.
- Erythrocyte sedimentation rate: The rates are usually mildly elevated, with values from 20-50 in most patients. Less than 50% of patients have erythrocyte sedimentation rates higher than 50.
- Culture: The highest yield of N gonorrhoeae organisms is from mucosal sites, including the pharynx, the urethra, the cervix, or the rectum. Urethral and cervical cultures are typically the most revealing. Blood cultures yield positive culture results in 10-30% of patients and joint fluid in 20-30% of patients. Skin lesions yield organisms in only about 10% of patients. Immunofluorescence studies may improve the effectiveness in skin and joint fluid.
- Polymerase and/or ligase chain reaction: These methods have a high sensitivity and a high specificity (78.6% and 96.4%, respectively). They are easily performed on urethral specimens and can even be performed on first-void urine specimens. These methods are noninvasive, rapid, sensitive, and specific, and they have facilitated the diagnosis of gonococcal infection.15 However, these methods cannot report antibiotic sensitivities; therefore, they do not eliminate the need for culture in these patients.
- Nucleic acid amplification tests, including the polymerase chain reaction, are sensitive and specific tests, as noted above. A pseudo-outbreak of pharyngeal gonorrhea in a group of prostitutes was determined to be the result of false-positive test results due to commensal oropharyngeal Neisseria species.16
- Specific molecular tests may produce erroneous results. In certain circumstances, it may be advisable, in consultation with a medical microbiologist, to take a sample for culture or to perform a second molecular test aimed at a different part of the bacterial genome.
- N gonorrhoeae was identified as the causative agent in a case of culture-negative dermatitis-arthritis syndrome using real-time polymerase chain reaction.17 This technology can improve the speed and sensitivity of diagnosis and consequent management of patients with this syndrome.
- Serologic tests: These tests include latex agglutination, enzyme-linked immunosorbent assay, immunoprecipitation, and complement fixation tests. Because of their lower sensitivity and specificity, especially in populations with a low prevalence of disease, these tests are not routinely used for diagnosis, but they can be used as adjuncts to the other laboratory tests and may help in making the diagnosis.
- Other screenings: The US Preventive Services Task Force recommends that women at increased risk of gonorrhea also be screened for chlamydia, HIV, and syphilis.18
Other Tests
- Because of the potential severity of pericarditis and endocarditis, a cardiologic examination, including echocardiography, is recommended, even though these conditions are rare.
Histologic Findings
Histopathologic examination reveals a vasculitislike picture with a perivascular neutrophilic infiltrate and neutrophils containing pustules in the epidermis.
Cytologic smear of cutaneous acral pustule showing gram-negative intracellular diplococci.
More on Gonococcemia |
| Overview: Gonococcemia |
 Differential Diagnoses & Workup: Gonococcemia |
| Treatment & Medication: Gonococcemia |
| Follow-up: Gonococcemia |
| Multimedia: Gonococcemia |
| References |
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References
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Further Reading
Keywords
gonococcemia, gonococcal infection, gonorrhea, arthritis-dermatitis syndrome of gonorrhea, disseminated gonococcal infection, DGI, Neisseria gonorrhoeae, N gonorrhoeae
