Case Series of Three Patients with Disseminated Gonococcal Infection and Endocarditis

Introduction: The increasing incidence of Neisseria gonorrhoeae infections and emergence of cephalosporin-resistant strains means the threat of disseminated gonococcal infection and endocarditis needs to be reimagined into the differential diagnosis for patients treated in the emergency department (ED) for sexually transmitted infections and for endocarditis itself. Only 70 cases of disseminated gonococcal infection (DGI) with endocarditis had been reported through 2014.1-4 In 2019, however, an outbreak of DGI with one case of endocarditis was reported.5 This case series of three patients with DGI and endocarditis, in addition to the recent outbreak, may represent a warning sign for reemergence of this threat. Case Report: We describe three cases within a recent three-year period of gonococcal endocarditis as seen and treated at our institution. These cases show divergent presentations of this insidious disease with both classical and atypical features. One case displayed a classic migratory rash with positive urine testing and a remote history of sexually transmitted infections, while another patient developed isolated culture-confirmed endocarditis with negative cervical testing and imaging, and the final case was a male patient who presented to the ED with fulminant endocarditis as the first ED presentation of infection. Conclusion: Secondary to an overall rise in incidence and possibly due to increasing antibiotic-resistance patterns, gonococcal endocarditis should be included in the differential diagnosis of any case of endocarditis. Reciprocally, increased vigilance should surround the evaluation of any patient for sexually transmitted diseases while in the ED for both the development of DGI and endocarditis.

Gonococcus infection probably acquired from bathing in a natural thermal pool: a case report

Background Authorities need to recognize that, while rare, gonorrhea can be transmitted nonsexually, and should not be presumed definitive evidence of abuse. We report the unusual case of a girl diagnosed with Neisseria gonorrhoeae after bathing in a heavily frequented hot pool at the edge of the crater lake Specchio di Venere (“Mirror of Venus”) on Pantelleria Island, Italy. Case presentation Two days after bathing in the pool, this 11-year-old Austrian girl developed vulvovaginitis that partially settled with antifungal cream. Subsequent swabs cultured positive for Neisseria gonorrhoeae. Family members tested negative. The child adamantly denied any sexual contact, and no opportunities for sexual exposure could be identified. It was therefore concluded that she must have acquired the infection from pool water contaminated by gonococcus after a 2-day incubation period. The infection was successfully treated with ceftriaxone and azithromycin with no adverse effects. Conclusions The pools are shallow, close to body temperature, isotonic, slightly acidic from CO2 bubbles, and contain organic particles, all potentially supporting survival of gonococcus. There are historical case reports in the literature of gonococcal epidemics in children’s hospitals being traced to common baths. It is imperative that all cases of gonococcal infection in children are fully investigated, including examining all other relevant family members, to determine whether sexual assault has occurred. This is not a diagnosis to be missed. However, both sexual and nonsexual transmission are possible. A presumption that a gonococcal infection is diagnostic of sexual abuse can be dire, with children wrongfully removed from their parents’ care, and their caregivers facing false charges of sexual crimes. Our case serves to illustrate that the very uncommon diagnosis of gonorrhea in a child may be the result of nonsexual transmission of the infection, and that contaminated hot pools are a very rare source of infection that should be considered.

Meningitis secondary to disseminated gonococcal infection

We report one of the unusual presentations of disseminated gonococcal infection. This case report describes a 24-year-old woman who presented with disseminated gonococcal infection manifesting as meningitis. Cerebrospinal fluid (CSF) and throat swab PCR were positive for Neisseria gonorrhoeae. Blood and CSF cultures were negative for bacterial growth. The patient was treated with a total of 14 days of intravenous ceftriaxone. She was discharged with no neurological sequelae.

Multiple drug allergy syndrome in pregnancy: Lessons for sexual health physicians

Co-existence of multiple drug allergies and pregnancy often results in vexing dilemmas for physicians. A 21-year-old pregnant woman presented with asymptomatic cervicitis with dual infection with Chlamydia trachomatis and Neisseria gonorrhoeae during her third trimester. She reported a history of generalised rash with mucous membrane involvement following use of both macrolides and penicillins. Her gonococcal infection was successfully treated with a single dose of intramuscular gentamicin and chlamydial infection with oral clindamycin and rifampicin.