Cutaneous Figures Manifestations of Disseminated Cutaneous manifestations of Gonococcal Infection: Petechiae, Pustules, disseminated gonococcal and Purpura infection include abscesses, Joel Burnett, MD, Janel DeSalvo, MD, Jacob Luty, MD cellulitis, petechiae and purpura, Department of Medicine, Oregon Health & Science bullae, necrotizing fasciitis, and

University, Portland, OR Image 1. Image of petechiae on the medial vasculitis (not just pustules!). aspect of the right lower leg. Case Presentation A 35 year-old man with a 5-year Gonococcal infections are on history of untreated human immunodeficiency virus (HIV) the rise, especially among men had urogenital gonococcal exposure two weeks prior to who have sex with men (MSM). presentation. A week prior, he received single doses of intramuscular ceftriaxone and oral azithromycin for presumed pharyngeal gonococcal infection. Image 2. Image of petechiae on the medial aspect of the left knee and proximal left lower He presented to the emergency leg. department with fever, sweats, Discussion left dorsal foot and ankle pain, Disseminated gonococcal and a rash on his bilateral lower infection (DGI) frequently extremities (Images 1 & 2) for 1 presents with a dermatitis week. syndrome, classically Figure 1. Rates of reported gonorrhea cases by year, United States 1941-2018 (Source: CDC) characterized by pustules. Exam was notable for petechiae However, cutaneous and tenosynovitis of dorsal left manifestations may be highly foot. The CD4 count was 264 variable in DGI. per cubic mm with a viral load of 26,000 copies per mL. Nucleic Clinicians should be mindful of acid amplification test (NAAT) gonococcal infections, for gonococcal infection of the especially in at-risk populations, throat, rectum, and urine were given the rising incidence of negative as were blood cultures. disease (Figures 1 & 2). He was treated for presumptive References disseminated gonococcal Sexually transmitted disease surveillance 2018. Centers for Disease Control and Prevention. Accessed 10/8/19. infection. With intravenous https://www.cdc.gov/std/stats18/Gonorrhea.htm

ceftriaxone, all presenting Figure 2. Gonorrhea cases by MSM, MSW, and Women, Beatrous SV et al. Cutaneous manifestations of disseminated symptoms resolved. STD Surveillance Network†, 2010-2018 (Source: CDC) gonoccocemia. Dermatology Online Journal 2016; 23(1):6 Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infectious Disease Clinics of North America 2005; 19:853-861