Disseminated Multidrug Resistant Neisseria gonorrhoea infection in a patient with vasculitic skin rash

A 48-year-old man was admitted with a 2-day history of a vasculitic skin rash on both his hands and feet. The rash first appeared on his hands before spreading to his lower limbs. Following the rash’s appearance, he developed a fever. His medical history included a metallic valve replacement in 2015 and long-term warfarin therapy. He was diagnosed with nasopharyngeal carcinoma in February 2021 and was awaiting chemotherapy. The rash was painful, non-blanching, multiple, raised, smooth, and erythematous (Figure 1, 2, and 3). A cardiovascular examination revealed no murmur, but a clear, crisp mitral prosthetic click was audible. The abdominal examination was unremarkable. Infective endocarditis was initially suspected, and treatment with penicillin and gentamicin was initiated. However, a trans-thoracic echocardiography showed no vegetation. Blood cultures subsequently grew Gram-negative bacilli identified as Neisseria gonorrhoeae, which was resistant to penicillin, tetracycline, and ciprofloxacin but sensitive to ceftriaxone. The treatment was switched to intravenous ceftriaxone in place of penicillin and gentamicin, which was continued for 2 weeks, resulting in complete resolution. Further investigations, including a transoesophageal echocardiography and a sexual health screen for HIV, hepatitis B and C, syphilis, and Chlamydia trachomatis IgM, were negative. The majority of gonococcal infections in men are asymptomatic^1,2 and can lead to disseminated bacteraemia, as demonstrated in this case. Gonococcal vasculitic lesions can also present a diagnostic challenge, and there is increasing awareness of drug resistance³.

FIGURE 1:
Vasculitic lesions over the right arm.

FIGURE 2:
Vasculitic lesions over the palm.

FIGURE 3:
Vasculitic lesions over both feet.

ACKNOWLEDGMENTS

We express our deepest gratitude to the staff at Hospital Sultanah Aminah who were involved in the care of the patient.

REFERENCES

• ¹
  Handsfield HH, Lipman TO, Harnisch JP, Tronca E, Holmes KK. Asymptomatic gonorrhea in men. Diagnosis, natural course, prevalence and significance. N Engl J Med. 1974;290(3):117-23.
• ²
  Klouman E, Masenga EJ, Sam NE, Klepp KI. Asymptomatic gonorrhoea and chlamydial infection in a population-based and work-site based sample of men in Kilimanjaro, Tanzania. Int J STD AIDS. 2000;11(10):666-74.
• ³
  Costa-Lourenço APRD, Barros Dos Santos KT, Moreira BM, Fracalanzza SEL, Bonelli RR. Antimicrobial resistance in Neisseria gonorrhoeae: history, molecular mechanisms and epidemiological aspects of an emerging global threat. Braz J Microbiol. 2017;48(4):617-28.

• Financial Support: The authors declared the project is self- funded and no external funding received.

Publication Dates

• Publication in this collection
  22 Sept 2023
• Date of issue
  2023

History

• Received
  16 June 2023
• Accepted
  03 Aug 2023