What type of rash is associated with Neisseria (N.) gonorrhoeae?

Rash Associated with Neisseria Gonorrhoeae Infection

The classic rash associated with Neisseria gonorrhoeae is a pustular or papulopustular eruption that occurs primarily on the extremities as part of disseminated gonococcal infection (DGI), often accompanied by tenosynovitis and migratory polyarthritis. 1, 2

Disseminated Gonococcal Infection (DGI) Skin Manifestations

Classic Presentation

• Pustular or papulopustular lesions (most common)
• Distribution: Limited to extremities, particularly on hands, wrists, feet, and ankles
• Lesion progression: Begin as papules → evolve into pustules → may develop into bullae, petechiae, or necrotic lesions 1
• Number: Usually sparse (5-40 lesions)
• Characteristics: Often painless but can be tender

Atypical Presentations

• Petechial and purpuric rash (less common variant) 3
• Vesicular lesions
• Hemorrhagic lesions
• Necrotic lesions in advanced cases

Arthritis-Dermatitis Syndrome

This is the most common clinical presentation of DGI, characterized by:

1. Skin manifestations as described above
2. Tenosynovitis - particularly affecting wrists, fingers, ankles, and toes
3. Migratory polyarthritis - commonly involving wrists, ankles, and small joints of hands and feet 4, 2

Pathophysiology

DGI occurs in approximately 0.5-3% of untreated gonococcal infections when the bacteria disseminate from the primary mucosal site (genital, rectal, or pharyngeal) via the bloodstream 2. The skin lesions represent septic emboli from bacteremia.

Risk Factors for DGI

• Female gender (more common in women)
• Menstruation
• Pregnancy
• Complement deficiencies
• Asymptomatic primary infection (leading to delayed treatment)
• Multiple sexual partners
• Men who have sex with men (MSM) 5

Diagnostic Approach

When evaluating a patient with suspected gonococcal rash:

1. Obtain cultures from all potential sites of infection:

   • Blood cultures (positive in 50-85% during early disseminated phase)
   • Skin lesion aspirates or biopsies
   • Genital, rectal, and pharyngeal specimens
   • Synovial fluid if joint involvement 5

2. Nucleic acid amplification tests (NAATs) from:

   • Urine
   • Genital specimens
   • Extragenital sites as indicated 5, 4

Management

Initial Treatment

• Hospitalization recommended for initial therapy, especially with:
  • Uncertain diagnosis
  • Purulent joint effusions
  • Inability to follow outpatient regimen 5

Recommended Regimen

• Ceftriaxone 1g IV/IM every 24 hours until clinical improvement begins 5
• Continue parenteral therapy for 24-48 hours after improvement begins

Transition to Oral Therapy

After 24-48 hours of clinical improvement:

• Cefixime 400 mg orally twice daily to complete at least 1 week of total therapy 5

Special Considerations

• Evaluate for endocarditis and meningitis in all DGI patients
• Treat presumptively for concurrent Chlamydia trachomatis infection
• Test for other STIs including HIV 1

Common Pitfalls

• Misdiagnosis - DGI skin lesions may be confused with other conditions like meningococcemia, Rocky Mountain spotted fever, or drug eruptions
• Failure to recognize DGI due to minimal or absent genital symptoms
• Inadequate treatment duration - full course needed to prevent recurrence
• Neglecting partner treatment - essential to prevent reinfection 5

Key Points to Remember

• The rash of DGI is typically sparse, pustular, and limited to the extremities
• Skin lesions often appear during the bacteremic phase and may be transient
• Joint symptoms frequently accompany the rash in the arthritis-dermatitis syndrome
• Primary mucosal infection may be asymptomatic, particularly in women
• Treatment requires parenteral antibiotics initially, followed by oral therapy to complete at least 1 week of treatment 5, 4