Signs and Symptoms of Disseminated Gonorrhea
Disseminated gonococcal infection (DGI) classically presents with the triad of dermatitis, tenosynovitis, and migratory polyarthralgia, though it can also manifest as purulent septic arthritis. 1, 2
Clinical Presentation Patterns
DGI typically manifests in two distinct clinical patterns that may represent different stages or variations of the same disease process:
Pattern 1: Bacteremic/Tenosynovitis-Dermatitis Syndrome
- Tenosynovitis occurs in approximately 87% of patients with this presentation, making it the most common musculoskeletal finding 3
- Skin lesions appear in 90% of these patients and include 4, 3:
- Hemorrhagic pustules (most characteristic)
- Petechiae
- Purpuric macules
- Vesiculopustular lesions
- Rarely: abscesses, cellulitis, necrotizing fasciitis, or vasculitis
- Migratory polyarthralgia is the most common initial symptom, affecting multiple joints in a non-fixed pattern 3
- Blood cultures are positive in approximately 43% of these patients 3
- Fever and chills are common systemic manifestations 5, 2
Pattern 2: Suppurative Arthritis
- Purulent septic arthritis develops in approximately 40% of DGI cases, most commonly affecting the knee 3
- Tenosynovitis is less common in this pattern, occurring in only 21% of patients 3
- Skin lesions are less frequent, present in only 42% of these patients 3
- Synovial fluid cultures are positive in approximately 47% of cases, while blood cultures are typically negative 3
Important Clinical Features
Genitourinary Symptoms
- Most patients lack genitourinary symptoms at presentation, making DGI a diagnostic challenge 3
- Women are often asymptomatic with cervical gonorrhea, which is why dissemination can occur unrecognized 4, 6
- When present, women may report mucopurulent discharge or pelvic pain 6
- Men may have penile discharge and dysuria, but these are often absent in DGI 6
Risk Factors and Timing
- Menstruation or pregnancy increases risk, with 33% of women presenting during these periods 3
- Patients may have history of previous gonococcal infections (reported in 27% of cases) 3
Rare but Serious Manifestations
- Endocarditis and meningitis are rare complications that require evaluation in all DGI patients 1
- Osteomyelitis can occur but is uncommon 5
- Liver function abnormalities may be present without clear explanation 3
Key Diagnostic Pitfalls
- Skin lesions may progress despite appropriate treatment and some patients are unaware of their presence, requiring careful examination 3
- The absence of genitourinary symptoms does not exclude DGI - maintain high clinical suspicion based on the triad of findings 3
- Pharyngeal and anorectal infections are often asymptomatic primary sites that can lead to dissemination 6
- Complement deficiencies should be considered in patients with recurrent DGI 3