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Disseminated gonococcal infection — ABIM Board MCQ

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ModerateInfectious DiseaseDisseminated gonococcal infectionABIM Board

A 24-year-old woman presents with 3 days of fever and pain that has migrated among her wrists, knees, and ankles. Examination shows tenderness along multiple wrist extensor tendons and several tender pustules on erythematous bases over the distal extremities. She has had new sexual partners but reports no dysuria or vaginal discharge. Synovial fluid Gram stain and culture are negative, and nucleic acid amplification testing from exposed mucosal sites is pending. Which of the following is the most likely diagnosis?

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Correct answer: E — Disseminated gonococcal infection

The correct answer is E, disseminated gonococcal infection (DGI). Its arthritis-dermatitis syndrome classically combines fever, asymmetric migratory polyarthralgia, tenosynovitis, and sparse petechial or pustular lesions on the distal extremities. Genital symptoms may be absent because the primary mucosal infection is often asymptomatic; cultures from blood, skin, or synovial fluid may also be unrevealing, so testing exposed mucosal sites is important. Chlamydial reactive arthritis more often causes asymmetric lower-extremity oligoarthritis, enthesitis, and sometimes conjunctivitis or urethritis, not this pustular-tenosynovitis syndrome. Acute HIV may cause fever and a diffuse maculopapular rash but does not characteristically cause tenosynovitis with acral pustules. Rocky Mountain spotted fever causes a macular-to-petechial rash rather than sparse pustules. Rheumatoid arthritis is typically chronic and symmetric and does not explain the fever and pustular lesions.

Reference: Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021: Gonococcal Infections Among Adolescents and Adults, section “Disseminated Gonococcal Infection.” https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm