Disseminated Gonococcal Infection Masquerading as Systemic Lupus Erythematous Flare

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Journal of Investigative Medicine





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Case Report A 16 year female who had been recently diagnosed with systemic lupus erythematous (SLE) presents to the emergency department with one month history of right shoulder swelling and decreased range of motion in addition to left hand swelling and left index finger contracture. She had gradually increasing pain with minimal response to over the counter analgesics. On review of systems, she had no fever, weight loss, or trauma. She admitted to sexual activity, but insisted on consistent use of barrier contraceptives. In the emergency department, ultrasound was suggestive of bursitis and patient was admitted for pain control. MRI was performed which was suggestive of abscess versus complex bursitis. Rheumatology was consulted and recommended that aspiration of the right shoulder be done in order to rule out infection before starting pulse steroids for presumed SLE flare. Aspiration of the right subacromial joint revealed purulent drainage which required subsequent washout. Initial gram stain of the aspirate demonstrated rare gram negative coccobacilli. Treatment was initiated with vancomycin and ceftriaxone pending culture results. All immunosuppressants were discontinued except low dose prednisone. Culture of the abscess eventually returned positive for Neisseria gonorrhoeae. Nucleic acid amplification testing of the urine also returned positive for N. gonorrhoeae. Vancomycin was discontinued and patient was given standard one time dose of azithromycin for coverage of Chlamydiae. After seven days of intravenous ceftriaxone, patient demonstrated near resolution of right shoulder and left hand swelling in addition to improved range of motion of right shoulder, left hand, and left index finger. Patient was discharged home to complete 2–3 week course of IV ceftriaxone for treatment of septic joint. This case highlights the importance of considering disseminated gonococcal infection in young patients presenting with arthritis, even those with chronic arthritis. Although only occurring in 0.5–3% of those infected with N. gonorrhoeae, recognition is essential for adequate treatment. Moreover, as exemplified in this case, distinguishing between septic joint versus exacerbation of a chronic autoimmune disease is critical for the proper management of both conditions.


Medicine and Health Sciences



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