A 23‐year‐old Asian female health care technician presented to the emergency department with left wrist pain, painful rash, fever, and occasional shortness of breath. She denied dysuria, vaginal discharge, sore throat, insect or animal bites, inappropriate exposure to body fluids, or history of STDs. She did have recent new tattoos. She was monogamous, used condoms inconsistently, and had an intrauterine device (IUD). Physical exam revealed multiple 4‐ to 5‐mm tender maculopapular lesions and pustules with eschar in her hands, multiple tattoos, and mild swelling with limited range of motion in the left wrist. No heart murmurs were appreciated. Pelvic examination revealed white, thin discharge with no cervical motion tenderness. Laboratory data were remarkable for leukocytosis of 16,340 (4000‐11,000/μL) with 85% neutrophils, ESR of 49 (0–25 mm/hour), and CRP of 61.3 (<10 mg/L). The patient was treated empirically with intravenous vancomycin, gentamicin, and levofloxacin. The cervical swab was positive for gonorrhea. Testing for Chlamydia, pregnancy, HIV, syphilis, and autoimmune panel were all negative. Antibiotics were changed to intravenous ceftriaxone and oral doxycycline. Blood cultures were positive for N. gonorrhea. IUD was removed. Transesophageal echocardiogram revealed a 1 × 0.7 mm mobile echodensity on pulmonic valve that was concerning for vegetation. Cardiothoracic surgery recommended deferring surgery until there was pulmonic valve dysfunction. Her symptoms improved with antibiotic treatment. She was subsequently discharged home on continuation of intravenous ceftriaxone for 4 weeks.
Gonorrhea is the second most commonly reported sexually transmitted disease (STD) in the United States, with approximately 300,000 cases reported annually. Gonococcemia occurs in 0.5%–3% of patients infected with Neisseria gonorrhea. Endocarditis is a rare complication, which was reported in 1%–2% of patients with gonococcemia. Literature review shows high predilection to aortic valve (50%), followed by mitral valve (30%). Isolated pulmonic valve gonococcal endocarditis is very rare with only 3 reported cases in the postantibiotic era. Patients with gonococcal endocarditis generally present with nonspecific symptoms. This is an aggressive infection and can destroy the valve in hours to days, even with antibiotic treatment. Echocardiogram is an indispensable tool for diagnosis, but late presentations and negative blood cultures can make the diagnosis challenging. Valve replacement is warranted in cases with severe pulmonary valve dysfunction. Nonetheless, unlike left‐sided endocarditis, right‐sided endocarditis responds well to antibiotic therapy.
The incidence of gonococcal endocarditis has decreased in the postantibiotic era; however, the mortality rate continues to be high around 20%. High index of suspicion, good history, and early antibiotic therapy with close monitoring are essential in diagnosis and management of gonococcal endocarditis.
To cite this abstract:Chandra K, Arwari A. A Rare Case of Disseminated Gonococcal Endocarditis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 428. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-rare-case-of-disseminated-gonococcal-endocarditis/. Accessed April 4, 2020.