Cutaneous manifestation of infection with Neisseria gonorhoeae

Gonococcemia - cutaneous manifestation of infection with Neisseria gonorhoeae Gonococcemia is defined as the presence of the bacterium Neisseria gonorrhoeae in blood flow, leading to disseminate gonococcal infections. Gonorrhea is the second sexually transmitted disease after chlamydia. Gonococcemia occurs in 3% of patients with gonorrhea. Clinical manifestations of this process are biphasic with an early phase consisting of bacteremia tenosynovitis, dermatitis and arthralgia, followed by a localized phase consisting of localized septic arthritis. Other serious clinical complications include osteomyelitis, meningitis, endocarditis, acute respiratory distress syndrome, adult and septic shock. Poliomiozita may also be a rare complication of gonococcemiei.
Patients who are pregnant or menstruating are prone to gonococcemie. Other population groups at risk of infection include women and those with complement deficiencies, HIV disease or systemic lupus erythematosus. Disseminated Gonococcal Infection is a life threatening condition but easily treatable, is the most common cause of acute septic arthritis in sexually active young adults. Initial empirical therapy consisted of intravenous administration of third generation cephalosporins, was obtained after antibiotic sensitivity of bacteria will be given penicillin G and ampicillin. Coinfection with chlamydia is treated with tetracycline or macrolide.
Pathogenesis and causes
Bodies of Neisseria gonorrhoeae are spreading from the primary site such as endocervixul, urethra, throat or rectum and disseminates in the blood to infect other organs and systems. Usually there are multiple locations as infected skin and joints. Disseminates bodies in the blood due to a variety of factors. These predisposing factors include changes in psychological factors on the virulence of the organism and host immune deficiencies. For example, vaginal pH changes during menses and pregnancy with vaginal environment puerperium are organisms responsible for growth and allow open access to blood circulation.
Factors such as the virulence of the organism to inhabit it pilii help to prevent mucus and macrophage phagocytosis. Some membrane proteins are involved in determining virulence and bacterial strain used for chick body. Lipooligozaharidele cell membrane of the bacteria were resistant to the action and determine endotoxic serum bactericidal action. Some strains produce immunoglobulin A, which helps them survive in living tissues. Defects in host defense are also involved in pathogenesis. Patients with deficiencies of the complement system are less able to fight off infection. Other causes include HIV infection, lupus.
Signs and symptoms
Gonococcemia remains an important disease of teenagers and young adults, with a peak of incidence in men between 20-24 years and women 15-19. Anamnesis showed classic manifestations gonococcemiei: skin lesions, arthritis and pericarditis. A dramatic increase is observed in the incidence of gonorrhea in pregnancy.
Physical examination. Gonococcemice disseminate clinical course of infection is biphasic phase consisting out of a bacteremia and a phase with effusion, localized.
Phase bacteremia. Begins 2-3 days gonococcemie. Poliartralgii patient experience and constitutional symptoms such as feeling sick. Fever and weakness. Classic skin lesions are hemorrhagic pustules sour. This phase is associated with the clinical appearance of arthritis, dermatitis and tenosinovitelor. The joints most affected are the extremities, including wrists, fingers, elbows, knees and heels. 70% of patients experiencing a migratory poliartralgie of joints 1-3 and the remaining 30% shows the involvement of more than three joints. This arthritis is considered sterile culture negative. Some patients such as those with HIV may experience unusual damage to joints and arthritis is more aggressive, with its potential destruction.
75% of patients ranging from dermatitis macula / papular to vesiculo / pustular rash until necrotic or hemorrhagic. Dermatitis does not leave scars. It has been reported and vasculitis. The skin lesions are different stadium development and may be present 5-50 of injuries. They are located on the distal extremities. Face, scalp, palms, soles and trunk are avoided, but not always. The lesions may be painful but are usually asymptomatic and resolve in 4-7 days even without treatment. In phase pericarditis can bacteremia, endocarditis, perihepatitei, osteomyelitis, glomerulonephritis and other organ damage should be considered, but the incidence is rare or continue to decline with effective treatment and early diagnosis of disease.
Localized suppurative phase. This phase begins 3-6 days after infection and consists of arthritis. Unlike arthritis / arthralgia phase that bacteremia is a septic arthritis and purulent joint culture positive in 50% of patients. White cell count in joint fluid aspiration shows 50. 000-100. 000 cells / ml and consisted of 90% neutrophils. Skin elements from this phase are minimal, only 10-15% of patients had active skin lesions and the remaining 80% had dermatitis for healing.
Diagnosis
Laboratory studies: -Counts show neutrophilia, erythrocyte sedimentation rate is high,> 50 -Highest number of harvested body in mucous membranes, including the pharynx, urethra, cervix, rectum, urethral and cervical cultures are the most positive, positive cultures of skin lesions is only 10%, only 20-30% of the joint cultures, the 10-30% of blood -Polymerase chain reaction is a method of high sensitivity and high specificity, noninvasive, rapid diagnosis and to identify body Serological tests include latex-agglutination, ELISA, immunoprecipitation and complement fixation, specificity and sensitivity were poor.
Histological examination showed the appearance of vasculitis and perivascular infiltrates neutrophilous pustules with neutrophils in the epidermis. The differential diagnosis is made with the following conditions: acanthosis nigricans, cutaneous manifestations of hepatitis C, Lyme disease, meningococcemia, psoriatic arthritis, reactive arthritis, syphilis.
Treatment
It is indicated hospitalization and intravenous antibiotics for 24-48 hours, then therapy can be administered orally. Initial empirical therapy include third generation cephalosporins: ceftriaxone. Once we obtained the sensitivity of bacterial therapy can be switched to penicillin G and ampicillin. Patients with allergies to penicillin are treated with spectinomycin. Patients associated with chlamydia infection and require treatment with tetracycline co-azithromycin-doxycycline or a macrolide. Disseminated form of the disease requires prolonged therapy.