By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: The diagnosis of disseminated gonococcal infection often is delayed, but the infection can most often be readily treated with ceftriaxone. Patients often lack urogenital symptoms.
SOURCE: Tang EC, Johnson KA, Alvarado L, et al. Characterizing the rise of disseminated gonococcal infections in California, July 2020-July 2021. Clin Infect Dis 2023;76:194-200.
Having become aware of an apparent increase in reported cases of disseminated gonococcal infections (DGI), the California Department of Public Health (CDPH) implemented enhanced surveillance and case investigations in October 2020. Cases of interest occurred within the California Research Project, which includes all of the state with the exception of the health jurisdictions of Los Angeles and San Francisco, which have a separate surveillance system. From July 1, 2020, through July 31, 2020, 149 (0.24%) of the total of 63,338 reported infections were disseminated, for an estimated incidence of DGI within the region of 0.47 cases per 100,000 person years. Of the 149 cases of DGI, 115 were considered confirmed and 34 were probable; the former had organism isolation from a site of dissemination, while the latter had isolation from a mucosal site.
Overall, both the age (mean and median) of the patients was 36 years, but the mean was lower among cisgender females than cisgender males at 36 years and 45 years, respectively. Cisgender females accounted for 49% of cases, while 50% were cisgender males; one (1%) was a transgender female. Thirteen of 45 males had sex only with male partners. Of the total, 54% were individuals identified as Hispanic/Latinx (compared to 40% in the state as a whole). Twenty-three percent reported homelessness within the previous 12 months, and illicit drug use, most commonly methamphetamines, was common. Nine patients (8%) were human immunodeficiency virus-infected, and six patients (5%) were receiving immunosuppressive therapy.
The majority of patients lacked urogenital, pharyngeal, or rectal symptoms. Fifty-nine patients (53%) presented with septic arthritis, and more than one-third presented with fever and polyarthralgia, while 21 patients (19%) had tenosynovitis and 19 patients (17%) had skin lesions. Five (5%) patients had endocarditis, two had osteomyelitis, and one had a liver abscess, but no cases of meningitis were reported. Two patients (2%) died — each of whom had presented with sepsis.
Synovial fluid and blood cultures were positive in 47/69 (68%) and 40/97 (41%), respectively, and, while performed in only a minority, the organism often was detected (primarily by nucleic acid amplification tests) in pharyngeal, oral, and urine specimens. All 47 isolates tested were susceptible to ceftriaxone, cefixime, and azithromycin, while 20/46 (43%) were resistant to ciprofloxacin and 7/45 (16%) were resistant to tetracycline.
COMMENTARY
Among the previously reported risk factors for DGI have been younger age, female gender, menstruation, pregnancy, and complement deficiency (including deficiency caused by eculizumab administration). This California experience identified illicit use of methamphetamines in more than one-third of patients. There also was a skewing of the age of cases toward somewhat older groups than previously observed, with 35% being ≥ 45 years of age, and this group included 11% who were > 55 years of age.
Although two patients who presented with sepsis died, the infection generally is readily treated. Five patients in this series had endocarditis, but none had meningitis. Ceftriaxone is the recommended first-line treatment of patients with DGI, and all isolates tested in the patients in this series were susceptible to this cephalosporin as well as to cefixime and azithromycin. Therapy can be completed by oral administration of cefixime.
However, effective treatment requires timely diagnosis, and many of these patients had multiple emergency department visits before this occurred. Clinicians must be alert to the diagnosis of DGI, including in patients without urogenital symptoms, and testing should include oropharyngeal and rectal sampling.
