Advertisement

Sparse pustules and tenosynovitis in a young man

      1. Case description

      A man in his 37 s consulted about a two-day-history of pustules on his both hands (Fig. 1A-C ) and his right elbow (Fig. 1D). He complained also about edema, polyarthralgia with asymmetric small joint involvement and articular impairment in his hands. No other joints were affected. Furthermore, no other skin lesions were advised on clinical examination. He had no associated fever but generalized malaise.
      Fig. 1
      Fig. 1Clinical (1A-D) and histological (1E) findings. Pustules on hands (1A-C) and elbow (1D). 1E, Biopsy (H/E ×4) revealing a broken pustule with dermal edema and dense perivascular infiltrate composed mostly of neutrophils.
      Anamnesis revealed he had multiple sexual men partners in the previous 3 months, one was HIV positive.
      Blood test revealed leukocytosis [17,00 × 103/μL (normal range: 3,50–10,50 × 103/μL), with 13,62 × 103/μL neutrophils (normal range: 1,9–7,3 × 103/μL)] and an elevated CRP [100,9 mg/L (normal range: 0–5 mg/L)] associating negative procalcitonin levels.
      Swabs were taken on pustules and a biopsy of one pustule was performed. In addition, urogenital, rectal, and pharyngeal specimens, were submitted for microbiologic testing despite lack of symptoms at those sites. Two sets of blood cultures were obtained.
      Ultrasonography revealed tenosynovitis involving the extensor muscles of his right hand.

      2. What's your diagnosis?

      Disseminated Gonococcal Infection (DGI).

      3. Discussion

      Nucleic acid amplification testing [
      • Centers for Disease Control and Prevention
      Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014.
      ] of the pustule rendered a positive result for Neisseria gonorrheae. Also, histological findings revealed a broken pustule, associating perivascular neutrophilic infiltrate with fibrinoid necrosis (Fig. 1E) (infection-related leukocytoclastic vasculitis) [
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ]. This are diagnostic findings of DGI [
      • Centers for Disease Control and Prevention
      Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014.
      ,
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ].
      Patients with DGI may debut with the classical triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis (“arthritis-dermatitis syndrome”) [
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ].
      As our patient, history of prior symptomatic genital infection is generally uncommon. Despite several joints could be affected, typically depicts asymmetric joint involvement. Moreover, migratory arthralgias and tenosynovitis, both relatively common in DGI, are distinctive findings over other infectious arthritis [
      • García-De La Torre I.
      • Nava-Zavala A.
      Gonococcal and nongonococcal arthritis.
      ].
      Skin is often involved with painless, pustular or vesiculopustular lesions, which are mostly found on the distal extremities [
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ]. Usually, pustules last for only few days, even without treatment [
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ].
      Septic arthritis, HBV, HIV, Syphilis, HSV, infective endocarditis, parvovirus B19, measles, rubella, and arboviral infections, have to be considered, as they can also cause rash and arthritis [
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ]. Albeit rare, early Lyme disease, Reactive arthritis, rheumatoid arthritis, psoriatic arthritis and Lupus arthritis, should be taken into account, especially for articular symptoms [
      • García-De La Torre I.
      • Nava-Zavala A.
      Gonococcal and nongonococcal arthritis.
      ].
      Treatment with parenteral therapy with ceftriaxone 1 g intravenously every 24 h for three days was established, and was completed with a seven-day course of oral cefixime (400 mg twice daily) plus one single dose of azithromycin 1 g orally [
      • Centers for Disease Control and Prevention
      Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014.
      ,
      • Beatrous S.V.
      • Grisoli S.B.
      • Riahi R.R.
      • Matherne R.J.
      • Matherne R.J.
      Cutaneous manifestations of disseminated gonococcemia.
      ,
      • García-De La Torre I.
      • Nava-Zavala A.
      Gonococcal and nongonococcal arthritis.
      ], leading to complete, clinical and microbiological, restoration.

      Funding sources

      None.

      Conflict of interests

      None of the authors have any conflicts of interest to declare.

      References

        • Centers for Disease Control and Prevention
        Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014.
        in: MMWR Recomm reports Morb Mortal Wkly report Recomm reports. vol. 63 (RR-02). 2014: 1-19https://doi.org/10.1016/j.biotechadv.2011.08.021 ([Secreted])
        • Beatrous S.V.
        • Grisoli S.B.
        • Riahi R.R.
        • Matherne R.J.
        • Matherne R.J.
        Cutaneous manifestations of disseminated gonococcemia.
        Dermatol Online J. 2017; 23
        • García-De La Torre I.
        • Nava-Zavala A.
        Gonococcal and nongonococcal arthritis.
        Rheum Dis Clin North Am. 2009; 35: 63-73https://doi.org/10.1016/j.rdc.2009.03.001