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Gonococcal subcutaneous abscess and pyomyositis: a case report.

Jitmuang A, Boonyasiri A, Keurueangkul N, Leelaporn A, Leelarasamee A - Case Rep Infect Dis (2012)

Bottom Line: Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, its manifestation varies from a classic arthritis-dermatitis syndrome to uncommon pyogenic infections of several organs.Herein, we reported atypical presentation of DGI with subcutaneous abscess of right knee, pyomyositis of right lower extremity, and subsequently complicated by Escherichia coli pyomyositis.This infection responded to appropriate antimicrobial therapy and prompt surgical management with good clinical outcome.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Disease and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT
Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, its manifestation varies from a classic arthritis-dermatitis syndrome to uncommon pyogenic infections of several organs. Herein, we reported atypical presentation of DGI with subcutaneous abscess of right knee, pyomyositis of right lower extremity, and subsequently complicated by Escherichia coli pyomyositis. This infection responded to appropriate antimicrobial therapy and prompt surgical management with good clinical outcome.

No MeSH data available.


Related in: MedlinePlus

Gram stain of pus specimens obtained from aspiration and incisional drainage of right knee joint showed moderate amounts of gram-negative kidney-shaped diplococci (arrowhead). Pus culture on chocolate agar grew Neisseria gonorrhoeae.
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fig1: Gram stain of pus specimens obtained from aspiration and incisional drainage of right knee joint showed moderate amounts of gram-negative kidney-shaped diplococci (arrowhead). Pus culture on chocolate agar grew Neisseria gonorrhoeae.

Mentions: A 48-year-old woman with a poorly controlled diabetes mellitus for 12 years, presented with acute severe right knee pain and fever for 7 days. Three weeks before the onset, she fell on the ground accidentally and developed right knee pain. However, she was able to walk after the event and there was no open wound nor knee swelling. A physician provided a short slab for right knee immobilization, but her knee pain was progressive and she was unable to mobilize or leave her bed for one week before admission. She also complained of perianal pain during this illness. At Siriraj Hospital, body temperature was 38.2°C, pulse rate 102/minute, blood pressure and respiratory rate were normal. Her right knee was swollen, fluctuated on the lateral sides with diameter about 7 × 15 centimeters (cm), and marked tenderness and warmth. Anal examination found a draining abscess on the left side of perianal area, sized about 3 × 4 cm. Others were unremarkable. An aspiration of the right knee revealed frank pus. Plain radiography of the right knee was unremarkable. Blood sugar was 413 mg/dL, complete blood count showed hemoglobin of 7.5 g/dL, hematocrit 23.6%, white blood cell count of 23,180 cell/mm3 (neutrophil 88.2%, lymphocyte 4.3%, monocyte 4.4%), platelets count of 547,000 cell/mm3, ESR 102 mm/hr, and CRP 330 mg/L. Serum BUN and creatinine were within normal limits. She was admitted to the hospital and ceftriaxone 2 g/day with clindamycin 1,800 mg/day were empirically commenced. The surgeon performed incision and drainage (I&D) of the right knee abscess and perianal abscess on the first day of hospitalization. Operative findings showed 300 mL of subcutaneous pus around the right knee without connection to the joint cavity, and 20 mL of pus drained from perianal and intersphincteric abscesses. Gram stain of both specimens of pus showed moderate gram-negative diplococci as shown in Figure 1 and culture on chocolate agar grew Neisseria gonorrhoeae with positive beta lactamase testing. The organism was susceptible to ceftriaxone, ciprofloxacin, and tetracycline, but resistant to penicillin by disc diffusion method. Strain and serotype identification of Neisseria spp. were not tested in the hospital. Gram stain of pus from perianal abscess showed polymicrobial micro-organisms with gram-negative diplococci, gram-positive cocci in pairs, and rare gram-positive rods. The pus culture grew mixed microorganisms without N. gonorrhoeae. All blood cultures were negative. Disseminated gonococcal infection with polymicrobial perianal and intersphincteric abscesses were diagnosed. This patient denied previously multipartners sexual activity, receptive anal intercourse, and prior sexually transmitted diseases. She has been in menopausal period for two years and has been living with her healthy husband. Her last sexual intercourse was 2 months before admission. Atrophic vaginal mucosa and minimal mucus cervical discharge were identified from per vaginal examination and no microorganisms grew from cervical swab cultures. Nucleic acid amplification test (NAAT) of the vaginal discharge was negative for N. gonorrhoeae and Chlamydia trachomatis. The NAAT of rectal specimens was not approved to detect N. gonorrhoeae and C. trachomatis coinfection by our regulatory unit. The Anti-HIV antibody test and VDRL were also nonreactive. Serum C3 and C4 complements levels were 70.5 mg/dL (normal range; 87–177) and 23.8 mg/dL (normal range; 7–40), respectively. The initial antibiotics were continued and doxycycline 200 mg/day was added for 7 days for potential chlamydial coinfection. Insulin injection was used for control hyperglycemia. The anal abscesses resolved, however, fever was temporarily subsided. Besides there was persistent pus drainage from the incised wound of right knee and progressive swelling extended downward to calf area (Figure 2(a)). Ultrasonography of the right leg was done and discovered large multiloculated peri- and intramuscular abscesses of the right calf as shown in Figures 2(b) and 2(c). Repeated surgical debridements were performed on day 8 and day 16 of hospitalization, there was foul-smell pus draining from muscles of posterior part of right lower thigh and right calf. Pus culture grew moderate amount of Escherichia coli, then intravenous meropenem was then substituted for treatment of complicated pyomyositis. Fever, swollen right leg, and pus drainage were resolved, then the wound was resutured. Meropenem was discontinued after 14 days of therapy. The patient was discharged from the hospital on day 34 of hospitalization. Two weeks later, the patient's condition almost returned to normal and anemia was improving from iron supplementation. Her husband was not available for investigation of gonococcal infection because he had been working in another province.


Gonococcal subcutaneous abscess and pyomyositis: a case report.

Jitmuang A, Boonyasiri A, Keurueangkul N, Leelaporn A, Leelarasamee A - Case Rep Infect Dis (2012)

Gram stain of pus specimens obtained from aspiration and incisional drainage of right knee joint showed moderate amounts of gram-negative kidney-shaped diplococci (arrowhead). Pus culture on chocolate agar grew Neisseria gonorrhoeae.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3420083&req=5

fig1: Gram stain of pus specimens obtained from aspiration and incisional drainage of right knee joint showed moderate amounts of gram-negative kidney-shaped diplococci (arrowhead). Pus culture on chocolate agar grew Neisseria gonorrhoeae.
Mentions: A 48-year-old woman with a poorly controlled diabetes mellitus for 12 years, presented with acute severe right knee pain and fever for 7 days. Three weeks before the onset, she fell on the ground accidentally and developed right knee pain. However, she was able to walk after the event and there was no open wound nor knee swelling. A physician provided a short slab for right knee immobilization, but her knee pain was progressive and she was unable to mobilize or leave her bed for one week before admission. She also complained of perianal pain during this illness. At Siriraj Hospital, body temperature was 38.2°C, pulse rate 102/minute, blood pressure and respiratory rate were normal. Her right knee was swollen, fluctuated on the lateral sides with diameter about 7 × 15 centimeters (cm), and marked tenderness and warmth. Anal examination found a draining abscess on the left side of perianal area, sized about 3 × 4 cm. Others were unremarkable. An aspiration of the right knee revealed frank pus. Plain radiography of the right knee was unremarkable. Blood sugar was 413 mg/dL, complete blood count showed hemoglobin of 7.5 g/dL, hematocrit 23.6%, white blood cell count of 23,180 cell/mm3 (neutrophil 88.2%, lymphocyte 4.3%, monocyte 4.4%), platelets count of 547,000 cell/mm3, ESR 102 mm/hr, and CRP 330 mg/L. Serum BUN and creatinine were within normal limits. She was admitted to the hospital and ceftriaxone 2 g/day with clindamycin 1,800 mg/day were empirically commenced. The surgeon performed incision and drainage (I&D) of the right knee abscess and perianal abscess on the first day of hospitalization. Operative findings showed 300 mL of subcutaneous pus around the right knee without connection to the joint cavity, and 20 mL of pus drained from perianal and intersphincteric abscesses. Gram stain of both specimens of pus showed moderate gram-negative diplococci as shown in Figure 1 and culture on chocolate agar grew Neisseria gonorrhoeae with positive beta lactamase testing. The organism was susceptible to ceftriaxone, ciprofloxacin, and tetracycline, but resistant to penicillin by disc diffusion method. Strain and serotype identification of Neisseria spp. were not tested in the hospital. Gram stain of pus from perianal abscess showed polymicrobial micro-organisms with gram-negative diplococci, gram-positive cocci in pairs, and rare gram-positive rods. The pus culture grew mixed microorganisms without N. gonorrhoeae. All blood cultures were negative. Disseminated gonococcal infection with polymicrobial perianal and intersphincteric abscesses were diagnosed. This patient denied previously multipartners sexual activity, receptive anal intercourse, and prior sexually transmitted diseases. She has been in menopausal period for two years and has been living with her healthy husband. Her last sexual intercourse was 2 months before admission. Atrophic vaginal mucosa and minimal mucus cervical discharge were identified from per vaginal examination and no microorganisms grew from cervical swab cultures. Nucleic acid amplification test (NAAT) of the vaginal discharge was negative for N. gonorrhoeae and Chlamydia trachomatis. The NAAT of rectal specimens was not approved to detect N. gonorrhoeae and C. trachomatis coinfection by our regulatory unit. The Anti-HIV antibody test and VDRL were also nonreactive. Serum C3 and C4 complements levels were 70.5 mg/dL (normal range; 87–177) and 23.8 mg/dL (normal range; 7–40), respectively. The initial antibiotics were continued and doxycycline 200 mg/day was added for 7 days for potential chlamydial coinfection. Insulin injection was used for control hyperglycemia. The anal abscesses resolved, however, fever was temporarily subsided. Besides there was persistent pus drainage from the incised wound of right knee and progressive swelling extended downward to calf area (Figure 2(a)). Ultrasonography of the right leg was done and discovered large multiloculated peri- and intramuscular abscesses of the right calf as shown in Figures 2(b) and 2(c). Repeated surgical debridements were performed on day 8 and day 16 of hospitalization, there was foul-smell pus draining from muscles of posterior part of right lower thigh and right calf. Pus culture grew moderate amount of Escherichia coli, then intravenous meropenem was then substituted for treatment of complicated pyomyositis. Fever, swollen right leg, and pus drainage were resolved, then the wound was resutured. Meropenem was discontinued after 14 days of therapy. The patient was discharged from the hospital on day 34 of hospitalization. Two weeks later, the patient's condition almost returned to normal and anemia was improving from iron supplementation. Her husband was not available for investigation of gonococcal infection because he had been working in another province.

Bottom Line: Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, its manifestation varies from a classic arthritis-dermatitis syndrome to uncommon pyogenic infections of several organs.Herein, we reported atypical presentation of DGI with subcutaneous abscess of right knee, pyomyositis of right lower extremity, and subsequently complicated by Escherichia coli pyomyositis.This infection responded to appropriate antimicrobial therapy and prompt surgical management with good clinical outcome.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Disease and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT
Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, its manifestation varies from a classic arthritis-dermatitis syndrome to uncommon pyogenic infections of several organs. Herein, we reported atypical presentation of DGI with subcutaneous abscess of right knee, pyomyositis of right lower extremity, and subsequently complicated by Escherichia coli pyomyositis. This infection responded to appropriate antimicrobial therapy and prompt surgical management with good clinical outcome.

No MeSH data available.


Related in: MedlinePlus