Disseminated gonococcal infection case series: clinical presentations, microbiology findings and whole genome sequencing results

BackgroundDisseminated gonococcal infection (DGI) is a rare complication of Neisseria gonorrhoeae (NG) infection arising from bacteraemia. It classically manifests as one or more of acute arthritis, tenosynovitis and dermatitis, more commonly in females. Anecdotally, DGI is increasing. We describe eight cases of DGI; seven presented within 13 months.MethodsAll cases presented/referred, to STI/ID at a large teaching hospital, in England and diagnosed with proven/probable DGI. Demographic, clinical and microbiological data were prospectively collected. Whole genome sequencing (WGS) of positive cultures was undertaken.ResultsThree proven (synovial fluid/skin NG culture positive) and five probable cases were identified, all males (7/8 MSM), and most (7/8) with no genital symptoms. Hip and wrist were the most commonly affected joints. Dermatitis featured in 5/8. All were NG NAAT-positive at an extra-genital site (pharynx or rectum); only 3/8 were urine NAAT-positive. Five cultured isolates from five patients underwent WGS: 2/5 had no linkage to other DGI or database isolates, 3/5 were 8–20 single nucleotide polymorphisms apart and from ST-7822, one of commonly circulating lineages in England. 6/8 presented initially to non-STI specialties, and experienced a delay in diagnosis and initiation of appropriate antibiotic therapy (mean 10.7 versus 4 days). Five required hospital admission (mean stay 14.4 days).ConclusionThis is the first study of WGS in DGI. DGI cases were not all associated with a single clone or outbreak, but several were from the same lineage, consistent with ST-7822 possibly causing more invasive infection. Our series supports an increased rate of DGI (our department saw <1 case/year historically). This may be related to host factors combined with increased NG prevalence in MSM worldwide. The cases demonstrate the lack of genital symptoms, which may contribute to delay in management and highlights the importance of extra-genital NAAT testing and awareness outside of STI services.