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Gonococcal endocarditis

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Gonococcal infection is a rare cause of endocarditis but one to be borne in mind. An illustrative case has been described from Cardiff, UK.

A 28 year old man developed symptoms several days after having unprotected sexual intercourse with a partner who had been treated for genitourinary symptoms. The patient’s symptoms included sore throat, lethargy, malaise, joint pains, sweating, and mainly nocturnal fevers. He was given a course of amoxycillin 500 mg three times a day but his symptoms persisted and when next seen by his general practitioner he had developed a new, moderately loud, pansystolic murmur at the apex and radiating to the axilla. On admission to hospital finger clubbing and a vasculitic lesion of the left great toe were noted as well as the murmur. Investigations showed a neutrophil leukocytosis (18×109/litre), raised C reactive protein (>120 mg/litre), raised erythrocyte sedimentation rate (51 mm/hour), and low serum albumin (29 g/litre). Treatment for bacterial endocarditis (intravenous benzylpenicillin 1.2 g four hourly plus gentamicin 80 mg twice daily) was begun after taking four separate sets of blood cultures. On transthoracic echocardiography there was a large (1.35 cm diameter) echodense mass on the anterior mitral valve leaflet with severe mitral regurgitation.

On the fourth hospital day growths of Neisseria gonorrhoeae serotype WI were reported from three blood culture bottles. The organism had a minimum inhibitory concentration for penicillin of 0.03 μg/ml and was resistant to ciprofloxacin. The antibiotic treatment was not changed at that time but on day 17 the gentamicin was replaced by rifampicin 600 mg daily because of lack of clinical response. Two days later he developed severe nausea that was attributed to the penicillin and cefotaxime 2 g six hourly was substituted for penicillin but he remained feverish and the markers of inflammation remained high. Mitral valve replacement was therefore performed on day 25. Intravenous cefotaxime was continued for two weeks and he was well when he left hospital on oral anticoagulant treatment 38 days after admission.

Disseminated gonococcal infection occurs in up to 3% of all patients with gonococcal infection and gonococcal endocarditis in 2% or fewer of those with disseminated infection (up to one in 1670 patients with gonorrhoea). There has, however, been an increase in the incidence of gonococcal infection in the UK in recent years and increasing rates of ciprofloxacin resistance may lead to more patients being treated inadequately and therefore being at risk of disseminated infection. Gonococcal endocarditis tends to occur in younger people (age 15–35 years) and is more common in men. The period from symptom onset to diagnosis of endocarditis averages around 45 days and is intermediate between the acute endocarditis of staphylococcal and pneumococcal infections and the subacute endocarditis of Streptococcus viridans infection. Two thirds of patients with gonococcal endocarditis have no genitourinary symptoms and only about one in eight has a history of prior valvular heart disease. More than half need valve surgery and mortality may be as high as 20%.

Gonococcal endocarditis is rare but may become more common with increasing rates of gonococcal infection. Its clinical features differ from those of other types of bacterial endocarditis but a firm diagnosis will depend on blood cultures.

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