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C2 Gonococcal tenosynovitis in two HIV-infected heterosexual males: delayed diagnoses following negative urine NAAT testing
  1. Jonathan Shaw,
  2. Peter Flegg,
  3. John Sweeney
  1. Blackpool Sexual Health Services, Blackpool, UK

Abstract

Background Disproportionately high gonococcal incidence rates amongst men have altered the clinical picture of disseminated gonococcal infection (DGI). The ‘classical’ female patient experiencing a triad of arthritis, tenosynovitis and cutaneous lesions no longer predominates. We present two cases emphasising the need for thorough investigation with evident clinical signs of DGI.

Cases A 48 year old Nigerian heterosexual male presented with a 6 cm inguinal mass and oral hairy leukoplakia. Impression was of lymph node abscess; HIV testing was positive. Urine Nucleic Acid Amplification Testing (NAAT) for chlamydia and gonorrhoea (CT/GC) was negative. Subsequently he developed a swollen tender left wrist. Inguinal abscess aspiration for NAAT testing returned a positive gonococcal result. Treatment was instigated with intravenous ceftriaxone for 4 days, subsequently switching to cefixime for a further week. 3 weeks later his wrist swelling resolved.

A 50 year old HIV-positive British heterosexual male presented after returning from Thailand. He had developed a tender swollen left wrist. Urine NAAT for CT/GC was negative. He reported condomless oral and vaginal sex with multiple Thai females. Gonococcal tenosynovitis was suspected and extragenital NAATs and cultures for CT/GC were taken; NAAT for pharyngeal gonorrhoea was positive. Single dose ceftriaxone and azithromycin was prescribed, followed by cefixime for 1 week. Two weeks later his symptoms cleared.

Conclusion Reflecting on these cases a DGI diagnosis was attained following careful consideration of possible differentials and persistence in identifying Neisseria gonorrhoeae. Both diagnoses would have been missed if following current testing guidance which recommends penile-only sampling of heterosexual men.

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