4-40
Plan:
Find treatments that allow the service member to complete their mission, treat the process, and prevent
recurrence. Explain the disease process and treatment thoroughly in words the patient can understand.
Bacterial Skin Infections
Skin: Disseminated Gonococcal Infection
MAJ Daniel Schissel, MC, USAIntroduction: Gonococcemia is a systemic infection with Neisseria gonorrhoeae following the bloodborne
spread (dissemination) of the gram-negative diplococci from infected sites (1% of untreated cases).
Subjective: Symptoms
Prodrome of fever and chills, anorexia, malaise during the 7 to 30 day incubation period. May have migratory
polyarthritis.
Objective: Signs
Using Basic Tools: Lesions: 1.0 -5.0 mm erythematous macules (2 to 20 lesions) that evolve to slightly
tender, deep-seated, hemorrhagic pustules within 24-48 hrs; center may become necrotic; located on arms
and hands more often than legs or feet, in regions near the joint spaces. (see Color Plates Picture 4).
Tenosynovitis of the extensors / flexors of the hands and feet is common. Septic arthritis occurs with asym-
metrical, erythematous, hot, tender knee, elbow, ankle or metacarpophalangeal joints. Other organ systems
may also be infected: hepatitis, carditis, meningitis, and others. Evaluate for other STDs.
Using Advanced Tools: Lab: Gram stain of mucosal surfaces may yield gram-negative diplococci; culture
mucosal sites (80-90% yield).
Assessment:
Differential Diagnosis: Meningococcemia (CNS effects); other bacteremias; psoriatic arthritis (plaque
lesions, multiple joints); systemic lupus erythematosus (multiple joints, multiple organ effects) See appropriate
sections in this book.
Plan:
Treatment:
Primary: Ceftriaxone 1 gm IM or IV q 24 hrs
Alternative: Ceftizoxime or cefotaxime 1 gm IV q 8 hrs, or spectinomycin 2 gm IM q 12 hrs
After initial symptoms resolve, the uncomplicated patient should be treated for 1 week with oral cefuroxime
axetil 500 mg bid, or amoxicillin 500mg with clavulanic acid tid, or ciprofloxacin 500 mg bid if patient
is not pregnant.
Patient Education
Prevention: Re-educate patient on safe sexual habits
Follow-up Actions
Evacuation/Consultant Criteria: Evacuate patients if possible. Consult as needed.