often seen in young women during menses or pregnancy (49). Most patients will present with
fever, rash, polyarthritis, and tenosynovitis (47).
Skin lesions, which occur in 50% to 70% of patients with DGI, are the most common
manifestation (49). The rash usually begins on the first day of symptoms and becomes more
prominent with the onset of each new febrile episode (50). The lesions begin as tiny red
papules or petechiae (1–5 mm in diameter) that evolve to a vesicular and then pustular form
(Fig. 4). The pustular lesions develop a gray, necrotic center with a hemorrhagic base (47,50).
The rash of DGI tends to be sparse and widely distributed, and the distal extremities are most
commonly involved. Gram stain of the skin lesions rarely demonstrates organisms.
Clinical clues of DGI include the symptoms of fever, rash, and arthritis/tenosynovitis.
Early in the infection, blood cultures may be positive; later, synovial joint fluid from associated
effusions may yield positive cultures. Smears of the cervix and urethral exudates may also
yield positive results.
Capnocytophaga Infection
Capnocytophaga canimorsusis a fastidious gram-negative bacillus that is part of the normal gingival
flora of dogs and cats (51,52). Human infections are associated with dog or cat bites, cat scratches,
and contact with wild animals (51,52). Predisposing factors include trauma, alcohol abuse, steroid
therapy, chronic lung disease, and asplenia (51,52). The clinical syndrome consists of fever,
disseminated intravascular coagulation (DIC), necrosis of the kidneys and adrenal glands,
thrombocytopenia, hypotension, and renal failure. The mortality rate approaches 25%.
Skin lesions occur in 50% of infected patients, often progressing from petechiae to
purpura to cutaneous gangrene (53). Other dermatologic lesions include macules, papules,
painful erythema, or eschars.
Clinical clues include a compatible clinical syndrome and a history of a dog- or cat-
inflicted wound. Diagnosis depends on the culture of the bacteria from blood, tissues, or other
body fluids. Unfortunately, the diagnosis is missed in greater than 70% of cases because of lack
Figure 4 Cutaneous lesions on the left ankle and calf
of a patient with disseminatedNeisseria gonorrheae
infection.Source: Courtesy of the CDC/Dr S.E.
Thompson, Public Health Image Library.28 Engel et al.