Case Description:
A 42-year-old woman with a history of asthma and diet-controlled type 2 diabetes presented to the hospital with fever, skin rash, knee, and ankle pain for four days. Prior to admission, the patient developed a fever of 103.9 followed by the development of a generalized non-pruritic rash and subsequently developed polyarticular swelling and erythema in her right foot and bilateral knees. The patient reported unprotected sexual intercourse with a new partner a week prior to the presentation. Vitals on admission were blood pressure of 137/80 mmHg, pulse 88 beats per minute, temperature 36.6 degrees Celsius, respirations 18 breaths per minute, and oxygen saturation of 99% on room air. On examination, the skin showed the presence of diffuse vesiculopustular, non-tender, non-pruritic rashes (Figure 1). The right foot was erythematous and associated with ankle edema, and the left knee exhibited mild swelling with a reduced range of motion due to tenderness. Labs on admission showed a white count of 21,000/microL. HIV antigen and antibody testing was negative. Two sets of blood cultures were negative. The urine NAAT was indeterminate. She was started empirically on intravenous vancomycin and ceftriaxone. Right knee swelling confirmed joint effusion on imaging which was aspirated, revealing monosodium urate crystals in synovial fluid analysis and the culture growing gram-negative diplococci. No cervical motion tenderness was noted. Disseminated gonococcal infection was suspected and the patient underwent recurrent synovial joint washouts due to persistent symptoms of pain and reduced range of motion. The patient’s symptoms improved over the 5-day hospital course and ultimately discharged home to continue ceftriaxone for a total of 7 days post-final joint washout.