A case report describes gonococcal infective endocarditis presenting with rapid valvular destruction and systemic embolization despite persistently negative blood cultures, with diagnosis ultimately established by molecular testing of valvular tissue.
In the report, published in Cureus, Neisseria gonorrhoeae infective endocarditis is characterized as a rare but aggressive manifestation of disseminated infection that can be difficult to identify using standard diagnostic approaches and can lead to severe complications.
Study Design and Clinical Course
The report describes a single-patient case of a 53-year-old man who presented with cardiac arrest due to ventricular fibrillation in the setting of an ST-segment elevation myocardial infarction and an acute headache. Initial evaluation revealed leukocytosis with a white blood cell count of 21.36 × 10⁹/L with neutrophilic predominance of 86%.
A transthoracic echocardiogram identified a large mitral valve vegetation measuring 2.5 x 1.0 cm. Magnetic resonance imaging demonstrated multiple acute and subacute cerebral infarcts, and chest radiography showed scattered reticulonodular opacities concerning for septic emboli.
Despite these findings, blood cultures remained negative. The patient received empiric ceftriaxone and vancomycin for suspected infective endocarditis.
Diagnostic Findings
Given extensive valvular involvement and embolic complications, the patient underwent mitral valve replacement. Histopathologic examination confirmed infective endocarditis, and broad-range polymerase chain reaction testing of valve tissue identified Neisseria gonorrhoeae as the causative organism.
Additional history obtained during hospitalization revealed multiple sexual partners and lack of routine sexually transmitted infection screening or consistent barrier protection.
Treatment and Outcomes
The patient received one dose of azithromycin and completed a six-week course of ceftriaxone. The postoperative course was complicated by bleeding and pericardial hematoma requiring emergent sternal re-exploration with ligation of the sinoatrial nodal artery.
Context and Mechanisms
The researchers note that gonococcal infective endocarditis occurs in approximately 1% to 2% of patients with disseminated gonococcal infection and is associated with rapid valvular destruction, large vegetations, abscess formation, fistula development, and septic embolization. Up to 72% of affected patients require surgical intervention due to extensive valvular damage.
Diagnostic challenges arise because Neisseria gonorrhoeae is difficult to recover in standard blood culture systems, in part due to growth requirements and inhibitory effects of common culture additives.
Conclusion
This case highlights the importance of obtaining a thorough sexual history, which may facilitate timely recognition and management, as well as the importance of maintaining a broad differential diagnosis and utilizing adjunctive diagnostic modalities, such as polymerase chain reaction, to establish an accurate diagnosis.
“Recognition of atypical infectious causes such as Neisseria gonorrhoeae is important in patients presenting with aggressive or culture-negative infective endocarditis, particularly when embolic phenomena are present,” the researchers wrote.
Source: Cureus
Disclosures:The researchers reported no financial conflicts of interest.
