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Training Level

Resident PGY 3


Henry Ford Hospital


Patient History & Physical: A pregnant 21-year-old African American female (G5P2, 34w2d) presented with one day of painful, red bumps of her upper and lower extremities. Associated symptoms included chills, malaise, headache, photophobia, phonophobia, and edematous arthralgias (left shoulder, left ankle). Personal and family history were negative for thromboembolic phenomena, autoimmune disorders, or coagulopathies. She denied intravenous drug use, new sexual partners, blood transfusions, sick contacts, or recent travel. Physical examination demonstrated sparse, irregularly-distributed, exquisitely tender erythematous to necrotic pinpoint papules and pustules of the abdomen and distal extremities. Vital signs were notable only for mild tachycardia.

Biopsies: Punch biopsies of lesions of the left ankle and left thigh revealed large neutrophilic aggregates surrounding dermal vessels featuring sludging and engorgement within the vessels themselves. This perivascular suppurative dermatitis was suspicious for infection. Tissue culture ultimately indicated presence of Neisseria gonorrhea.

Laboratory Data: Inpatient work-up revealed: elevated ESR (122 mm/hr), elevated CRP (8.8 mg/dL), negative CSF studies (VZV/CMV/EBV/HSV/cryptococcal antigen/bacterial culture), three negative peripheral blood cultures, negative syphilis serologies, normal WBC count, and normal transthoracic echocardiogram. Neisseria gonorrhea and Chlamydia trachomatis rRNA (cervical swabs) were negative 10 days prior to presentation to the hospital. However, following the biopsy and tissue culture results, urine gonococcal and chlamydial rRNA were rechecked and found to be positive.

Diagnosis: Disseminated gonococcal infection (acute arthritis-dermatitis syndrome).

Clinical Course and Treatment: Patient was treated with one week of intravenous ceftriaxone and single-dose oral azithromycin for chlamydial co-infection. At 3-week outpatient follow-up, all symptoms and cutaneous findings had resolved.

Presentation Date


Tender Erythematous and Necrotic Papules in a Young Pregnant Woman