An Evasive Case of Gonococcal Endocarditis

Neisseria gonorrhoeae is one of the most common sexually transmitted infections in the United States, and disseminated infection can lead to a variety of complications. This includes the less common, but potentially life-threatening complication of gonococcal endocarditis. The authors report a case of a formerly incarcerated middle-aged man with a three-day history of dyspnea on exertion, fever, headache, and productive cough with green sputum. He endorsed a several-week history of an untreated right molar infection but denied any history of genitourinary symptoms. Given concerns for heart failure, a transthoracic echocardiogram was obtained showing mitral regurgitation with a mass on the mitral valve leaflet, as well as a smaller aortic valve mass that was subsequently confirmed with a transesophageal echocardiogram. Initially, the patient was transferred from an outside hospital (OSH), and discrepancies were noted between the blood cultures obtained at the OSH and a private lab. Given that the patient was already started on antibiotics prior to transfer, a Karius assay was sent and returned positive for N. gonorrhoeae. He was started on empiric antibiotic coverage before ultimately undergoing mitral valve replacement with a mosaic valve. The patient completed six weeks of intravenous ceftriaxone with complete resolution of symptoms. This case demonstrates a rare incident of N. gonorrhoeae bacteremia without any common symptoms causing endocarditis and valvular destruction. Timely diagnosis, a multidisciplinary approach, and treatment of gonococcal endocarditis led to positive outcomes in this case.