Gonococcal Infective Endocarditis: The Importance of a Sexual History

Neisseria gonorrhoeae (NG), a commonly encountered sexually transmitted pathogen, rarely presents with cardiac involvement and therefore may be underrecognized in this context. Gonococcal infective endocarditis (IE) is associated with an aggressive clinical course characterized by rapid valvular destruction and systemic embolization. Diagnosis is often challenging, particularly when standard blood cultures fail to isolate the causative organism. A 53-year-old man was admitted following a ventricular fibrillation arrest associated with ST-segment elevation and an acute headache. Magnetic resonance imaging demonstrated multiple acute and subacute cerebral infarcts, and chest radiography showed scattered reticulonodular opacities concerning for septic emboli. Transthoracic echocardiogram identified a mitral valve vegetation concerning for IE. Despite persistently negative blood cultures, the extent of valvular involvement prompted empiric antimicrobial therapy and eventual surgical valve replacement. Molecular testing performed directly on the valvular tissue detected NG, establishing the microbiologic diagnosis. Additional history later obtained during hospitalization disclosed high-risk sexual exposure without routine screening practices. In modern clinical practice, NG IE is infrequently encountered yet continues to represent a severe form of disseminated infection characterized by extensive valvular damage, embolic sequelae, and mortality. NG's antigenic variability and evolving antibiotic resistance patterns may delay timely identification and complicate management, particularly in cases of culture-negative IE. Ceftriaxone remains the cornerstone of therapy; however, extensive valvular damage often necessitates surgical intervention. This case underscores the importance of a comprehensive sexual history and highlights the utility of universal polymerase chain reaction (PCR) when standard diagnostic testing does not establish an etiology. In cases of destructive valvular involvement with embolic complications and persistently negative blood cultures, uncommon etiologies such as NG should remain within the differential diagnosis. Utilization of universal PCR may provide definitive pathogen identification and support appropriate therapeutic decision-making in this life-threatening condition.