Hidden in Plain Sight: Gonorrhea-Associated Flexor Tenosynovitis-A Case Report

Disseminated gonococcal infection (DGI) is an uncommon but potentially serious complication of Neisseria gonorrhoeae infection in which infection extends from a mucosal site to distant tissues. The literature describes two types of clinical presentation: an arthritis-dermatitis syndrome characterized by tenosynovitis, polyarthralgia, and skin lesions and a suppurative monoarthritis. In the former presentation, synovial fluid cultures are usually negative, whereas synovial fluid cultures are more often positive in the latter suppurative gonococcal arthritis. This distinction is important in the present case because Neisseria gonorrhoeae was recovered from the surgically drained collection associated with the fourth-digit flexor tendon sheath rather than from synovial fluid; therefore, we characterize the case as gonococcal flexor tenosynovitis associated with DGI rather than culture-proven septic arthritis. A 53-year-old man with well-controlled HIV presented with pain, swelling, and limited motion of the right fourth finger and shoulder after recent travel to Cuba and sexual contact with a new male partner with inconsistent condom use. Laboratory evaluation revealed leukocytosis and elevated inflammatory markers. Ultrasound of the finger demonstrated flexor tenosynovitis with a 10-mm abscess. Bedside incision and drainage was performed, and the surgical specimen grew Neisseria gonorrhoeae. The patient was treated with intravenous ceftriaxone followed by oral amoxicillin based on antimicrobial susceptibility results, with complete clinical recovery. This case highlights an unusual localized musculoskeletal manifestation of DGI in the absence of urogenital symptoms. Point-of-care ultrasound identified a drainable collection, while culture of the affected site established the diagnosis. DGI should be considered in atraumatic flexor tenosynovitis, particularly when there is a relevant sexual exposure.