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Pharyngeal gonorrhea presenting with isolated neck pain

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Lourdes Delrosso at UCSF University of California, San Francisco
Lourdes Delrosso
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Vol.2, No.1, 44-45 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.21012
Pharyngeal gonorrhea presenting with isolated neck
pain
Lourdes DelRosso1,2*, Jennifer Smith1, Michael Harper1, Romy Hoque2
1Department of Family Medicine, Louisiana State University School of Medicine, Shreveport, USA;
*Corresponding Author: lordydel@yahoo.com
2Department of Neurology, Louisiana State University School of Medicine, Shreveport, USA
Received 25 January 2013; revised 26 February 2013; accepted 5 March 2013
ABSTRACT
We present a case of a 22-year-old man with
isolated neck pain due to pharyngeal gonorrhea.
Keywords: Pharynx; Gonorrhea; Neck Pain
1. INTRODUCTION
Gonorrhea is a common sexually transmitted disease
(STD) that can involve many areas. We present a case of
a 22-year-old man with isolated neck pain due to pha-
ryngeal gonorrhea.
2. CASE REPORT
A 22-year-old African American man presents with
one month history of right sided neck pain worsened by
head turning to the right. He denies fever, chills, night
sweats, productive cough, diarrhea, abdominal pain,
weight loss, throat pain, dysphagia, odynophagia, head-
aches, skin rashes, focal weakness, or focal sensory chan-
ges. He reported having unprotected oral sex with men.
He denies smoking tobacco, drinking alcohol, or use of
illicit drugs. On physical examination his head was nor-
mocephalic and atraumatic with full range of motion in
his neck. His throat was clear without exudates, adeno-
tonsillar hypertrophy or soft palate erythema. No sensory
deficits were noted in the face or neck. The remainder of
the physical examination and neurological examination
was normal.
Serum testing for human immunodeficiency virus (HIV)
and reactive plasma reagent were negative. Throat cul-
tures for chlamydia were negative, and positive for gon-
orrhea. With his positive pharyngeal gonorrhea testing,
the patient revealed having oral sex with men for money.
The patient was treated with ceftriaxone 250 mg intra-
muscular injection, and azithromycin 1 gram orally. Ex-
tensive counseling regarding sexually transmitted dis-
eases (STD) risks and prevention were provided. Trans-
nasal flexible laryngoscopy revealed diffuse lymphoid
hyperplasia in posterior nasopharynx and hypopharynx
(Figure 1).
3. DISCUSSION
Gonorrhea is the second most common reported infec-
tion requiring partner notification in the United States
with over 300,000 cases in 2011 [1]. Kent et al. found
that gonorrhea most commonly affects non-urethral sites.
Up to 64% of gonorrhea would be missed without rectal
and pharyngeal screening with 36% of men infected in
the pharynx alone and 28% of men infected in more than
one site [2]. In adolescent women, 11% - 26% of gonor-
rhea cases would be missed without pharyngeal culture
Figure 1. A: Diffuse lymphoid hyperplasia in a patient with pharyngeal gonorrhea present-
ing with isolated neck pain; B: Close-up of nodular hyperplasia in posterior pharyngeal wall.
Copyright © 2013 SciRes. OPEN ACCESS
L. DelRosso / Case Reports in Clinical Medicine 2 (2013) 44-45 45
[3]. Positive predictors of pharyngeal gonorrhea infection
are younger age and increased number of insertive oral
sex partners [4]. Pharyngeal infections with gonorrhea
are common in patients with HIV, and other STDs [5].
The Centers for Disease Control recommends treatment
for both gonorrhea and chlamydia, given the prevalence
of concurrent genital infection [1].
4. CONCLUSION
The neck pain in our patient resolved with treatment
and was likely secondary to pharyngeal lymphoid hyper-
plasia. Isolated neck pain has also been reported in re-
tropharyngeal abscess [6]. If the patients neck pain con-
tinued despite treatment, a computerized tomography of
the neck would have been ordered to assess for retropha-
ryngeal abscess.
REFERENCES
[1] CDC (2012) Update to CDC’s sexually transmitted dis-
eases treatment guidelines 2010: Oral cephalosporins no
longer a recommended treatment for gonococcal infec-
tions. MMWR Morbidity and mortality weekly report, 61,
590-594.
[2] Kent, C.K., Chaw, J.K., Wong, W., Liska, S., Gibson, S.,
Hubbard, G., et al. (2005) Prevalence of rectal, urethral,
and pharyngeal chlamydia and gonorrhea detected in 2
clinical settings among men who have sex with men: San
Francisco, California, 2003. Clinical Infectious Diseases,
41, 67-74. doi:10.1086/430704
[3] Giannini, C.M., Kim, H.K., Mortensen, J., Marsolo, K.
and Huppert, J. (2010) Culture of non-genital sites in-
creases the detection of gonorrhea in women. Journal of
Pediatric and Adolescent Gynecology, 23, 246-252.
doi:10.1016/j.jpag.2010.02.003
[4] Morris, S.R., Klausner, J.D., Buchbinder, S.P., Wheeler,
S.L., Koblin, B., Coates, T., et al. (2006) Prevalence and
incidence of pharyngeal gonorrhea in a longitudinal sam-
ple of men who have sex with men: The explore study.
Clinical Infectious Diseases, 43, 1284-1289.
doi:10.1086/508460
[5] Mayor, M.T., Roett, M.A. and Uduhiri, K.A. (2012) Di-
agnosis and management of gonococcal infections. Ame-
rican Family Physician, 86, 931-938.
[6] Schott, C.K., Counselman, F.L. and Ashe, A.R. (2012) A
pain in the neck: Non-traumatic adult retropharyngeal
abscess. The Journal of Emergency Medicine, 44, 329-
331.
Copyright © 2013 SciRes. OPEN ACCESS
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Prevalence and Incidence of Pharyngeal Gonorrhea in a Longitudinal Sample of Men Who Have Sex with Men: The EXPLORE Study
Article
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  • CLIN INFECT DIS
The prevalence of gonorrhea of the pharynx among select samples of men who have sex with men (MSM) ranges from 9% to 15%. To our knowledge, there have been no longitudinal studies in a prospective MSM cohort to estimate pharyngeal gonorrhea incidence or predictors of infection. We examined the prevalence, incidence, and sociodemographic and behavioral predictors of pharyngeal gonorrhea in a cohort of sexually active, human immunodeficiency virus-negative MSM. We conducted a prospective study of pharyngeal gonorrhea among MSM who were enrolled in a behavioral intervention study to prevent human immunodeficiency virus infection (Project EXPLORE). Participants were enrolled in this ancillary study from March 2001 through July 2003. At baseline and every 6 months thereafter until 31 July 2003, participants were tested for pharyngeal gonorrhea and were administered a questionnaire regarding their oral sex practices. Rectal and urethral gonorrhea testing were also performed. Prevalence of pharyngeal gonorrhea was 5.5% (136 cases diagnosed from 2475 tests). The incidence rate was 11.2 cases per 100 person-years. Pharyngeal gonorrhea was positively associated with younger age and the number of insertive oral sex partners in the past 3 months. Ejaculation did not increase the risk of pharyngeal gonorrhea. Gonorrhea of the pharynx was asymptomatic in 92% of cases. The pharynx is a common, asymptomatic reservoir for gonorrhea in sexually active MSM.
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Diagnosis and Management of Gonococcal Infections
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Neisseria gonorrhoeae causes urogenital, anorectal, conjunctival, and pharyngeal infections. Urogenital tract infections are most common. Men with gonorrhea may present with penile discharge and dysuria, whereas women may present with mucopurulent discharge or pelvic pain; however, women often are asymptomatic. Neonatal infections include conjunctivitis and scalp abscesses. If left untreated, gonorrhea may cause pelvic inflammatory disease in women, or it may disseminate, causing synovial and skin manifestations. Urogenital N. gonorrhoeae infection can be diagnosed using culture or nucleic acid amplification testing. Urine nucleic acid amplification tests have a sensitivity and specificity comparable to those of cervical and urethral samples. Fluoroquinolones are no longer recommended for the treatment of gonorrhea because of antimicrobial resistance. A single intramuscular injection of ceftriaxone, 250 mg, is first-line treatment for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections. This dosage is more effective for common pharyngeal infections than the previously recommended dose of 125 mg. Ceftriaxone should routinely be accompanied by azithromycin or doxycycline to address the likelihood of coinfection with Chlamydia trachomatis. Azithromycin may be used as an alternative treatment option for patients with previous allergic reactions to penicillin, but because of the likelihood of antimicrobial resistance, its use should be limited. Gonococcal infection should prompt physicians to test for other sexually transmitted infections, including human immunodeficiency virus. Because of high reinfection rates, patients should be retested in three to six months. The U.S. Preventive Services Task Force recommends screening for gonorrhea in all sexually active women at increased risk of infection. It also recommends intensive behavioral counseling for persons with or at increased risk of contracting sexually transmitted infections. Condom use is an effective strategy to reduce the risk of infection.
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A Pain in the Neck: Non-traumatic Adult Retropharyngeal Abscess
Article
  • Jan 2012
  • J EMERG MED
Background: We present the case of a 47-year-old man who presented to the Emergency Department (ED) with complaint of left-sided neck pain. He was thought to have a musculoskeletal sprain on his initial visit. However, he returned the following evening with worsening symptoms. On further investigation, he was found to have a non-traumatic retropharyngeal abscess (RPA), a rare infection in the adult patient population. Objectives: This infection has been studied primarily in the pediatric population, and extrapolation of their studies demonstrates the importance of airway stabilization, antibiotic use targeting polymicrobial organisms, and conservative medical management vs. surgical drainage. We aim to summarize this case and review the literature on retropharyngeal abscess. Case report: This patient presented to the ED with complaints of left-sided neck pain. There was no history of trauma or injury to the affected area. He was evaluated and discharged but returned with a deteriorating clinical picture. On further evaluation, he was found to have a non-traumatic RPA. He was admitted to the Otolaryngology service and managed conservatively with intravenous (IV) antibiotics. His condition resolved and he was subsequently discharged from the hospital. Conclusions: The majority of data on diagnosis and treatment of adult RPA have come from the pediatric population. However, the same essential treatment principles apply: airway stabilization, resuscitation, initiation of IV antibiotics, and consultation with an otolaryngology specialist.
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Culture of Non-Genital Sites Increases the Detection of Gonorrhea in Women
Article
  • Apr 2010
Although gonorrhea may infect the cervix, rectum, or pharynx of women, culturing non-cervical sites is rare outside of sexually transmitted disease (STD) clinics. This study aims to compare rectal and pharyngeal gonorrhea prevalence in adolescent and adult women and to calculate the percentage of cases that would be missed with cervical culture alone. Retrospective review of two laboratory databases. STD clinic (2006-2007) and urban children's hospital (2003-2007). Adolescent women (age 14-21, n = 16,039) in the hospital database; adolescent (n=525) and adult (age >21) women (n = 1424) in the STD database. Prevalence of gonorrhea by group and culture source. Cervical plus additional culture was performed in 76% of adult STD, 52% of adolescent STD, and 2% of adolescent hospital samples. Pharyngeal gonorrhea prevalence in the adolescent hospital (3.5%) was similar to adolescent STD (6.8%, P = 0.1) and adult STD (2.5%, P = 0.4) samples. Rectal gonorrhea prevalence in adolescent hospital (2.9%) was lower than adolescent STD (13.4%, P = 0.01) but not adult STD (5.2%, P = 0.6) samples. Pharyngeal gonorrhea occurred in 0.6-3.4% and rectal gonorrhea in 0-2.7% of women with a negative cervical culture. Culturing only the cervix missed 20-40% of adult STD, 14-26% of adolescent STD, and 11% of adolescent hospital infected cases. Pharyngeal gonorrhea is as high in adolescent women from a children's hospital as in adult women from an STD clinic. Without pharyngeal culture, 11-26% of infected adolescent women would be missed. Increased pharyngeal testing may impact the gonorrhea epidemic among adolescent women.
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Prevalence of Rectal, Urethral, and Pharyngeal Chlamydia and Gonorrhea Detected in 2 Clinical Settings among Men Who Have Sex with Men: San Francisco, California, 2003
Article
  • Aug 2005
  • CLIN INFECT DIS
The Centers for Disease Control and Prevention developed screening and diagnostic testing guidelines for chlamydia and gonorrhea at urethral, rectal, and pharyngeal sites for men who have sex with men (MSM). However, in most clinical settings, rectal chlamydial testing is not performed for MSM, and primarily sexually transmitted disease (STD) clinics alone perform routine rectal and pharyngeal gonorrhea screening for asymptomatic men. We evaluated the prevalence of rectal, urethral, and pharyngeal chlamydial and gonococcal infections among MSM seen at the municipal STD clinic and the gay men's community health center. We also determined the proportion of asymptomatic rectal infections, described the patterns of single and multiple anatomic sites of infection, and evaluated the proportion of chlamydial infections that would be missed and not treated if MSM were not routinely tested for chlamydia. We tested specimens using previously validated nucleic acid amplification tests (NAATs). The prevalence of infection varied by anatomic site (chlamydia: rectal, 7.9%; urethral, 5.2%; and pharyngeal, 1.4%; for gonorrhea, rectal, 6.9%; urethral, 6.0%; and pharyngeal, 9.2%). Approximately 85% of rectal infections were asymptomatic supporting the need for routine screening. Because 53% of chlamydial infections and 64% of gonococcal infections were at nonurethral sites, these infections would be missed and not treated if only urethral screening was performed. In addition, >70% of chlamydial infections would be missed and not treated if MSM were tested only for gonorrhea. Because these infections enhance both HIV transmission and susceptibility, clinical settings serving MSM should evaluate the prevalence of chlamydial and gonococcal infections by anatomic site using validated NAATs.
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Update to CDC's sexually transmitted diseases treatment guidelines 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections
  • Jan 2012
  • 590-594
CDC (2012) Update to CDC's sexually transmitted diseases treatment guidelines 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morbidity and mortality weekly report, 61, 590-594.