Episode Details

Hepatic encephalopathy basics, disseminated gonococcal infections, polyarthralgia question winner, jokes.

Today is March 29, 2021.

On December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter because of the increasing reports of disseminated gonococcal infections (DGI). Today, we want to share with you parts of that letter. 

CDPH is working with local health departments to investigate these cases of DGI, where some patients have experienced homelessness or using illicit drugs, particularly methamphetamine. The CDC noted a similar increase in cases in Michigan in late 2019.

What is DGI? DGI is an uncommon but severe complication of untreated gonorrhea. DGI occurs when the sexually transmitted pathogen Neisseria gonorrhoeae invades the bloodstream and spreads to distant sites in the body, leading to clinical manifestations such as septic arthritis, polyarthralgia, tenosynovitis, petechial/pustular skin lesions, bacteremia, or, on rare occasions, endocarditis or meningitis. Patients have initially presented with joint pain attributed to another cause, which was only later determined to be due to DGI. 

Why is DGI increasing? Increased cases may be caused by decreased STD testing and treatment because of the COVID-19 pandemic, and not necessarily because of a more virulent strain of gonorrhea. 

What do we need to do as medical providers?

Screen: Reinstate routine screening recommendations for STDs in females <25 years of age (or older females with risk factors for STDs), pregnant females, men who have sex with men (MSM) and individuals with HIV, and other risk groups.

Suspect: For patients reporting joint pain, obtain a social history that includes a sexual and drug use history, and housing status. Suspect DGI in patients with joint pain and treat them according to the CDC STD Treatment Guidelines. Remember that most cases of uncomplicated gonococcal infections are now treated with a single dose of Ceftriaxone 500 mg IM PLUS doxycycline for 7 days. DGI, however, needs IV meds and longer duration of treatment.

Test: Order Nucleic acid amplification test (NAAT) and culture specimens from urogenital, extragenital mucosal sites (e.g., pharyngeal and rectal), and from disseminated sites (e.g., skin, synovial fluid, blood, and cerebrospinal fluid) before initiating empiric antimicrobial treatment for patients with suspected DGI. Hospitalization and consultation with ID is recommended for initial therapy. Test all isolates from DGI cases for antibiotic susceptibility, and send all isolates from DGI cases to the local public health laboratory.  

Report: all suspected and confirmed cases of DGI to public health within 24 hours of identification. Instruct patients to refer their sex partners for evaluation, testing, and presumptive treatment for gonorrhea.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

Hepatic Encephalopathy
Guest: Stephanie Rubio, MS3

What is it?

Hepatic encephalopathy is a reversible decline in brain function in patients with advanced liver failure and/or portosystemic shunting and may present with ascites. The liver cannot effectively remove ammonia and other toxins from the blood causing a buildup in the bloodstream. Bacteria in the gut can also increase these toxins leading to a rapid progression of signs and symptoms of hepatic encephalopathy. 

How is the presentation?

A wide spectrum of neurological and/or psychiatric abnormalities may be se