neisseria gonorrhoeae is a well - known cause of sexually transmitted diseases such as genital , pharyngeal , and anorectal infections . bloodstream invasion , however , occurs only in 0.5 - 3% of the infections and results in disseminated gonococcal infection ( dgi ) . we report a patient with n. gonorrhoeae bacteremia in whom massive variceal hemorrhage occurs coincidently . on june 5th , 2010 , a 42-yr - old man was admitted to the hospital via the emergency room due to multiple seizures , a history of chills , myalgia over the previous 2 weeks , and 3 days of melena . the patient was treated in a primary clinic and his cough improved ; however , myalgia and melena continued and worsened after 4 days . at admission , he was pale and febrile with a temperature of 38.0. intermittent fever of 37.8 - 38.0 continued until hospital day 3 . the patient had a blood pressure of 108/64 mmhg , a pulse of 86/min , and a respiratory rate of 20/min . there were no signs and symptoms related to the genitourinary systems , skin , and joints . l - tube irrigation was performed , and the aspirate was bloody and had old clots . laboratory investigations showed a hb of 4.6 g / dl , a leukocyte count of 19.410/mm , a platelet count of 5110/mm , a c - reactive protein level of 10.56 mg / dl , prothrombin time ( international normalized ratio ) of 1.58 , ast / alt of 56/55 iu / l , alp of 102 iu / l , bun / creatinine of 37/1.1 mg / dl , and total protein / albumin of 3.5/1.5 g / dl . three sets of blood cultures were taken and gram - variable cocci in clusters were detected after a 25.9- to 26.9-hr incubation in aerobic vials . initially , cocci were reported as gram - positive . in 5% co2 at 35 , tiny , glistening , and raised colonies grew after overnight incubation . the colonies grew to 1 - 2 mm in diameter after a 2-day incubation on both blood agar and chocolate agar plates ( fig . the bacterium was positive for catalase , oxidase , and acid production from glucose but not maltose . it was identified , with 98% probability , as n. gonorrhoeae ( bionumber 464001 ) by the vitek neisseria - haemo - philus identification ( nhi ) card ( biomrieux vitek , inc . , sequencing of 16s rrna covering nucleotides 30 - 1,370 of this isolate showed the greatest homology ( 99.9% ) to the published sequence of n. gonorrhoeae strain nctc 83785 ( genbank accession no . nr_026079.1 ) , followed by 98.6% homology to neisseria meningitidis 8013 ( genbank accession no . it was resistant to penicillin , ciprofloxacin , and tetracycline ; and susceptible to cefuroxime , cefotaxime , and cefepime by disk diffusion on gc agar plates after a 20- to 24-hr incubation at 35 and 5% co2 . cefotaxime was started empirically in the emergency room , and vancomycin was added after the report of positive blood cultures of gram - positive cocci on day 2 . on day 3 , fever was no longer present , and follow - up blood cultures were negative . the patient was discharged on day 8 . urine and throat swabs were obtained when he visited the outpatient clinic on september 28th , and were cultured on modified thayer - martin agar plates and blood agar plates . , he reported that he had not had sexual contact with his wife for several months , and that he had traveled to china during the previous april . n. gonorrhoeae is a pathogenic neisseria species that mainly causes genital infections , and , less frequently , also causes pharyngeal and anorectal infections [ 2 , 3 ] . dissemination occurs in only 0.5 - 3% of the gonococcal infections [ 2 , 3 ] . disseminated infections typically present with low - grade fever , skin lesions , tenosinovitis , and migratory polyarthralgias [ 2 , 3 ] . only one case of dgi with polyarthralgias and skin lesions has been previously reported in korea . this is the second case of dgi , and , to the best of our knowledge , the first culture - proven bacteremia of n. gonorrhoeae in korea . predisposing risk factors for dissemination include being a female , a homosexual or bisexual male , recent menstruation , pregnancy , immediate postpartum states , gonococcal pharyngitis , complement deficiencies , and systemic lupus erythematosus [ 2 , 3 , 5 ] . because this patient had hbv - associated liver cirrhosis , he may have had a complement deficiency [ 6 , 7 ] . liver cirrhosis patients are susceptible to immune and nutritional deficiencies , including vitamin , protein , immunoglobulin , and complement deficiencies [ 6 - 8 ] , which cause increased morbidity and mortality of infectious diseases [ 9 , 10 ] . although the patient 's medical history and physical examinations related to other risk factors were not taken initially in this case , he had neither female - related risk factors nor exhibited homosexual behavior . because the patient had no symptoms related to the skin or joints , dgi was hardly suspected , even when n. gonorrhoeae was identified from blood cultures . in this case , intermittent fever , a leukocyte count of 19.410/mm , and a c - reactive protein level of 10.56 mg / dl indicated a stage of acute inflammation . therefore , there was on acute onset of dissemination of n. gonorrhoeae at admission without time enough to involve skin and the joints . gonococcal bacteremia is often intermittent and only half of the patients with dgi have positive cultures from blood or synovial fluid . positive results , with practically the same time to positivity in all three sets of blood cultures , suggested direct introduction of n. gonorrhoeae into the blood stream , or endocarditis , a rare , life - threatening condition of dgi . however , no signs or symptoms of endocarditis were observed during a 6-month follow - up . therefore , it was speculated that asymptomatic gonococcal pharyngitis preceded dissemination , and that ruptured vessels on the esophageal mucosa were a likely route of n. gonorrhoeae dissemination . the n. gonorrhoeae isolated from this patient was penicillinase - positive , resistant to penicillin , ciproflocxacin , and tetracycline , but sensitive to cefuroxime , cefotaxime , and cefepime . this resistance pattern was consistent with the previous report of resistance rates of korean gonococcal isolates against penicillin , quinolone , tetracycline , and ceftriaxone ( 55.4% , 95.7% , 10 - 34% , and 0% , respectively , in 2008 ) . for treatment of dgi , intramuscular or intrave - nous injection of 1 g ceftriaxone every 24 hr is recommend - ed and it should be continued for 24 - 48 hr after an improvement of symptoms is observed . initial 7-day empirical therapy of cefotaxime should be sufficient to provide a bacteriological cure , and prevent progression of dgi in this case . biochemical testing of this organism indicated n. gonorrhoeae ; however , fair growth of the bacteria on blood agar as well as on chocolate agar made that identification more suspicious because it is known that some n. gonorrhoeae strains can grow , but more slowly , and less well , on commercially available sheep blood agar . this is longer than the average detection time for common gram - negative pathogens isolated from blood cultures . severe liver cirrhosis complicated with variceal hemorrhage is clearly associated with an increased risk of bacteremia by opportunistic pathogens that live in the gastrointestinal tract , such as enterobacteriaceae and staphylococcus aureus [ 15 - 17 ] . bacterial infections have been reported among 35 - 66% of patients with cirrhosis who have variceal hemorrhage [ 17 , 18 ] . certain strains such as por1a serovar and ahu auxotype are alleged to be prone to dissemination ; however , this assumption has been challenged   and these strains are rare in korea . further phenotypic or serologic characterization of this isolate was not performed . in this case , unusual clinical conditions of the patient , combined with the microbiological characteristics of the isolates , postponed the identification of n. gonorrhoeae . hemorrhage of esophageal varices should be considered as a risk factor for dgi in patients in which n. gonorrhoeae grows from blood cultures .
a 42-yr - old man with hepatitis b virus associated liver cirrhosis was admitted to the emergency room because of multiple seizures , a history of chills and myalgia over the previous 2 weeks , and 3 days of melena . 
 he was febrile with a temperature of 38.0. there were no symptoms and signs related to the genitourinary system , skin , or joints . 
 three sets of blood cultures were obtained and oxidase - positive , gram - negative diplococci were detected after 25.9 - 26.9 hr of incubation in all aerobic vials . 
 the organism was positive for catalase and oxidase , and was identified as neisseria gonorrhoeae , using a vitek neisseria - haemophilus identification card ( biomrieux vitek , inc . 
 , usa ) . 
 further , 16s rrna sequencing of this isolate revealed a 99.9% homology with the published sequence of n. gonorrhoeae strain nctc 83785 ( genbank accession no . 
 nr_026079.1 ) . 
 acute bleeding by variceal rupture seems to be a likely route of introduction of n. gonorrhoeae from the mucosa into the blood . to the best of our knowledge , 
 this is the first case of gonococcal bacteremia in korea .