Disseminated gonococcal infection developing two days after initial eculizumab administration in a patient with neuromyelitis optica spectrum disorder: A case report and literature review

Abstract

Disseminated gonococcal infection (DGI) is a rare complication of Neisseria gonorrhoeae infection. Eculizumab, a complement C5 inhibitor used in conditions such as paroxysmal nocturnal hemoglobinuria, increases the risk of invasive Neisseria spp. infections. Although previous reports have described DGI in eculizumab-treated patients, evidence involving individuals with neuromyelitis optica spectrum disorder (NMOSD) is limited, and all cases occurred weeks to months after treatment initiation. In the present case, the patient received a quadrivalent meningococcal vaccine before receiving eculizumab. Two days after the first dose, the patient presented with fever, chills, and headache. Laboratory findings revealed leukocytosis and mildly elevated C-reactive protein levels, with unremarkable urinalysis and cerebrospinal fluid results. Blood cultures revealed the presence of N. gonorrhoeae, confirming DGI. A blood test on day 5 revealed a CH50 level of 6.0 U/mL. Screening for other sexually transmitted infections was negative. Antimicrobial susceptibility testing revealed elevated minimum inhibitory concentrations (MICs) for penicillin G, ciprofloxacin, azithromycin, and minocycline, whereas the MIC for ceftriaxone remained low. The patient received intravenous ceftriaxone for 14 days. Following the patient's refusal to continue eculizumab therapy, the patient has chosen inebilizumab, resulting in stable management of NMOSD symptoms. The patient has been attending outpatient appointments approximately every two months, and no recurrence of gonococcal infection has been observed for at least 2 years. This is a case of DGI in a patient with NMOSD, and the earliest reported onset of DGI following eculizumab initiation. Clinicians should remain vigilant for invasive gonococcal infections, even shortly after initiating complement-inhibiting therapy.