We present a case of a generally healthy, immunocompetent, 57 year old male on HIV pre-exposure prophylaxis (PrEP) who developed the sudden onset of right wrist pain and swelling with associated left second finger tenosynovitis, due to a disseminated gonococcal infection (DGI) with purulent arthritis. This case’s aim is to demonstrate a well-documented but infrequently seen manifestation of Neisseria gonorrhoeae infection and to highlight the need for awareness of extragenital manifestations of gonococcal infection in the era of HIV PrEP. DGI accounts for less than 3 % of N. gonorrhoeae infections, with purulent arthritis being one presentation. The incidence of N. gonorrhoeae infections has increased in recent years and is high among those taking PrEP. Providers should be aware of the possibility of DGI and N. gonorrhoeae as a potential etiologic agent in septic bacterial arthritis.

BACKGROUND Cladophialophora bantiana is a dematiaceous, saprophytic fungus and a rare but reported cause of intracranial abscesses due to its strong neurotropism. Although it predominantly affects immunocompetent individuals with environmental exposure, more recently, its significance as a highly lethal opportunistic infection in transplant recipients has been recognized. Successful treatment requires timely but often challenging diagnosis, followed by complete surgical excision. Next-generation sequencing of microbial cell-free DNA (cfDNA) from plasma is a novel diagnostic method with the potential to identify invasive fungal infections more rapidly and less invasively than conventional microbiological testing, including brain biopsy. OBSERVATIONS The authors described the case of a recipient of a liver transplant who presented with seizures and was found to have innumerable ring-enhancing intracranial lesions. The Karius Test, a commercially available method of next-generation sequencing of cfDNA, was used to determine the causative organism. Samples from the patient’s plasma identified C. bantiana 6 days before culture results of the surgical specimen, allowing optimization of the empirical antifungal regimen, which led to a reduction in the size of the abscesses. LESSONS The authors’ findings suggest that microbial cfDNA sequencing may be particularly impactful in improving the management of brain abscesses in which the differential diagnosis is wide because of immunosuppression.

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