Gonorrhea
James W. Myers
Lamis Ibrahim
INTRODUCTION
Gonorrhea (GC) is the second most commonly reported bacterial sexually transmitted disease (STD).
In the United States, an estimated 700,000 new infections occur each year.
The majority of infections are symptomatic in males but can be asymptomatic in females.
MICROBIOLOGY
Nonmotile, gram-negative diplococci.
GC can use glucose but not maltose, sucrose, or lactose.
Chocolate agar containing vancomycin, colistin, nystatin, and trimethoprim is known as Thayer-Martin media.
It should be used to plate specimens from nonsterile sites only.
Should be sent to the lab to be incubated quickly.
The sensitivity of culture ranges from 70% to 95%.
GC is known to be fastidious and to require aerobic conditions with increased carbon dioxide atmosphere.
EPIDEMIOLOGY
Transmitted both sexually and perinatally.
The transmission rate of GC to females after a single sexual encounter is about 50%.
Rates are highest in these groups.
Ages 15 to 24
Men who have sex with men (MSM)
African Americans
Lower socioeconomic classes
Those with less education
Residents in the southeastern part of the country
Single patients
Drug users
Forty-six percent had concurrent chlamydia detected.
GC facilitates the transmission of HIV.
CLINICAL MANIFESTATIONS
Genital infections in males:
Uncomplicated infection:
Acute urethritis is the most common presentation.
Incubation period 2 to 5 days but can be 10 days.
Dysuria
Purulent urethral discharge
Most infections resolve in several weeks even without antimicrobials.
Acute epididymitis is the most common localized complication seen with GC.
Other less common presentations include prostatitis and strictures.
Genital infections in females:
Cervicitis
It is the most common presentation.
Urethral infection is less common.
Accessory gland infection can also occur.
Many can be asymptomatic, up to 50%
Usually presents with vaginal discharge, dysuria, bleeding, purulent cervical discharge, cervical swelling, and friability on exam.
Pelvic inflammatory disease
Incidence of approximately 20% in females who have cervicitis.
Endometritis, salpingitis, tuboovarian abscess, perihepatitis, and peritonitis.
Patients may present with lower abdominal pain, nausea, vomiting, fever, and chills.
They will have cervical motion tenderness, adnexal tenderness, and lower abdominal pain on physical exam.
Laboratory testing will often show an elevated sedimentation rate (ESR), C-Reactive protein (CRP), and leukocytosis.
Perihepatitis can be a complication with GC or chlamydia, but infertility is more common with chlamydia infection.
Gonorrhea and Pregnancy
It is associated with increased fetal mortality, preterm labor, and abortion.
Pelvic inflammatory disease (PID) and perihepatitis seldom occur after the first trimester.
Infection in males and females:
Gonococcal pharyngitis
Oral sex is the major risk factor.
Usually asymptomatic but when present can be severe.
More common in females and MSM than in heterosexual men.
Rarely would be the only infection site.
Can be source for disseminated infection.
Nucleic acid amplification tests (NAATs) are not FDA approved for pharyngeal swabs.
Some recommend MSM or HIV (receptive oral sex) patient screening.
Gonococcal conjunctivitis
Autoinoculation
Purulent exudate
Photophobia and pain
Corneal ulceration
Gonococcal proctitis
Occurs in both females and homosexual men secondary to anal receptive intercourse.
Can be asymptomatic at times.
Mucopurulent discharge can be seen.
Tenesmus or bleeding can occur.
Disseminated gonococcal infection
A consequence of bacteremia or from immune complex formation.
Three percent of cases
Presents with arthritis-dermatitis syndrome in most patients.
Starts with asymmetrical arthralgia/arthritis of the knees, elbows, and distal joints and is associated with tenosynovitis.
Fifty percent of patients may have positive blood or synovial fluid cultures.
Skin lesions can be sent for gram stain and cultures can be done.
Test for GC at mucosal surfaces as well.
Other rare manifestations of disseminated disease include endocarditis, meningitis, osteomyelitis, and septic shock.
Up to 13% of cases of DGI are associated with complement deficiency, and patients with repeated episodes of gonococcal bacteremia should be evaluated for such.
Skin manifestations occur in up to 75% of patients and usually occur on the extremities.
Papules and pustules
Hemorrhagic lesions
Neonatal infection
Ophthalmia neonatorum (Gonococcal conjunctivitis).
Occurs secondary to perinatal transmission
Routine screening and treatment of pregnant women before term
Prophylaxis with antibiotics or a 1% aqueous solution of silver nitrate into the conjunctivae soon after delivery prevents infection. Silver nitrate itself can cause a chemical conjunctivitis.
It develops quickly, within few days of delivery, and it is diagnosed by finding GC in conjunctival secretions.
Septicemia and arthritis can occur as well.
DIAGNOSIS
Gram stain:
Symptomatic in men.
A gram stain of urethral specimen showing polymorphonuclear cells (PMNS) with intracellular gram-negative diplococci is considered diagnostic!
Specificity (>99%) and sensitivity (>95%)
Gram staining of endocervical specimens, pharyngeal, or rectal specimens is not recommended.
Other diagnostic methods: culture, nucleic acid hybridization tests, and NAATs
Culture and nucleic acid hybridization tests are usually done on endocervical or male urethral swabs.
Cultures are also used to assess antibiotic susceptibilities if drug resistance is suspected.Related posts:
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