Updated: 4/9/2019

Gonorrhea

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Snapshot
  • A 24-year-old female graduate student presents to the student health clinic with a complaint of dysuria and pain in her right knee. On physical exam, her knee is erythematous and tender with pain elicited on passive range of motion. Pelvic examination is significant for purulent endocervical discharge. The patient is sexually active and recalls having unprotected sexual intercourse with her most recent partner. Gram stain of a cervical swab shows gram-negative, kidney-shaped cocci in pairs.
Introduction
  • Classification
    • Neisseria
      • Gram-negative diplococci
      • often intracellular within neutrophils
  • Epidemiology
    • incidence
      • the second most common bacterial sexually-transmitted infection after Chlamydia
    • location
      • genital tract
    • risk factors
      • unprotected sexual intercourse
  • Pathogenesis
    • mechanism
      • molecular biology
        • pili facilitate attachment to mucosal surfaces
        • antigenic variation 
        • IgA protease allows invasion of mucosal surfaces
        • contains lipooligosaccharides (LOS) with strong endotoxin activity
      • invasion of mucosal surfaces results in inflammation
    • transmission 
      • sexual
      • perinatal
  • Associated conditions 
    • septic arthritis 
    • neonatal conjunctivitis (2-5 days after birth)
      • prophylaxis with erythromycin eye drops
    • pelvic inflammatory disease (PID)
    • Fitz-Hugh-Curtis syndrome
Presentation
  • Symptoms 
    • dysuria 
    • purulent discharge 
    • fever 
    • prostatitis (men)
    • endocervicitis (women)
    • urethritis
Studies
  • Labs
    • cervical and urethral culture
      • Thayer-Martin agar
        • selects for growth of Neisseria
        • contains vancomycin, trimethoprim, colistin, and nystatin to inhibit growth of gram-positive organisms, gram-negative organisms except for Neisseria, and fungi
    • nucleic acid amplification testing (NAAT)
  • Histology
    • Gram stain of a cervical swab
      • gram-negative, kidney-shaped diplococci
Differential
  • Chlamydia
    • distinguishing factor
      • visualization of intracytoplasmic inclusions (reticulate bodies) on histology
  • Urinary tract infection
    • distinguishing factor
      • lack of growth on Thayer-Martin agar
  • Genital herpes simplex
    • distinguishing factor
      • painful vesicles and ulcers
Treatment
  • Medical
    • IM ceftriaxone 
      • add azithromycin or doxycycline for possible concomitant chlamydial infection
      • treat sexual partner to prevent reinfection
Complications
  • Fitz-Hugh-Curtis syndrome
    • perihepatitis
      • infection and inflammation of liver capsule
      • adhesions of peritoneum to liver
  • Pelvic inflammatory disease (PID)
    • may include salpingitis, endometritis, hydrosalpinx, tubo-ovarian abscess
    • risk factor for ectopic pregnancy, infertility, chronic pelvic pain, and adhesions
  • Disseminated gonococcal infection (DGI) 
    • presents with a triad of:
      • polyarthralgias
        • asymmetric and migratory
      • tenosynovitis
      • vesiculopustular lesions 
        • most commonly on extremities, including palms and soles
    • diagnosis
      • arthrocentesis
        • elevated leukocyte count (up to 50,000/mm^3)
        • Gram stain positive <25% of cases
        • culture
      • can also culture blood, skin lesions, or mucosal sites
      • molecular testing

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