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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(M2.ID.16.4691) A 24-year-old man presents to the clinic with a one week history of pain in his left hand and stiffness in his right knee, with associated malaise and chills. He has no other past medical history, denies intravenous drug abuse, and has had no sick contacts. Vital signs are: T 38.5 C, BP 135/85, P 78, RR 16. Physical exam reveals swelling on the dorsum of the left hand and a warm erythematous right knee. The following non-painful lesions on the patients hands and ankles can be seen in Figure A. Laboratory analysis reveals a mild leukocytosis and negative blood cultures. Which of the following conditions is causing the presentation of this patient? Tested Concept

QID: 107605
FIGURES:
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Acute meningococcemia

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Reiter's syndrome

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Acute bacterial endocarditis

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Disseminated gonococcal infection

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Sweet's syndrome

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Select Answer to see Preferred Response

(M2.ID.16.4686) A 25-year-old male presents to your clinic complaining of a yellow discharge from his urethra. He states that for the past week he has had pain with urination and yesterday the discharge developed. He admits to unprotected sex with multiple sexual partners. Gram stain of the discharge is shown in Figure A. What is the most appropriate treatment for this patient's condition? Tested Concept

QID: 107391
FIGURES:
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Doxycycline

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Penicillin G

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Ceftriaxone

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Azithromycin

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Ceftriaxone and azithromycin

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(M2.ID.16.4676) A 23-year-old woman presents to your office for a gynecological exam. She says that she has been in good health and has no complaints. She has been in a steady monogamous relationship for the past year. Physical examination was unremarkable. Screening tests are performed and return positive for gonorrhea. You treat her with an intramuscular injection of ceftriaxone and 7 day course of doxycycline. What else is recommended for this case? Tested Concept

QID: 107231
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Treatment with penicillin G for potential co-infection with syphilis

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Treat her partner for gonorrhea and chlamydia

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Recheck her in 1 week for gonorrhea and chlamydia

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Inform her that her partner is likely cheating on her

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Perform an abdominal ultrasonography in order to rule out pelvic inflammatory disease

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Select Answer to see Preferred Response

Evidence (3)
Topic COMMENTS (9)
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