GONORRHEA

Key Concepts:

Terms in this set (30)

Definition
Gonorrhea is a contagious sexually transmitted purulent infection of the mucous membrane surfaces caused by the gram negative diplococcus Neisseria gonorrhoeae
broad range of presentations

Most commonly, the term gonorrhea refers to urethritis and/or cervicitis in a sexually active person
N gonorrhoeae
is a gram-negative,
intracellular,
aerobic
Kidney shaped
Diplococcus
affects the host's columnar or cuboidal epithelium.
Virulence factors
Pili help in attachment of gonococci to mucosal surfaces and contribute to resistance by preventing ingestion and destruction by neutrophils.

Opacity-associated (Opa) proteins increase adherence between gonococci and phagocytes, promote invasion into host cells.

Porin channels (porA, porB) in the outer membrane give inherent resistance to normal human serum and an increased ability to invade epithelial cells, explaining their association with bacteremia.

Certain acquired plasmids and genetic mutations enhance drug resistance to several groups of antibiotics (B lactams, quinolones, tetracyclines)
Pathogenesis
Gonococci attach to the host mucosal cell by pili and Opa proteins

within 24-48 hours, penetrate through and between cells into the subepithelial space.

Neutrophils accumulate in response with epithelial sloughing, formation of submucosal microabscesses, and purulent discharge.

macrophage and lymphocyte infiltration replaces the neutrophils if untreated.
MOT
sexual contact (vaginal, anal, or oral)

inoculation of mucosa by contaminated fingers (Autoinoculation)or

other objects (towels, toilets, underwear's and instruments) = indirect contact.

Vertical during childbirth.
IP
incubation period for gonorrhea is between 2-14 days but usually present 2-7 days after exposure
Risk factors
Sexual exposure to an infected partner without barrier protection

Multiple sex partners

Male homosexuality

Low socioeconomic status

History of concurrent or past STDs

Early age of onset of sexual activity

Pelvic inflammatory disease (PID)

- Use of an intrauterine device (IUD)
International occurrence
the most common STD worldwide for at least most of the 20th century

200 million new cases of gonorrhea occur annually.

since the mid-1970s medical efforts resulted in declining incidence of the disease.

male-to-female ratio for gonorrhea is 1: 1.2

Females may be asymptomatic,

whereas males are rarely asymptomatic

Serious sequelae are much more common in women

Highest age incidence (15-24 years).

incidence of antibiotic-resistant strains has been rising.
Signs and symptoms
WOMEN
- Endocervicitis 80%-90%
- Urethritis 80%
- Infection of Skene's (paraurethral) and Bartholin glands in chronic phase.
- pelvic inflammatory disease (PID)= salpingitis, endometritis, and/or tubo-ovarian abscess
- frank abdominal peritonitis
- perihepatitis known as Fitz-Hugh-Curtis syndrome(right upper quadrant pain and nausea).
- Vulva and vagina: protected as stratified squamous epithelium and acidic (Except in children as it is thin and non acidic so vulnerable).

Males.
1- Asymptomatic in 10%

2- Acute anterior urethritis:
- burning upon urination,
profuse, purulent yellow or green, and, at times, tinged with blood discharge.
- Turbid urine
- Signs: red edematous meatus oozing pus and stained underwears.
- Turbid urine with purulent threads.

3- Acute posterior urethritis
- Constituitional symptoms
- frequent micturation, urgency, dysuria and terminal hematuria
Endocervicitis:
- Asymptomatic in 50%.

- Vaginal discharge : The most common presenting symptom of gonorrhea, thin & watery or thick & yellow/green, and mildly odorous;

- Intermenstrual bleeding

- Dyspareunia (painful intercourse)

- Mild lower abdominal pain
Complications in females
Bartholin abscess

Skenitis

Periurethritis and abscess

Salpingitis pyosalpinx

Pelvic inflammatory disease

Infertility

Ectopic pregnancy

Chronic pelvic pain
Complications in pregnant women
miscarriage.

Preterm labor.

Premature rupture of the membranes (PROM)

Premature delivery.

Infection of the lining of the uterus (endometritis).
If PID
Asymptomatic in 10-20%.

Lower abdominal pain: Most consistent symptom of PID

Increased vaginal discharge or mucopurulent urethral discharge

Dysuria: Usually without urgency or frequency

Intermenstrual bleeding

Fever, chills, nausea, and vomiting (less common)
Signs of PID
Cervical friability - Tendency to bleed upon manipulation.

Cervical motion tenderness during bimanual pelvic examination

Fullness and/or tenderness of the adnexa, unilateral or bilateral (eg, ovaries, fallopian tubes)

Lower abdominal
pain/tenderness, with or without rebound tenderness.
Perihepatitis
Fitz-Hugh-Curtis syndrome
direct extension of N gonorrhoeae from the fallopian tube to the liver capsule and overlying peritoneum.

Right upper quadrant pain
Complications In males
Balanitis

Litteritis

Cowperitis

Periurethritis periurethral
abscess

Urethral fistula and stricture

Chronicity

Prostatitis

Vesiculitis

Epididymitis

Infertility
Complications due to dissemination Gonococcemia
presence of N gonorrhoeae in the blood stream, which can lead to the development of disseminated gonococcal infection (DGI).

In 0.5-3% of patients with gonorrhea.
Disseminated gonococcal infection (DGI) arthritis-dermatitis syndrome
Biphasic.

early bacteremic phase consisting of tenosynovitis, arthralgias, and dermatitis.

Presenting as fever, asymmetrical polyarthralgias, and skin rash overlying small joints in patients with gonorrhea

Rash that may be painful before it is visible.

localized chronic phase consisting of localized septic arthritis (the most common cause of acute septic arthritis in young, sexually active adults).

The knee is the most common site of purulent gonococcal arthritis.
Signs
SKIN -
Maculopapular,
pustular,
necrotic,
or vesicular rash,

typically occurring on the torso, limbs, palms, and soles usually spares the face, scalp, and mouth;

hemorrhagic lesions, erythema nodosum, urticaria, and erythema multiforme occur less frequently;
Risk factors for DGI
pregnant or menstruating females

complement deficiencies

HIV disease,

systemic lupus erythematosus (SLE).

Strains of bacteria usually causing asymptomatic infections.
Neonates (gonococcal conjunctivitis)
Eye pain
Redness
Purulent discharge
Other presentations in both sexes
Pharyngitis 40%
(asymptomatic; or exudative pharyngitis with cervical lymphadenopathy. )

Proctitis 10%-20% (rectal pain, pruritus, tenesmus, bloody diarrhea and rectal discharge )

purulent conjunctivitis, which may rapidly progress to panophthalmitis and loss of the eye unless promptly treated.
Prognosis
complete cure and return to normal function if early treated.

Late, delayed, or inappropriate therapy may lead to significant morbidity or, on rare occasions, death
Complications in both
increased susceptibility to human immunodeficiency virus (HIV) infection
osteomyelitis,

adult respiratory distress syndrome (ARDS),

fatal septic shock

Polymyositis

Corneal scarring after ocular gonococcal infections

Destruction of cardiac valves in gonococcal endocarditis

Death from congestive heart failure related to endocarditis
(CNS) complications of gonococcal meningitis
DD
In FEMALES: bacterial vaginosis, vaginitis, ectopic pregnancy, pregnancy, tubo-ovarian abscess, endometriosis, and mucopurulent cervicitis.

In MEN, consider epididymitis, orchitis, and testicular torsion.
Causes of urethral discharge in male:
PHYSIOLOGICAL
Urethrorrhea:
Prostatorrhea
Spermatorrhea

PATHOLOGICAL
1. Organismal:
Gonorrhea
Chlamydia Mycoplasma
Candida
Trichomonas vaginalis
Intrameatal: chancre wart or herpes
Non specific infection

2. Non organismal:
Instrumentation
Catheterization
Urinary stone
Urethral lavage
Urine retention
Causes of vaginal discharge
PHYSIOLOGICAL:
Sexual activity
Around menstruation
Pregnancy
Lactation
At puberty
Oral contraceptive

PATHOLOGICAL
1. Organismal:
Gonorrhea
Trichomonas vaginalis
Chlamydia
Gardenella vaginalis
Mycoplasma
Candida
Viral (wart and HSV)
Chancre
Non specific
2. Non organismal:
Instrumentation
Foreign body
Chemical vaginitis
Erosion
Polyp
Neoplasm
Diagnosis
- Direct Smear and Culture on Thayer-Martin plates incubated in a carbon dioxide atmosphere from endocervical, urethral, pharyngeal, or rectal discharge.

- DNA probe (an antigen detection test that uses a probe to detect gonorrhea DNA in specimens. )

- PCR

- Serology is of low sensitivity and specificity

- Chest X ray, CT scan and abdominal US for complications.

- Test for other STDs

- Pregnancy test in females.
Treatment
- Education: personal hygiene, no intercourse during treatment

- Partner treatment

- Condom

- CDC recommends that all patients with gonorrheal infection also be treated for presumed co-infection with Chlamydia trachomatis.
Treatment guidelines from the CDC
- gonorrhea at any anatomic site is treated with a single IM injection of 250 mg ceftriaxone and either 1 g azithromycin as a single oral dose or 100 mg doxycycline orally twice per day for 7 days.

- If ceftriaxone is unavailable, patients can be given a single oral dose of cefixime 400 mg and either a single dose of azithromycin or doxycycline 100 mg orally twice per day for 7 days.

If the patient is allergic to cephalosporins, either a single dose of azithromycin 2gm or spectinomycin 2 gm can be used.
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