Makindo Medical Notes

Uncomplicated gonorrhoea is most common in young adults aged 15-24-year olds. Complications of infection include epididymo-orchitis, prostatitis, urethral stricture, pelvic inflammatory disease (PID), tubal infertility, ectopic pregnancy, and chronic pelvic pain.

About

• Causes urethritis and sepsis and arthritis
• Those with complement C8 and C9 deficiency are more susceptible

Characteristics

• Gram negative kidney-shaped diplococcus typically
• Has no capsule and does not ferment maltose but is oxidase-positive
• Outer membrane contains modified lipopolysaccharide which can trigger cytokine release
• Grows best at 37 C on complex media + 5% CO₂

Virulence

• IgA proteases adds to virulence
• Pili help attachment to epithelial surfaces
• Outer membrane contains modified lipopolysaccharide which can trigger cytokine release
• Bind to and invade epithelial cells and sequester iron

Source

• Spread as a sexually transmitted infection
• Swab throat, urethra, anus
• Asymptomatic carriers particularly women

Pathogenesis

• Genitourinary : Causes urethritis or cervicitis several days after sexual contact with a white milky discharge. Vaginal infection is less symptomatic than urethral and females can be carriers and have more systemic disease. Typically, symptoms are a urethral discharge and dysuria in men and vaginal discharge in females. Anal sex can lead to proctitis, Oral sex to pharyngitis. Advanced infection can lead to epididymitis and prostatitis in men and salpingitis and Bartholin's abscess in women
• Fitz Hugh Curtis syndrome: infection can spread to the fallopian tubes and the abdominal cavity to cause a perihepatitis with RUQ pain and can be due to gonorrhoea or chlamydial infection
• Ophthalmia neonatorum: which is picked up as the baby passes through the vagina. Can lead to neonatal blindness. Clinically there is purulent exudative conjunctivitis with swelling of the eyelids. Prevented with the use of silver nitrate eye drops as soon as possible to both eyes after birth.
• Disseminated Gonococcal infection: is commoner in women especially postpartum or menstruation or those with complement deficiencies or SLE and can lead to painful joints, fever and rash. Treatment requires a more prolonged course of antibiotics

Clinical

• Genital gonorrhoea: Purulent urethral discharge
• Rectal gonorrhoea: Anal discharge, Perianal/ anal pain or discomfort
• Pharyngeal gonorrhoea: Usually asymptomatic and Pharyngitis
• Urogenital gonorrhoea: Increased or altered vaginal discharge
• Lower abdominal pain, Dysuria, Dyspareunia
• Intermenstrual bleeding and menorrhagia
• On examination, a mucopurulent endocervical discharge may be seen and easily induced endocervical bleeding
• Rectal gonorrhoea: Anal discharge, Perianal/ anal pain or discomfort
• Prostatitis, epididymitis and orchitis, and pelvic inflammatory disease and rarely disseminated gonococcal infection (skin lesions, arthralgia, arthritis and tenosynovitis)
• Perihepatic inflammation due to ascending infection can be seen in PID and is known as the Fitz-Hugh-Curtis syndrome. Violin string adhesions of the peritoneum to the liver are classically seen in this syndrome

Investigations

• Microscopy shows polymorphonuclear leukocytes with intracellular Gram-negative diplococci
• Urine gonorrhoea NAAT test is positive
• Check chlamydia NAAT test and HIV test
• Culture for N. gonorrhoea on Thayer-Martin agar
• Oxidase reaction and beta-lactamase production
• Carbohydrate fermentation
• Gonochek test detects prolyl aminopeptidase
• Phenotyping may be useful to identify separate strains

Sensitivities

• Penicillin in 95% - penicillinase produced by 5%
• Cephalosporin, Ciprofloxacin

Management

• Referral to STD clinic for contact tracing and treatment
• Pharyngeal, urethral and anal swabs. Screening for other STDs - Syphilis, HSV, HIV, Chlamydia, Genital warts
• Ceftriaxone IM 1g intramuscularly as a single dose (off-label dose)
• Ciprofloxacin 500mg orally as a single dose (monotherapy) When antimicrobial susceptibility is known prior to treatment. Increasing antibiotic resistance due to a penicillinase-producing form is an ongoing issue e.g. fluoroquinolone. Where sensitive a single dose of Ciprofloxacin. CDC recommends treatment of‚ gonorrhoea with both ceftriaxone and azithromycin.
• All patients diagnosed with gonorrhoea should be advised to return for a Test of cure