Gonorrhoea is a sexually transmitted disease caused by N. gonorrhoeae. Hippocrates referred to acute gonorrhea as “strangury” obtained from the “pleasures of Venus” in the fourth and fifth centuries B.C. (229). It was not until A.D. 130 that Galen, who mistakenly confused the purulent discharge associated with gonococcal urethritis with semen, introduced the term gonorrhea, i. e., “flow of seed” . N gonorrhoeae is the second most commonly occurring reportable sexually transmitted infection after Chlamydia trachomatis.

1. Gonorrhoea

2. Introduction
• Infection with Sexually Acquired Bacterial Pathogen
 Neisseria gonorrhoeae
• Dates back over 2000 years
• Hippocrates: acute gonorrhea as “Strangury”
 Obtained from the “Pleasures of Venus”
• Galen (A.D. 130) confused discharge with semen
 Flow of seed

3. Introduction
• Humans as the sole natural host
• Neisser [1879] described the Causative agent
• Leistikow & Loffler [1882] cultivated Gonococcus

4. Introduction CDC Fact Sheet
• The second most commonly occurring reportable STI
• Approx. 820,000 new gonococcal infections occur each year
• 570,000 of them are among young people 15-24 years of age
• In 2017, 555,608 cases of gonorrhea were reported

5. Introduction Fact Sheet

6. Introduction Fact Sheet

7. Introduction Fact Sheet

8. Introduction
• Acquired at multiple mucosal sites
 Lower genital tract
o Urethra, Cervix, Bartholin’s & Skene’s glands
 Anorectal canal
 Pharynx & conjunctivae
• May spread to the Upper Genital Tract, Uterine Tubes, & Abdominal Cavity,
as well as Other Systemic Sites

9. Transmission
• Relies on sexual networks
The Core, High-risk Population
Medium-risk Group
Members’ Partners
• MUSIC
• Men to Partners:
 N. gonorrhoeae attaches to sperm
 Transmitted through ejaculates
• Women to Partners:
 Cervicovaginal microbiota secrete Sialiadases
 Desialylate N. gonorrhoeae lipooligosaccharide [LOS] to enable efficient
transmission from women to men

10. Pathogenesis factors
• Surface structures
• Adhesion, Invasion & Immune Evasion
 Type IV pili
• Cellular adherence to Epithelial Surface
• Twitching motility
• Immune Evasion
Antigenic Variation & Phase Variation
Adherence to the epithelial surface & subsequent pilus retraction bring the
gonococci close to the cell surface

11. Pathogenesis factors
• Surface structures
• Adhesion, Invasion & Immune Evasion
 Opacity (Opa) proteins
• Interact with carcinoembryonic antigen-related cell adhesion molecule [CEACAM]
• Heparin sulfate proteoglycans [HSPG]
• Immune Evasion
Antigenic Variation & Phase Variation

12. Pathogenesis factors
• Surface structures
• Adhesion, Invasion & Immune Evasion
 Major outer membrane protein porin
• Binds C4b-binding protein & Factor H
• Suppresses neutrophil oxidative burst & neutrophil apoptosis

13. Pathogenesis factors
• Surface structures
• Adhesion, Invasion & Immune Evasion
 LOS
• Similar LPS
• Activation of inflammatory transcription factors
Release of cytokines & chemokines

14. Pathogenesis factors
 Efflux Pump
• Protect from Antimicrobials & Fatty acid stress
 Membrane Transporters
• Allow to co-opt nutrients from the surrounding environment
 Transcriptional Regulators
• Respond to changing growth requirements, oxidative stress, DNA & protein damage &
antimicrobials
 Protective enzymes
• Detoxify various ROS

15. Pathogenesis factors – Summary

16. Transcriptional Regulatory Factors

17. Establishment of infection
OMVs: Outer Membrane Vesicles , NOD: Nucleotide-binding Oligomerization Domain-containing Protein, TLR: Toll Like
Receptor, HSP: Heptose-1,7-bisphosphate, TIFA: TRAF-interacting Protein With FHA Domain-containing Protein A

18. Immune Evasion
 Prevents Complement Activation, Opsonization & Bacterial Killing
 Modulates the Activities of Macrophages, DCs & Neutrophils
 Modulates T Cell Function & Varies its Surface Components

19. Complement Activation

20. Regulation of Complement

21. Immune Evasion
 Prevents Complement Activation, Opsonization & Bacterial Killing
Sialylates its lipooligosaccharide
Binds host Factor H, Factor I & C4b-binding protein

22. Immune Evasion
 Modulates the Activities of Macrophages, DCs & Neutrophils
Prevents PMN granules from releasing their contents at the plasma membrane or into phagosomes
TGFβ is inhibitory for Th1 and Th2 cells
IL-10 inhibits the activity of Th1 cells, NK cells, & macrophages
PD-L1 counteract T cell-activating signals

23. Immune Evasion
 Modulates T Cell Function & Varies its Surface Components

24. Clinical Aspects
Neonates
• Exposed to infected exudate during vaginal delivery
 Ophthalmia neonatorum [Purulent Conjunctivitis]
 Scalp abscesses
 Disseminated disease

25. Clinical Aspects
Prepubertal Children
• Occurs typically via sexual abuse
 Can occur in Pharynx, Rectum, & most commonly Vagina
 Purulent Vaginal Discharge
 Vaginitis
 Erythematous, Swollen Vulva

26. Clinical Aspects
Adolescents & Adults
• Either symptomatic or asymptomatic
• In Males
• Urethritis
• In Females
• Cervicitis, Urethritis, PID, Menometrorrhagia,
Dyspareunia
• In Either Sex
• Dysuria , Proctitis, Pharyngitis, & DGI

27. Complications
• In Males
• Epididymitis, Prostatitis, Seminal Vesiculitis, Infection of Cowper & Tyson Glands
• In Females
• Acute Endometritis, Salpingitis, Tuboovarian Abscess, Peritonitis, Perihepatitis
• Ectopic pregnancy [6 – 10 fold risk]
• Infertility [3% to 21% risk]
• In Either Sex
• Disseminated Gonococcal Infection

28. Disseminated Gonococcal Infection
• Two Common Classifications
• Tenosynovitis – Dermatitis Syndrome [Most Common]
• Suppurative Arthritis Syndrome
• Fever, Chills
• Arthralgia
• Skin Lesions
• Hemorrhagic or vesiculopapular lesions
• Painful
• On palmar & plantar surfaces

29. Disseminated Gonococcal Infection
• Less Common
• Endocarditis
• Pericarditis,
• Meningitis

30. Diagnosis
• Appropriate Sexual History
 The five “P”s :
1. Partners
2. Practices
3. Protection from STDs
4. Past history of STDs
5. Prevention of pregnancy
Areas that you should openly discuss with your patients

31. Diagnosis
 Dialogue With Patient
ℚ Are you currently sexually active? (Are you having sex?)
ℚ If no, have you ever been sexually active?
ℚ In recent months, how many sex partners have you had?
ℚ In the past 12 months, how many sex partners have you had?
ℚ Are your sex partners men, women, or both?
ℚ If a patient answers “both” repeat first two questions for each specific
gender.
Partners

32. Diagnosis
 Dialogue With Patient
ℚ What kind of sexual contact do you have or have you had?
ℚ Genital (penis in the vagina)?
ℚ Anal (penis in the anus)?
ℚ Oral (mouth on penis, vagina, or anus)?
Practices

33. Diagnosis
 Dialogue With Patient
ℚ Do you and your partner(s) use any protection against STDs?
ℚ If not, could you tell me the reason?
ℚ If so, what kind of protection do you use?
ℚ How often do you use this protection?
ℚ If “sometimes,” in what situations or with whom do you use protection?
ProtectionfromSTDs

34. Diagnosis
 Dialogue With Patient
ℚ Have you ever been diagnosed with an STD? When? How were you treated?
ℚ Have you had any recurring symptoms or diagnoses?
ℚ Have you ever been tested for HIV, or other STDs? Would you like to be tested?
ℚ Has your current partner or any former partners ever been diagnosed or
treated for an STD? Were you tested for the same STD(s)?
ℚ If yes, when were you tested? What was the diagnosis? How was it treated?
PastHistoryofSTDs

35. Diagnosis
 Dialogue With Patient
ℚ Are you currently trying to conceive or father a child?
ℚ Are you concerned about getting pregnant or getting your partner pregnant?
ℚ Are you using contraception or practicing any form of birth control? Do you
need any information on birth control?
Questions should be gender appropriate
PreventionofPregnancy

36. Diagnosis
 Dialogue With Patient
ℚ What other things about your sexual health and sexual practices should we
discuss to help ensure your good health?
ℚ What other concerns or questions regarding your sexual health or sexual
practices would you like to discuss?
 Thank the patient for being open and honest and praise any
protective practices
 Ensure that this information is kept in strict confidence
CompletingtheHistory

37. Laboratory Diagnosis
• Specimens
• Genital Specimens
• In females
• Endocervical swab/discharge
• Vaginal Swab/discharge
• In males
• Urethral swab/discharge in males
• Urine (First Voided)
• Non Genital Specimens
• Rectal, Pharynx, & Conjunctival swab
• Body Fluids from Arthritic Joints

38. Laboratory Diagnosis

39. Laboratory Diagnosis
• Transport of Specimens
• Stuart’s Medium
Specimens should be collected with Dacron or Rayon swabs because
Calcium alginate may be toxic to gonococci

40. Laboratory Diagnosis
• Methods
• Gram Stain
• Gram Negative Intracellular Diplococci
• Sensitivity:
• Urethral Smear: 90%
• Endocervical Smear: 50-70%
• Specificity:
• Urethral Smear: 95%
• Endocervical Smear: 90%

41. Laboratory Diagnosis
• Methods
• Culture
• Culture Media:
• Chocolate Agar
• Thayer-Martin
• Martin Lewis
• New York City
• GC agar
• Culture Conditions:
• 35°C to 37°C
• CO2 (3% to 7%)
Convex, 1-2mm, Moist, Transparent ( Dew Drop)

42. Laboratory Diagnosis
• Methods
• Identification
• Gram Negative Cocci
• Catalase: Positive
• Oxidase: Positive
• Ferment: Only Glucose
[Glucose+Maltose by N. meningitidis]
• Chromogenic enzyme substrate
• DIF
• Coagglutination tests
• Neuclic Acid Test

43. Laboratory Diagnosis

44. Laboratory Diagnosis
• Methods
• Non Culture Methods
 NAAT
 DNA probe system (AccuProbe, Gen-Probe, USA)
 PCR
 Ligase chain reaction
 Strand displacement amplification system
 Nucleic acid sequence-based amplification

45. Treatment

46. Treatment
• Uncomplicated Gonococcal Infections
Recommended Regimen
Ceftriaxone 250 mg in a single intramuscular dose
PLUS Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice
daily for 7 days
Alternative Regimens
Cefixime 400 mg in a single oral dose
PLUS Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice
daily for 7 days

47. Treatment
• Complicated Gonococcal Infections

48. 48
• Counseling and Education
 Nature of the disease
 Transmission
 Treatment and follow-up
 Risk reduction
• Management of Sex Partners
Prevention

49. Remember…
Its your health. Protect yourself.