neisseria gonorrhea disease

1. BY DR. BHAGWAN DASS

2. ⚫Gonorrhea (Greek, “flow of seed”) is attributed to Galen
(130 A.D.), who is said to have believed that urethral
exudate in males with gonorrhea was semen.
⚫In 1879, Neisseria gonorrhoeae was demonstrated by
Neisser in stained smears of urethral, vaginal, and
conjunctival exudates, making gonococcus 2nd identified
bacterial pathogen following discovery of Bacillus
anthracis.
⚫Firstcultured in vitro by Leistikow in 1882
⚫Effectiveantimicrobial therapy in form of sulfonamides
was firstapplied in 1930s.

3. ⚫Thayer- Martin medium forculture:- 1962
⚫Risk of infection fora man aftersingle episodeof vaginal
intercoursewith an infected woman is estimated to be 20%
and 60-80% after 4 exposure.
⚫Prevalenceof infection in women is 50-90%.
⚫N. Gonorrhoeae isgram –ve, nonmotile, non-spore
forming diplococci.
⚫Present intracellularly in neutrophils.

4. Pathogenesis

5. ⚫ Only mucous membranes lined by columnar or cuboidal,
noncornified epithelial cells are susceptible to gonococcal
infection.
⚫ Steps in pathogenesis:-
1. Adherence :- initial event , N. gonorrhoeae adhere to mucosal
cells , mediated by pili, Opa, and othersurface proteins.
2. Invasion :-Organism is then pinocytosed by epithelial cells,
which transport gonococci from mucosal surface to
subepithelial spaces.
⚫ Simultaneous with attachment of gonococci to nonciliated
epithelial cells, gonococcal LOS(endotoxin) impairs ciliary
motilityand contributes to destruction of surrounding ciliary
cells.

6. ⚫This process may promote furtherattachment of additional
organisms.
3. Tissue damage :-Progressive mucosal cell damageand
submucosal invasion are accompanied by a vigorous
neutrophil response, submucosal microabscess
formation, and exudation of purulent material into
lumen of the infected organ.
4. Dissemination:- ability to resist the killing activityof
antibodies and complement in normal human serum is
closely related to the ability of gonococci to cause
bacteremic illnesswith orwithout septicarthritis

7. CLINICAL MANIFESTATIONS

8. URETHRAL INFECTION IN MEN
⚫Acuteanterior urethritis is mostcommon in men.
⚫incubation period ranges from 1 to 14 days oreven longer;
however, majority of men develop symptoms within 2–5
days, as was the case in 36 (82%) of 44 men with
uncomplicated gonorrhea in one of few studies in which
timeof exposurecould beclearlydefined.
⚫Predominant symptomsare urethral dischargeordysuria
⚫initiallyscant and mucoid or mucopurulent in appearance,
in most males urethral exudate becomes frankly purulent
and relativelyprofusewithin 24 hours of onset.
⚫Dysuria usually beginsafteronset of discharge.

9. ⚫Variable degrees of
edemaand erythemaof
the urethral meatus
commonlyaccompany
gonococcal urethritis.

10. UROGENITAL INFECTION IN WOMEN
⚫Primary site:- endocervical
canal
⚫Urethral colonization :-
70–90% of infected
women, but is uncommon
inabsence of endocervical
infection.
⚫Infectionof Bartholin’s
gland ducts is also
common.
⚫IP:- variable but usually 10
days

11. ⚫Most common symptoms
are those of most lower
genital tract infections in
women:-
⚫ increased vaginal
discharge, dysuria,
intermenstrual uterine
bleeding, and
menorrhagia.
⚫Purulent exudate
occasionally may be
expressed from urethraor
Bartholin’s gland duct.

12. RECTAL INFECTION
⚫Rectal mucosa is infected in 35–50% of women with
gonococcal cervicitis. Only rectum is involved in 5%
women.
⚫ 40% in homosexual men.
⚫Symptoms range from minimal anal pruritus, painless
mucopurulent discharge (often manifested only by a
coating of stools with exudate), orscant rectal bleeding, to
symptoms of overt proctitis, including severe rectal pain,
tenesmus, and constipation.

13. ⚫External inspection :- only occasionally shows erythema
and abnormal discharge
⚫On Anoscopy:- mucoid or purulentexudate ( localized to
anal crypts), erythema, edema, friability, orother
inflammatory mucosal changes.

14. PHARYNGEAL INFECTION
⚫3–7% of heterosexual men, 10–20% of heterosexual women,
and 10–25% of homosexuallyactive men.
⚫acute pharyngitis or tonsillitis and occasionally is
associated with feverorcervical lymphadenopathy.
⚫ >90% are asymptomatic

15. INFECTION OF OTHER SITES
⚫Gonococcal conjunctivitis is rare.
⚫Primary cutaneous infection i.e. localized ulcerof genitals,
perineum, proximal lowerextremities, or finger is rare.

16. COMPLICATED GONOCOCCAL
INFECTIONS
⚫ LOCAL COMPLICATIONS IN MEN:-
⚫ Epididymitis:-present in upto 20%. mostcommoncausesof acute
epididymitis in patients under age 35 are C. trachomatis, N.
gonorrhoeae
⚫ Penile lymphangitis:- penile edema (“bull-headed clap”)
⚫ Post-inf lammatoryurethral strictures
⚫ Periurethral abscesses
⚫LOCAL COMPLICATIONS IN WOMEN:-
⚫ PID:- most commonof all complicationsof gonorrhea, aswell
as the most important in termsof public-health impact
⚫ 10–20% of thosewith acute gonococcal infection.

17. ⚫Bartholin’s gland abscess
⚫SYSTEMIC COMPLICATIONS:
⚫DISSEMINATED GONOCOCCAL INFECTION:- More
common in female.
⚫DGI, usually manifested by acute arthritis-dermatitis
syndrome, is most common systemic complication of
acutegonorrhea.
⚫“classic” skin lesion of gonococcal dermatitis:- a tender,
necrotic pustuleon an erythematous base,
⚫may presentas, macules, papules, pustules, petechiae,
bullae, orecchymoses

18. ⚫Located on distal portions of extremitiesand <30.
⚫Gonococcal endocarditis and meningitis:- Occurs in 1–3% of
patientswith DGI.

19. LABORATORY DIAGNOSIS
⚫ Gram’sstain:- Microscopic
examinationof stained smears
showsgram –vediplococci in
PMN are seen.
⚫ Culture:- antibiotic-containing
selective media (e.g., modified
Thayer- Martin medium) have
diagnosticsensitivitiesof 80–
95% for promptly incubated
specimens, depending in parton
anatomicsite being cultured.
⚫ Small pinpointcoloniescan be
seen.
⚫ 90% within 12 hrs and 100%
within 6 hrs of sample collection

20. ⚫Oxidasereaction:- aids to identify gonococci from mixed
culture
⚫A dropof tetra methyl-p-phenylenediamine hydrochloride
is poured over suspected colonies, which turn pink and
thendark blue
⚫Nonculture diagnostic techniques:-
⚫Nucleic acid amplification tests (NAATs):- polymerase
chain reaction (PCR), transcription-mediated
amplification (TMA), and other nucleicacid amplification
technologies.
⚫More sensitive than culture forgonorrhea diagnosis and
specificitiesare nearly as high as forculture.

21. ⚫Immunologic or biochemical detection of gonococcal
antigens or metabolic products, including surface proteins,
endotoxin and oxidase or other enzymes also has been
investigated in past butcurrently seem less promising than
nucleicacid detection.
⚫Fluorescein-conjugated antibodiesdetection give positive
results 24 hours beforeconventional culture technique.

22. SEROLOGICAL DIAGNOSIS
⚫complement fixation, immunoprecipitation, bacterial lysis,
immunofluorescence, hemagglutination, latex
agglutination, enzyme-linked immunoabsorbance, and
other techniques.
⚫sensitivitiesof about 70% and specificitiesof about 80%.
⚫Rapid carbohydrate utilization test(RCUT):-used todetect
β lactamase production by Neisseriaspecies.
⚫Detected bychange in colour of phenol red pH indicator
from red toyellow
.

23. Treatment
Uncomplicated Gonococcal
infection of cervix, urethra
and rectum
⚫ Singledose of Tab. cefixime
400mg, Inj. Ceftriaxone 125
mg IM, tab. Ciprofloxacin
500mg, tab. Ofloxacin 400mg,
or tab. Levofloxacin 250mg
PLUS
⚫ If chlamydial infection is not
ruled out- tab. Azithromycin 1
g single dose or tab.
Doxycyclin 100mg BID x
7days.
Uncomplicated Gonococcal
infection of pharynx
⚫ Single dose of Inj. Ceftriaxone
125 mg IM, or tab.
Ciprofloxacin 500mg
PLUS
⚫ If chlamydial infection is not
ruled out- tab. Azithromycin
1 g single dose or tab.
Doxycyclin 100mg BID x
7days

24. Disseminated gonococcal
infection (DGI)_
Gonococcal conjuctivitis:-
Inj. Ceftriaxone 1 g IM singledose
⚫ Inj. Ceftriaxone 1 g IM or IV daily
Alternative regimens
⚫ Inj. Cefotaxime 1 g IV 8 hourly, Inj.
Ceftizoxime 1 g IV 8 hourly, Inj.
Ciprofloxacin 400 mg IV BD, Inj.
Ofloxacin 400mg IV BD, Inj.
Levofloxacin 250mg IV daily OR
Inj. Spectinomycin 2 g IM BD
⚫ All of the preceding regimens
should be continued for 24-48 hrs
after improvement begins, at
which time therapy may be
switched to one of the following
regimens to complete at least 1
week of therapy
⚫ Tab. Cefixime 400mg BD, tab.
Ciprofloxacin 500mg BD,
ofloxacin 400mg BD OR tab.
Levofloxacin 500mg OD
⚫ Gonococcal meningitis:- Inj.
Ceftriaxone 1-2 g IV every 12 hrs
x 10-14 days.
⚫ Gonococcalendocarditis:- Inj.
Ceftriaxone 1-2 g IV every 12 hrs
forat least 4 weeks
⚫ Ophthalmia neonatorum:-
Inj. Ceftriaxone 25-50 mg/kg
IV/IM singledose( not more
than 125 mg)
⚫

25. ⚫Management of Sex partners:- all sex partners of patient
who have N. gonorroeae infection should be evaluate and
treated for both N. gonorroeae and C. trachomatis if their
last sexual contact with patientwas within 60 days before
onsetof symptomsordiagnosis.
⚫Follow up:- Treated patients with CDC regimen need not
follow up to confirm theircure but the patientwith
persistent symptoms may be tested forantimicrobial
susceptibilityand othercauseand tested accordingly.

26. Flowchart for management of urethral discharge(NACO 2007)
Syndrome:- urethral discharge in man
History of:-Urethral discharge
•Pain or burning while passing urine, increased frequency of urination
•Sxual exposure to high risk practices including oro-genital sex
Examination:-
•Look for urethral meatus for rednessand swelling
•If urethral discharge is not seen, then gently masage the urethra from ventral part
of penis towards meatusand thick, creamygreenish-yellowor mucoid discharge
Lab investigations:-
•Gram stain examination of urethral smearwill show G –ve intracellulardiplococci in
caseof gonorrhoea
•In non gonocacal urethritis more than 5 PMN cells per oil immersion field in
urethral smearor >10 PMN cells/high power field in the sediment of first void urine
areobserved.

27. TREATMENT
Dual infection is common, t/t should coverall the 3 organism
Regimen for uncomplicated gonorrhoea + chlamydia
•Tab. Cefixime 400 mg stat + Tab. Azithromycin 1 g stat, and adviseclient to return
after 7 days.
When the symptomspersistorrecurin patientorpartner then
•Tabsecnidazole 2 g stat
SYNDROME SPECIFIC GUIDELINES FOR
PARTNER MANAGEMENT
•Treatall recent partners
•Treatpartners on same lines
•Advise sexual absinencedurind thecourseof
treatmentor provide condoms.
•Refer forvoluntary counselling and testing for
HIV, syphilisand hepatitis B.
•Advise to returnafter 7 days.
FOLLOW UP AFTER 7 DAYS
•See reportsof HIV, syphilisand hepatitis B
•If symptoms persist, toassess t/t failure or
reinfection
MANAGEMENT OF
PREGNANT PARTNER
•Tab. Cefixime 400 mg stat or
Inj. Ceftriaxone 125 mg IM
stat
PLUS
•Tab. Erythromycin 500 mg
QID x 7 days or Cap.
Amoxicillin 500 mg TDS x 7
days.

28. Management of vaginal discharge syndrome
(NACO 2007)
History :- menstrual history to ruleout pregnancy
•Natureand type of discharge(amount, smell, consistency)
•Genital itching
•Burning micturation, frequrncyof urination
•Presenceof any ulcer, swelling on thevulval or inguinal region
•Genital complaints in sexual partners
•Low backache
EXAMINATION
•Perspeculumexamination todifferntiate b/wvaginitis and cervicitis.
a) Vaginitis:-
• Trichomoniasis:- greenish frothydischarge
• Candidiasis:- curdywhitedischarge
• Bacterial vaginosis:- adherentdischarge
• Mixed infection may presentwith atypical discharge.
b) Cervicitis:-
• Cervical erosion/ cervical ulcer/ mucopurulent cervical discharge.
• Bimanual pelvicexamination to ruleout PID
• If speculum examination is not possibleorclient is hesitant, treat both for
vaginitis and cervicitis

29. Lab investigations
•Wet mount microscopy of thedischarge for trichomonasvaginalis and cluecells
•10% KOH for candidiasis
•Grams stain of vaginal smear forcluecells
•Grams stain of endocervical smear todetectgonococci.
TREATMENT
•VAGINITIS (TV+BV+Candida):-
•Tab. Fluconazole 150 mg stat or Local clotrimazole 500 mg vaginal pessary
once
•Tab. Secnidazole 2 g statorTab. Tinidazole 500 mg BD x 5 days .
•CERVICAL INFECTION( chlamydiaand gonorrhoea ):-
•Tab. Cefixime 400 mg stat + Tab. Azithromycin 1 g stat
Management of pregnantwomen
•Vaginitis :-
•First trimesterof pregnancy:- local t/t with
clotrimazolevaginal pessary/cream
•Local Metronitazole pessary/cream.
•Second trimesterof pregnancy:- Tab.
Secnidazole 2 g stator tab tinidazole 500 mg BD
x5 days
Partner treatmentguideline
•Treatpartneronly if no
improvementafter initial t/t or
partner is symptomatic.

30. THANK YOU