Gonorrhea

Neisseria Gonorrhoeae

What sample is needed for Neisseria Gonorrhoeae?

1. The best sample for men is the urethral discharge smear.
2. Females can make a smear from the vagina.
3. In females, a cervical smear can also be taken.
4. An anal canal smear can be taken.
5. Smears are made from prostatic secretions, urethra, cervix, and pelvic inflammatory disease.

What are the indications for Neisseria Gonorrhoeae?

1. A urethral smear is stained to diagnose gonorrhea.
2. A cervical smear is stained to diagnose gonorrhea.
3. It is advised to diagnose sexually transmitted diseases.

How will you define Neisseria gonorrhea?

1. Neisseria is a human pathogen and does not cause infection in animals. So, the spread is through close contact through the sexual route.
2.  Neisseria is sensitive to drying and does not survive out of the body.
3.  Neisseria gonorrhoeae causes contagious diseases and is usually sexually transmitted.
4. Mother can transmit the disease to the newborn.

How will you describe the bacteriology of Neisseria Gonorrhoeae?

1. The incubation period is 2 to 10 days.
2. These are obligate parasites of the human urogenital area.
3. These are characteristically seen in pairs with adjacent sides concave.
4. In the purulent material, these are seen intracellularly and outside the cells.
5. N. Gonorrhoeae is gram-negative bacteria that can grow in the body, like the urethra, cervix, uterus, and fallopian tubes in females and the urethra in males.
6. These bacteria grow in enriched media (Chocolate agar).
   1. Incubation is done in a moist atmosphere containing 5% to 10% CO2.
   2. The optimal temperature is 35 to 37 C.
   3. These media may contain antibiotics (Lincomycin) to inhibit the growth of other bacteria.
   4. Small gray glistening colonies form after 24 hours of incubation, which may become larger after 48 hours.
   5. The identification test is carbohydrate utilization, which produces acid only from glucose.
7. There are two pathogenic Neisseria:
   1. N. Gonorrhoeae (Gonococcus).
   2. N. Meningitides (Meningococcus).
8. N.Gonorrhoeae can infect any epithelium lined by columnar cells with cilia-like:
   1. Urethra.
   2. Cervix.
   3. Rectum.
   4. Pharynx.
   5. Conjunctiva.
   6. But cannot vagina, which is the squamous epithelium.

Neisseria Gonorrhoeae stained smear

9. It grows in the warm, moist area of the female reproductive system.
10. It can also grow in the mouth, throat, and anus.

What are the signs and symptoms of Neisseria Gonorrhoeae (Gonorrhea)?

1. Neisseria gonorrhea causes:
   1. Genital infection.
   2. Proctitis.
   3. Oropharyngeal infection.
   4. arthritis.
2. Gonorrhea is not symptomatic in roughly 75% to 80% of the infected females and 10% to 15% of infected males.
3. This is more symptomatic in men than in women.
4. In the male:
   1. There is a urethral purulent discharge.
   2. There is dysuria.
   3. There may be proctitis and tenesmus.
   4. There is pelvic pain.
5. In the female:
   1. Females are usually asymptomatic.
   2. Gonorrhea in females is symptomatic in about 75% to 80% and 19% to 15% in males.
   3. There is mucopurulent cervicitis.
   4. There is vaginal discharge.
   5. There may be dysuria.
   6. There may be proctitis.
   7. N. gonorrhea causes gonorrheal urethritis and initiates the majority of cases of acute salpingitis, a so-called pelvic inflammatory disease.
6. Transmission from male to female is more efficient than from female to male.
7. While pharyngeal infections are asymptomatic.
8. Ascending pelvic infection occurs in 10% to 20% of the cases, leading to infertility and ectopic pregnancy.
9. This may involve the rectum and oropharynx.
10. Oropharyngeal infection is present in 10% of females and 20% of homosexual men.
    1. Pharyngeal gonorrhea is usually asymptomatic, self-limited in 10 to 12 weeks, and visible in <50% of the cases.
    2. Culture is needed for the diagnosis, and the smear is not diagnostic because of the nonpathogenic Neisseria species.
11. Gonococcal arthritis is diagnosed by the presence of gonococci in 1/3 of the cases.
    1. A variable number of WBCs are found, or synovial fluid may be purulent.
12. Proctitis is seen in symptomatic cases (∼ 5%). Bacterial culture on special media is confirmatory.
    1. Avoid contamination from the stool.
    2. Rectal gonorrhea is accompanied by genital gonorrhea.

What type of Gonorrheal disease is seen in females?

1. Urethritis
2. Conjunctivitis
3. Vulvitis.
4. Vaginal discharge.
5. Swollen lymph nodes.
6. Bleeding after intercourse.

What type of Gonorrheal disease is seen in males?

1. Urethritis (burning micturition).
2. Swollen, painful testes.
3. Enlarged lymph nodes in the throat.

What are the complications of Gonorrhea?

1. In females, ascending pelvic infection.
   1. Pelvic inflammatory disease (PID) complications are:
      1. Infertility.
      2. Ectopic pregnancy.
      3. Peritonitis.
      4. Abscess.
      5. Perihepatitis.
   2. There is salpingitis, which leads to infertility.
   3. There may be gonococcal vulvovaginitis.
   4. There may be bartholinitis.
2. In male:
   1. Epididymis-orchitis.
   2. There may be cystitis.
   3. There may be prostatitis.
   4. There may be a urethral stricture.
3. In the untreated mother, newborn babies can have Ophthalmia neonatorum (gonococcal conjunctivitis).
4. There may be septicemia, arthritis, and meningitis due to the spread through the blood.
5. Complications in both males and females:
   1. There may be gonococcal bacteremia, which leads to fever, joint pain, and skin lesions.
   2. Pericarditis, meningitis, and endocarditis are rare and are the complication of bacteremia.
   3. Septic arthritis.
   4. Gonococcal conjunctivitis.
6. Complications in newborn babies:
   1. Ophthalmia neonatorum occurs on the first or second day of life and can damage the cornea, leading to blindness.

How will you diagnose Neisseria Gonorrhoeae?

1. In males, in the case of urethritis, there is urethral discharge. Make the smear from the urethral discharge.
   1. Now stain with gram stain, which will show gram-negative intracellular diplococci.
2. The urethral smear is diagnostic and very specific.
   1. In the male, ask the patient to squeeze the penis to get a good amount of material.
   2. The patient can apply the material directly on the slide.
3. Females can make a cervical smear and do the culture.
   1. Endocervical smears are positive in 50% of the cases.
4. Make a smear for gram stain and do the culture on Thayer-Martin media (gold standard) simultaneously before starting the antibiotics.
5. Swab smears are taken from:
   1. Urethra.
   2. Endocervical canal.
   3. Anal canal.
   4. Pharynx.
6. Smears may be tested by a fluorescent antibody.
7. When there is no discharge, insert the swab into the urethra up to 2 cm and gently rotate.
8. Endocervical specimens can be taken under direct vision using a speculum.
9. Other sites for the swab are the pharynx, anorectal area, blood, CSF, and synovial fluid.
10. Ultimately, it can confirm the diagnosis by culture, and these bacteria need nutrient-rich selective agar media (Thayer-Martin).
    1. Culture needs 48 hours to form colonies.
11. It can take conjunctival swabs in infants who have conjunctivitis.
12. Blood and synovial fluid may be taken in case of arthritis.
13. Gram-stained smears:
    1. Smear is positive when you find intracellular gram-negative diplococci.
       1. Extracellular organisms are not diagnostic.
    2. Extracellular gram-negative diplococci are not confirmatory.
    3. Smears are only 50% positive in asymptomatic patients. These patients must have the culture of the sample.
    4. The smear becomes negative within a few hours of starting the antibiotics.
    5. In females, gram stain smears of the endocervical site are 45% to 65% positive.
    6. Smears from the vagina, oropharynx, and anal canal are not recommended.
    7. Urethral smears are >95% positive in symptomatic males.

Neisseria Gonorrhoeae  are intracellular bacteria (gram-negative)

13. Culture:
    1. It is done to supplement and confirm the diagnosis of gonorrhea.
    2. Culture is done on special media, such as Thayer-Martin solid media.
    3. Take a culture sample before starting the antibiotics.
    4. The endocervical canal is the best site for the culture and is 82% to 92% positive.
    5. Rectal cultures are 30% to 50% positive. These are positive in homosexual cases.
14. DNA probe tests are highly sensitive and specific.
15. DNA amplification by PCR is good for testing. It can be done on urine and swab specimens.

How will you treat Neisseria Gonorrhoeae?

Sensitivity to antibiotics:

1. These bacteria are sensitive to penicillin, ampicillin, tetracycline, macrolides, cefuroxime, and ciprofloxacin.
2. Give a single oral dose of Amoxycillin or ampicillin.
3. In 2% of the cases, gonorrhea is resistant to penicillin.
4. Give probenecid to delay the excretion of medicine.
5. Or a single dose of Ceftriaxone 250 mg I/M.
6. Or a single dose of Norfloxacin 800 mg.
7. Ciprofloxacin is given when an infection is complicated with Chlamydia infection.
8. Erythromycin is given to pregnant ladies and children.
9. The extragenital infection needs treatment for 5 to 7 days.
10. Penicillin-resistant gonorrhea is treated with cefuroxime, cefotaxime, erythromycin, ciprofloxacin, tetracycline, or aztreonam.

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