Gonococcal Infections

Key Features

Essentials of Diagnosis

• Purulent urethral discharge with intracellular gram negative diplococci on smear in male patients (usually adolescents)

• Purulent, edematous, sometimes hemorrhagic conjunctivitis with intracellular gram-negative diplococci in 2- to 4-day-old infants

• Fever, arthritis (often polyarticular) or tenosynovitis, and maculopapular peripheral rash that may be vesiculopustular or hemorrhagic

• Positive culture of blood, pharyngeal, or genital secretions

• Nucleic acid amplification test on urine on genital secretions

General Considerations

• Workup of every case of gonorrhea should include a careful and accurate inquiry into the patient's sexual practices, because pharyngeal infection resulting from oral sex must be detected if present and may be difficult to eradicate

• Efforts should be made to identify and provide treatment to all sexual contacts

• Programs of expedited partner treatment where prescriptions are provided without first examining the sexual contact increase successful treatment

• Prepubertal gonococcal infection outside the neonatal period should be considered presumptive evidence of sexual contact or child abuse

• Incubation period is short, usually 2–5 days

Demographics

• Reported cases of gonorrhea exceeded 333,000 in the United States in 2013

• Gonococcal disease in children may be transmitted sexually or nonsexually

Clinical Findings

Symptoms and Signs

• Asymptomatic gonorrhea

  • Ratio of asymptomatic to symptomatic gonorrheal infections in adolescents and adults is probably 3–4:1 in women and 0.5–1:1 in men

  • Asymptomatic and symptomatic infections are equally infectious

• Uncomplicated genital gonorrhea

  • Urethritis in males

    • Discharge is sometimes painful and bloody

    • May be white, yellow, or green

    • May be associated dysuria

    • Patient usually is afebrile

  • Prepubertal female with vaginitis

    • Dysuria and polymorphonuclear neutrophils in the urine

    • Vulvitis characterized by erythema, edema, and excoriation accompanied by a purulent discharge

  • Postpubertal female with cervicitis

    • Symptomatic disease is characterized by a purulent, foul-smelling vaginal discharge, dysuria, and occasionally dyspareunia

    • Fever and abdominal pain are absent

    • Cervix is frequently hyperemic and tender when touched

  • Rectal gonorrhea

    • Often is asymptomatic

    • May be purulent discharge, edema, and pain during evacuation

  • Pharyngeal gonorrhea

    • Usually is asymptomatic

    • May be some sore throat and, rarely, acute exudative tonsillitis with bilateral cervical lymphadenopathy and fever

• Conjunctivitis and iridocyclitis

  • Copious, usually purulent exudate is characteristic

  • Newborns are symptomatic on days 2–4 of life

  • In the adolescent, infection probably is due to infected genital secretions spread by the fingers

• Pelvic inflammatory disease (salpingitis)

  • The interval between initiation of genital infection and its ascent to the uterine tubes is variable and may range from days to months

  • Menses frequently are the initiating factor

    • With onset of a menstrual period, gonococci invade the endometrium, causing transient endometritis

    • Salpingitis may occur, resulting in pyosalpinx or hydrosalpinx

    • Rarely infection progresses to peritonitis or perihepatitis

• Gonococcal perihepatitis (Fitz-Hugh–Curtis syndrome)

  • Typically presents with right upper quadrant tenderness in association with signs of acute or subacute salpingitis

  • Pain may be pleuritic and referred to the shoulder

  • Hepatic friction ...