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A commonly reported infectious disease in the United States,
gonorrhea is sexually transmitted and principally affects adolescents
and young adults. Infants can be infected by passage through an
infected birth canal. Children can acquire the disease through sexual
play, molestation, and sexual abuse. The principal manifestation
of the uncomplicated infection is a urethral or vaginal discharge;
however, localized infections of the fallopian tubes, joints, conjunctiva,
and anus, as well as disseminated infection, can occur.
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The gonococcus is a gram-negative kidney bean–shaped
diplococcus, nonmotile and nonencapsulated, fastidious in its nutritional
requirements. It grows best aerobically in CO2 with increased
humidity on a medium of chocolate agar with antibiotics (Thayer-Martin
medium) that suppress the growth of other microorganisms.1,2 Gonococci
grow in small colonies that are easily identified; they elaborate
indophenoloxidase—the basis for identification by an oxidase
test. However, definitive identification (required in more complicated
clinical settings and for medicolegal purposes) requires the use
of specific fluorescein-conjugated antibody staining or sugar fermentation.
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Neisseria gonorrhoeae infects nonciliated columnar
and transitional epithelial cells.2 Attachment
to the cells is mediated by pili and the outer-membrane opacity
proteins. Within 24 to 48 hours after attachment, the organism synthesizes
enzymes to facilitate penetration to submucosal tissues. The host
produces a neutrophil response, which results in sloughing of the
epithelium, submucosal abscesses, and a purulent exudate. N
gonorrhoeae is capable of invading the bloodstream and
disseminating to other sites, such as the joints and meninges. Bacteremic
spread is also more likely to occur in conjunction with menstruation, which
facilitates spread to the upper genital tract (salpingitis). Deficiency
of one of the terminal components of the complement system (especially
factors 5, 6, 7, or 8) places the patient at increased risk of disseminated,
chronic, or recurrent gonococcal disease.3
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Gonococcal infections are limited to humans, and transmission
is almost always sexual (genital, anal, or oral). Over the past
two decades, there was a steady decline in reported gonorrhea cases;
however, in 2005 and 2006 rates of gonorrhea in the United States
increased.4 Rates varied by age: In those younger
than 1 year old, rates were 5/100,000, and in children
1 to 4 years of age rates were 0.82/100,000. In children
5 to 14 years of age, rates were 11/100,000. Rates were
highest in adolescents and young adults ages 15 to 24 years at 490/100,000.4 Sexual
transmission and risk factors for goncoccal infection are further
discussed in Chapter 233. Overall, the highest rates
were in the 20- to 24-year-old age group.5 For
sex-specific rates, females ages 15 to 19 years and 20 to 24 years
had the highest rates of gonorrhea (648/100,000 and 606/100,000,
respectively), and for males the highest rates were in 20- to 24-year-old
males at 454/100,000. In past years, gonorrhea rates in those
15 to 19 years old had decreased, but in 2006, the rate increased
by 6.3%.5 Sexual transmission ...