Neisseria gonorrhoeae : Clinical manifestations

Neisseria gonorrhoeae : Clinical manifestations


Introduction

  • MC cause of PID worldwide
  • MC cause of PID in India is TB
  •  MC cause of septic arthritis in adult [MC joint knee].
  • Cause most severe type of ophthalmia neonatorum

Complement deficiency and neisserial infections

  • The complement system :
  • Component of the innate immune defence against infection by Neisseria.
  • Lack or deficiency in complement ,susceptible to neisserial diseases.
  • Deficiencies 
  • Terminal complement component (C5 through C9) deficiencies
  • Deficiencies of the alternative pathway (Properdin, C3, Factor D)

Incubation period

  • 3 – 7 days

Epithelium most commonly affected :

  • Columnar epithelium
  • Transitional epithelium

Primary sites of infection :

  • Endocervix
  • Urethra
  • Skene’s gland
  • Bartholins gland
  • Others :
  • Oropharynx
  • Anorectal region
  • Conjunctiva.

Resistant 

  • Squamous epithelium is resistant to gonococcal invasion.
  •  Vaginitis in adults is not possible but vulvo­vaginits is possible in childhood. 

Vulvo vaginitis in children

  • Gonococal invasion of non keratinised membranes 
  • In prepubertal girls produces severe vulvo vaginitis.
  • The typical sign is a purulent vaginal discharge with dysuria.
  • The genital mucous membranes are red and swollen.
  • Infection is commonly introduced by adults
  • In such cases the physicians must consider the possibility of child abuse. 

Gonococcal infection in males

  • Acute urethritis
  • Acquired by sexual contact
  • They adhere to the mucosal surface
  • Penetrate to the intracellular spaces
  • Reach the subepithelial connective tissue.
  • Urethral stricture may occur as a complication of gonococcal urethritis.
  • Gonococci may extend to seminal vesicle and epididymis, along the urethra.
  • Mucopurulent discharge per urethra .
  • Prostate and rectum are not resistant to gonococci
  • Penis most  resistant.
  • Asymptomatic carriage of gonococci is rare in men.

Gonococcal infection in females:

  • Cervicitis
  • Adult vagina is resistant to gonococcal infection
  • Acquired by sexual contacts
  • Affects the mucous membran endocervix and urethra in females.
  • Clinical disease as a rule is less severe in females.
  • Cause asymptomatic infection.
  • Asymptomatic carriage in women makes them a reservoir serving to perpetuate infection among their male contacts.

PID

  • If Gonococcal infections are asymptomatic or unrecognized may progress to PID.

Fitz — Hugh Curtis syndrome

  • Occurs due to direct extension of the organism
  • Through fallopian tube to liver 
  • Liver capsule inflammation leading to the creation of adhesions.

Post-gonococcal urethritis

  • Chlamydia, Mycoplasma, and Ureaplasma are not effectively treated by penicillins and cephalosporins, and are important causes .

Gonorrhea in pregnant woman

  • Salpingitis and PID can occur during 1st trim
  • Can cause abortion.

Gonococcal infection in neonates:

  • Opthalmia-neonatorum

Septic arthitis

  • Main manifestation of systemic infection
  • Occurs in 5 – 3% of persons with untreated gonococcal infection.
  • Joint or tendon pain with decreased mobility. 
  • The knee is the most common site of purulent gonococcal arthritis.

Disseminated gonococcal infection (gonococcaemia) :

  • Septic arthitis
  • Skin rash
  • Small papules that turn into pustules on broad erythematous bases and necrotic centres.
  •  It occur on the trunk, limbs, palms and soles (usually spares the face, scalp and mouth)
  • Haemorrhagic lesions, erythema nodosum, urticaria, and erythema multiforme occur less frequently.
  • Fever, chills and malaise
  • Other organs involved are liver and heart.
Exam Question
 
  • Exclusive human pathogen
  • Some strains may cause disseminated disease
  • Acute urethritis is the most common manifestation in males
  • N. gonorrhea causes Salpingitis and Cervicitis
  • Asymptomatic carriage of gonococcal infection in female is commonly seen  endocervix
  • Gonococcal vaginitis occurs in in children
  • Most patients present with symptoms of dysuria in gonococcal urethritis
  • Gonococcal infection spreads by  ascending route and Involvement of adjacent structures
  • Vagina is not affected by gonococcal infections 
  • Chlamydia trachomatis can be isolated in up to 50% of women with gonorrhoea and because women treated for gonorrhoea only may soon go on to develop Chlamydia or pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhoea should also be treated for Chlamydia
  • Recurrent Neisseria infections are predisposed by late complement component deficiency
  • Complement necessary for neisseria infection are C5, C6 and C7

gonococcal urethritis

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