Neisseria gonorrhoeae : Clinical manifestations

Neisseria gonorrhoeae : Clinical manifestations

Q. 1

Asymptomatic carriage of gonococcal infection in female is commonly seen in :

 A

Endocervix

 B

Vagina

 C

Urethra

 D

Fornix

Q. 1

Asymptomatic carriage of gonococcal infection in female is commonly seen in :

 A

Endocervix

 B

Vagina

 C

Urethra

 D

Fornix

Ans. A

Explanation:

Endocervix


Q. 2

Gonococcal vaginitis occurs in :

 A

Adults

 B

Infants

 C

Children

 D

Adolescents

Q. 2

Gonococcal vaginitis occurs in :

 A

Adults

 B

Infants

 C

Children

 D

Adolescents

Ans. C

Explanation:

Ans. is b i.e. Children  

  • Gonorrohea infection is caused by Neisseria gonorrheae – a gram negative diplococci.
  • 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.

  • Squamous epithelium is resistant to gonococcal invasion. So, 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 and in such cases the physicians must consider the possibility of child abuse.


Q. 3

Gonococcal infection spreads by :

 A

Ascending route

 B

Hematogenous route

 C

Involvement of adjacent structures

 D

Option A and C both

Q. 3

Gonococcal infection spreads by :

 A

Ascending route

 B

Hematogenous route

 C

Involvement of adjacent structures

 D

Option A and C both

Ans. D

Explanation:

Option A and C both


Q. 4

One of the following in adult female genital tract is not affected by gonococcal infections :

 A

Vulva

 B

Vagina

 C

Cervix

 D

Fallopian tube

Q. 4

One of the following in adult female genital tract is not affected by gonococcal infections :

 A

Vulva

 B

Vagina

 C

Cervix

 D

Fallopian tube

Ans. B

Explanation:

Vagina


Q. 5 A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient’s gonorrhea infection, treatment must also be given for which of the following?
 A Bacterial vaginosis
 B Chlamydia
 C Herpes
 D Syphilis
Q. 5 A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient’s gonorrhea infection, treatment must also be given for which of the following?
 A Bacterial vaginosis
 B Chlamydia
 C Herpes
 D Syphilis
Ans. B

Explanation:

This patient has a gonorrhea infection. It is more common in patients of lower socioeconomic status, patients with multiple sexual partners, and in urban settings. The causative organism is N. gonorrhoeae, a gram-negative aerobic diplococcus. Up to 80% of women that are infected with the organism will have no symptoms at all or only vague symptoms. Symptoms that are frequently noted are vaginal discharge, postcoital spotting, and urinary symptoms if the urethra is involved. Examination may reveal a cervicitis, although this is not always present. A patient found to have gonorrhea should be treated with intramuscular ceftriaxone or oral cefixime, ofloxacin, or ciprofloxacin. These medications will effectively eradicate the gonococcus. However, because Chlamydia trachomatis can be isolated in up to 50% of women with gonorrhea and because women treated for gonorrhea only may soon go on to develop Chlamydia or pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea should also be treated for Chlamydia. Treatment of Chlamydia is with azithromycin or doxycycline. It is alsoessential that this patient’s partner be treated as well. When treating a patient for gonorrhea, there is no need to treat the patient with metronidazole to treat bacterial vaginosis as well, unless there is evidence of a bacterial vaginosis. Herpes often presents as painful vesicles and ulcers. Patients with ameonorrhea do not need to be treated for herpes as well, unless there is evidence for herpes infection. Patients with gonorrhea are at increased risk of having other sexually transmitted diseases, including syphilis. It would be prudent to check this patient for syphilis with a blood test. However, in the absence of a positive syphilis test, patients with gonorrhea do not need to be treated for syphilis.


Q. 6

Which of the following is not true about Neisseria gonorrhoeae ‑

 A It is an exclusive human pathogen
 B Some strains may cause disseminated disease
 C Acute urethritis is the most common manifestation in males
 D All strains are highly sensitive to penicillin
Q. 6

Which of the following is not true about Neisseria gonorrhoeae ‑

 A It is an exclusive human pathogen
 B Some strains may cause disseminated disease
 C Acute urethritis is the most common manifestation in males
 D All strains are highly sensitive to penicillin
Ans. D

Explanation:

All strains are highly sensitive to penicillin [Ref : Anantnarayan 8th/e p. 227-228; Harrison 17th/e p. 916-918; Jawetz 23″1/e p. 300]

  • Gonorrhoea is a gram negative organism.
  • The genus Neisseria contains two important human pathogens

N. gonorrhoea

– N. meningitides

  • Neisseria gonorrhoea causes gonorrhoea and Neisseria meningitides causes meningitis.
  • Neisseria gonorrhoea infections have a high prevalence and low mortality where as N. meningitides infections have low prevalence and high mortality.
  • Many Neisseria species are a part of normal flora in humans and animals.
  • Neisseria meningitides .frequently occurs in a carrier state in the absence of any disease.
  • However, Neisseria Gonorrhoea is an “obligate pathogen” and is never part of the normal human flora under any circumstances.

Gonococci is exclusive to humans

  • Gonorrhoea is an exclusive human disease, there being no natural infection in animals.
  • The only source of infection is a human carrier or less often a patient. In women gonococcus usually cause asymptomatic infection wheras in men the infection is usually symptomatic.

Clinical features of Gonococcal infection:-

  • Neisseria Gonorrhoea infection is acquired by sexual contacts and usually affects the mucous membrane of the urethra in males and endocervix and urethra in females.
  • They mainly affect the host’s columnar or cuboidal epithelium.

The vaginal mucosa is usually not affected in the adults because the stratified squamous epithelium is resistant to infection by the cocci and also because of the acid pH of vaginal secretions.

Clinical disease as a rule is less severe in females.

In women gonococcus usually cause “asymptomatic infection” the existence of asymptomatic carriage in women makes them a reservoir serving to perpetuate infection among their male contacts.

Gonococcal infection in men is usually “symptomatic”.
In men the disease starts as an acute urethritis.

PID

1f gonococcal infections

are asymptomatic or

unrecognized may

progress to P.1.D.

Fitz — Hugh Curtis syndrome

– Occurs due to direct

extension of the

organism through

fallopian tube to liver

Treatment of Gonorrhoea 😕

  • “Penicillin is ineffective in treatment of Gonorrhoea as most of the strains are resistant to penicillin because penicillinase producing N. gonorrhoea have spread widely”.

Neisseria Gonorrhoea has become resistant to numerous antibiotics because 😕

a)  It has got remarkable capacity to alter its antigenic structure.

b)  It can easily adopt to changes in microenvironment.

“Now the treatment of choice for gonococcal infection is ceftriaxone”.

  • “Quinolones” are the drug of choice for penicillin allergy.
  • In Patients who cannot tolerate both cephalosporin and quinolones, spectinomycin is the D.O.C.

Gonococcal infection: DOC

•  D.O.C.

-Ceftriaxonc

•  D.O.C. for penicillin allergey

-*Quinolones

•  If cannot tolerate both cephalosporins

and Quinolones

—4 Spectinomycin


Q. 7

Which of the following organisms is most likely to be implicated as a cause of urethritis that persists after antibiotic therapy for gonorrhea?

 A

Actinomyces

 B

Chlamydia

 C

Mycobacteria

 D

Nocardia

Q. 7

Which of the following organisms is most likely to be implicated as a cause of urethritis that persists after antibiotic therapy for gonorrhea?

 A

Actinomyces

 B

Chlamydia

 C

Mycobacteria

 D

Nocardia

Ans. B

Explanation:

Chlamydia, Mycoplasma, and Ureaplasma are not effectively treated by penicillins and cephalosporins, and are important causes of post-gonococcal urethritis. Chlamydial urethritis can be diagnosed by using fluorescent antibodies to identify inclusions in epithelial cells.
 
Actinomyces is a mouth commensal that rarely causes a deeper oral infection.
 
Mycobacteria cause chronic granulomatous diseases such as tuberculosis and leprosy.
 
Nocardia can cause necrotizing pneumonia and disseminated disease.

 


Q. 8

Recurrent Neisseria infections are predisposed by –

 A

Early complement component deficiency

 B

Late complement component deficiency

 C

C I esterase deficiency

 D

All

Q. 8

Recurrent Neisseria infections are predisposed by –

 A

Early complement component deficiency

 B

Late complement component deficiency

 C

C I esterase deficiency

 D

All

Ans. B

Explanation:

Ans. is ‘b’ i.e., Late complement component deficiency

Complement Deficiencies and Associated Diseases

Component                                  Associated Diseases

CLASSIC PATHWAY

C I q, Clr, C1 S, C4                     Immune-complex syndromes, “pyogenic infections”

C2                                                  Immune-complex syndromes, “few with pyogenic infections”

C I inhibitor                                  Rare immune-complex diseases, few with pyogenic infections

C3 ANDALTERNATIVE PATHWAY C3

C3                                                  Immune-complex syndrome, “pyogenic infections”, Neisseria infections

D                                                     Pyogenic infections, Neisseria infections

Properdin                                      Neisseria infections

I                                        Pyogenic infections

H                                                    Hemolytic uremic syndrome

MEMBRANE ATTACK COMPLEX

C5, C6, C7, C8                            Recurrent Neisseria infections, immune-complex disease

C9                                                  Rare Neisseria infections


Q. 9

Complement necessary for neisseria infection is/ are –

 A

C5

 B

C6

 C

C7

 D

All

Q. 9

Complement necessary for neisseria infection is/ are –

 A

C5

 B

C6

 C

C7

 D

All

Ans. D

Explanation:

Ans. is All ‘a’ i.e., C 5; ‘b’ i.e., C 6; ‘c’ i.e., C 7


Q. 10

N. gonorrhea causes –

 A

Urethritis

 B

Salpingitis

 C

Conjunctivitis

 D

All

Q. 10

N. gonorrhea causes –

 A

Urethritis

 B

Salpingitis

 C

Conjunctivitis

 D

All

Ans. D

Explanation:

Ans. is All-`a’ i.e., Urethritis; ‘b’ i.e., Salpingitis; ‘c’ i.e., Cervicitis


Q. 11

All are true about Neisseria gonorrhoeae except ‑

 A

Gram positive cocci

 B

Cause stricture of urethra

 C

Involves seminal vesicles and spreads to epididymis

 D

Drug of choice is ceftriaxone

Q. 11

All are true about Neisseria gonorrhoeae except ‑

 A

Gram positive cocci

 B

Cause stricture of urethra

 C

Involves seminal vesicles and spreads to epididymis

 D

Drug of choice is ceftriaxone

Ans. A

Explanation:

Ans. is ‘a’ i.e., Gram positive cocci 

  • Gonocci are gram negative diplococci.
  • Urethral stricture may occur as a complication of gonococcal urethritis.
  • Gonococci may extend to seminal vesicle and epididymis, along the urethra.
  • For uncomplicated gonorrhea, single dose of ceftriaxone is DOC.

Q. 12

Which is the true statement regarding gonococcal urethritis –

 A

Symptoms are more severe in females than in males

 B

Rectum and prostate are resistant to gonococci

 C

Most patients present with symptoms of dysuria

 D

All

Q. 12

Which is the true statement regarding gonococcal urethritis –

 A

Symptoms are more severe in females than in males

 B

Rectum and prostate are resistant to gonococci

 C

Most patients present with symptoms of dysuria

 D

All

Ans. C

Explanation:

Ans. is ‘c  i.e., Most patients present with symptoms of dysuria 

  • urinary frequency or urgency are the major symptoms.
  • Single doses of ciprofloxacin, ofloxacin or levofloxacin are effective first line regimens.
  • Prostate and rectum are not resistant to gonococci, as proctitis and prostitis can occur as complications of gonococcal urethritis.
  • Clinical disease is as a rule less severe in women, many of whom may carry gonococci in the cervix without any symptoms. Asymptomatic carriage of gonococci is rare in men.
  • DGI or gonococcal arthritis occurs in .5 – 3% of persons with untreated gonococcal infection.

Q. 13

A patient with conjunctival infection, which lead to corneal perforation, was positive for Gram-negative coccoid appearance on Gram stain. Further investigation showed small translucent colourless organism which is oxidase positive. What could be the most probable causative organism-

 A

Moraxella catarrhalis

 B

Neisseria gonorrhea

 C

Psedomonas aeruginosa

 D

Acinetobacter actinatus

Q. 13

A patient with conjunctival infection, which lead to corneal perforation, was positive for Gram-negative coccoid appearance on Gram stain. Further investigation showed small translucent colourless organism which is oxidase positive. What could be the most probable causative organism-

 A

Moraxella catarrhalis

 B

Neisseria gonorrhea

 C

Psedomonas aeruginosa

 D

Acinetobacter actinatus

Ans. B

Explanation:

Ans. is ‘b’ i.e., Neisseria gonorrhea 


Q. 14

Which of the following is most resistant to gonococcal infection –

 A

Prostate

 B

Epididymis

 C

Testis

 D

Urethra

Q. 14

Which of the following is most resistant to gonococcal infection –

 A

Prostate

 B

Epididymis

 C

Testis

 D

Urethra

Ans. C

Explanation:

Ans. is ‘c’ i.e., Testis 


Q. 15

Neisseria infection are associated with ‑

 A

Deficiency of early complements 

 B

Deficiency of late complements

 C

There is no such association

 D

Any deficiency can be associated

Q. 15

Neisseria infection are associated with ‑

 A

Deficiency of early complements 

 B

Deficiency of late complements

 C

There is no such association

 D

Any deficiency can be associated

Ans. B

Explanation:

Ans. is `b’ i.e., Deficiency of late complements 


Q. 16

Post gonococcal stricture urethra is most commonly situated in the –

 A

Bulbar Urethra

 B

Penoscrotal Jn.

 C

Distal part of spongy urethra

 D

Just distal to external meatus

Q. 16

Post gonococcal stricture urethra is most commonly situated in the –

 A

Bulbar Urethra

 B

Penoscrotal Jn.

 C

Distal part of spongy urethra

 D

Just distal to external meatus

Ans. A

Explanation:

Ans. is ‘a’ i.e., Bulbar Urethra 


Q. 17

Incubation period of gonococcal ophthalmia neonatorum is:

 A

24 hours

 B

5-7 days

 C

7-10 days

 D

None of the above

Q. 17

Incubation period of gonococcal ophthalmia neonatorum is:

 A

24 hours

 B

5-7 days

 C

7-10 days

 D

None of the above

Ans. D

Explanation:

Ans. None of the above


Q. 18

All of the following are commonly involved in disseminated gonococcal infection except:

September 2006

 A

Joint and tendons

 B

Skin

 C

Brain

 D

Liver

Q. 18

All of the following are commonly involved in disseminated gonococcal infection except:

September 2006

 A

Joint and tendons

 B

Skin

 C

Brain

 D

Liver

Ans. C

Explanation:

Ans. C: Brain

Signs and symptoms of disseminated gonococcal infection (gonococcaemia) include:

  • Joint or tendon pain with decreased mobility. The knee is the most common site of purulent gonococcal arthritis.
  • Skin rash – this is a common complaint in about one quarter of patients with disseminated gonococcal infection. On examination, rash is usually present in all patients with the disease.
  • Usually 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.

It is important to remember that patients presenting with disseminated gonococcal infection may not show any localised signs and or symptoms at the primary site of mucosal infection.


Q. 19

Patient presents with discharge per urethrum and microscopy shows presence of intracytoplasmic gram negative cocci; what is the most probable diagnosis ?

 A

Gonorrhea

 B

Donovanosis

 C

Bacterial vaginosis 

 D

Syphilis

Q. 19

Patient presents with discharge per urethrum and microscopy shows presence of intracytoplasmic gram negative cocci; what is the most probable diagnosis ?

 A

Gonorrhea

 B

Donovanosis

 C

Bacterial vaginosis 

 D

Syphilis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Gonorrhea 

  • Presence of pus discharge per urethrum in males with presence of intracytoplasmic gram negative cocci are pointers to the presence of N. gonorrhea infection.

GONOCOCCAL INFECTION

  • N.Gonorrhoeae is an intracytoplasmic gram negative coccus.
  • N. gonorrhoeae is exclusively a human pathogen although chimpanzees have been infected artificially.
  • It is never found as a normal commensal although a proportion of those infected, particularly women, may remain asymptomatic.
  • Acute urethritis is most common manifestation. Purulent discharge per urethra is the most common manifestation.
  • The process may extend, along the urethra, to prostate, seminal vesicle, epididymis.

Q. 20

Most common genetic play in Neisseria infection is 

 A

Male gender

 B

HLA b27

 C

Complement deficiency

 D

IgA deficiency

Q. 20

Most common genetic play in Neisseria infection is 

 A

Male gender

 B

HLA b27

 C

Complement deficiency

 D

IgA deficiency

Ans. C

Explanation:

Ans. is ‘c’ i.e., Complement deficiency 

Complement deficiency and neisserial infections

  • The complement system is an essential component of the innate immune defence against infection by Neisseria (N. Meningitidis and N. gonorrhoeae).
  • People who lack or have a deficiency in complement mediated bactericidal activity are most susceptible to neisserial diseases.
  • Terminal complement component (C5 through C9) deficiencies and deficiencies of the alternative pathway (Properdin, C3,Factor D) have a strong effect on susceptibility to, as well as severity of, neisserial infections.
  1. Deficiency of terminal complement (C, – C9) component :- Deficiency of one of the terminal components that compose membrane attack complex (MAC) predisposes patients to infection with Neisseria meningitidis or Neisseria gonorrhoeae. However, N. meningitidis infection is more common.
  2. Deficiencies of terminal pathway :- Deficiencies in components of alternative pathway, namely properdin, C3 and factor D, have been associated with increased susceptibility, almost exclusively, to meningococcal infection (amongst Neisseria).


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