Background.
Gonorrhea is an important public health problem, a purulent infection of the mucosal surface caused by the Gram-staining-negative diplococcus Neisseria gonorrhoeae. Sexual contact is the most common mode of transmission and can also be transmitted to the child through the mother’s genital tract during delivery, causing neonatal ophthalmia and systemic neonatal infections.
In women, the cervix is the most common site of infection, causing cervicitis and urethritis, which can be complicated by pelvic inflammatory disease. In men, it can cause anterior urethritis. Streptococci can also cause limited and disseminated disease through the body. Complications include ectopic pregnancy and increased HIV infection. It occurs most often in sexually active people.
In pediatrics, gonorrhea is even more important because.
STDs are common among sexually active adolescents and are preventable; neonatal birth canal infections occur during delivery; and contribute to the investigation of legal incidents of sexual assault.
Gonococcal haemorrhage.
Gonococcal bacteremia is the presence of Neisseria gonorrhoeae in the bloodstream, resulting in disseminated streptococcal infection. It occurs in 0.5-3% of the population. The clinical presentation is biphasic, with early bacteraemia presenting as tenosynovitis, arthralgia, and dermatitis, followed by a localized phase of infection including restrictive septic arthritis. Other serious complications include osteomyelitis, meningitis, endocarditis, adult respiratory distress syndrome, and fatal septic shock. Polymyositis is rare.
Women who are pregnant or menstruating are susceptible to gonococcal bacteremia. Other risk factors include complement deficiency, HIV infection, and systemic lupus erythematosus.
Pathophysiology.
Different types of gonococci have different characteristics of antigenicity based on surface antigens. Certain subtypes can evade the immune response and predispose to disseminated infection.
Plasmids carrying drug-resistant genes, most commonly penicillinase. Plasmid and non-plasmid genes are freely transmitted between subtypes. Resulting in a host susceptible to reinfection. Exchange of resistance genes leads to high levels of β-lactamase antibiotic resistance. Fluoroquinolone resistance has been seen in several regions.
Infections of the lower genital tract are most common, manifesting as urethritis in men and cervicitis in women. Infections can also occur in the pharynx, rectum, and female urethra, but are likely to be asymptomatic or mild. 20% of women with gonococcal cervicitis develop retrograde streptococcal infection, leading to pelvic inflammatory disease, tubal inflammatory disease, endometritis, and/or tubo-ovarian abscesses. Retrograde infections can lead to peritonitis and perihepatitis.
Up to 25% of patients with pelvic inflammatory disease develop long-term sequelae, such as tubal infertility, ectopic pregnancy, and chronic pain. Epididymitis or epididymal-orchitis can occur after gonorrheal urethritis in men. Infections of the lower genital tract also increase the chances of other STD infections, such as HIV.
Conjunctivitis can occur in subadults as well as children, is associated with direct contact infection (usually hand-eye contact), and can lead to blindness.
Etiology.
The gonococcus infects the columnar or cuboidal epithelium of the host through sexual contact. Virtually any mucosa can be infected. Physiological displacement of the squamous-columnar junction zone of the endometrium is a factor that predisposes young women to gonococcal infection.
Other factors that influence gonococcal virulence and pathogenicity are flagellin, which mediates gonococcal adhesion to the mucosal surface and prevents phagocytosis and neutrophil destruction. Opaque associated protein (Opa) increases adhesion of gonococci and macrophages, promotes host cell infection, and downregulates the immune response.
Pore proteins (porA and porB) on the outer membrane play a key role in virulence. Gonococci carrying porA can resist normal human serum and increase invasiveness.
Certain acquired plasmids and genetic variants increase virulence. tEM-1 type β-lactamase affects penicillin binding and promotes penicillin efflux, leading to penicillin resistance in gonococci. tetM protects ribosomes, leading to tetracycline resistance. gyrA and parC genes lead to resistance to fluoroquinolones.
Gonococci adhere to host mucosal cells via flagellin and Opa proteins and, within 24-48 hours, cross the cellular and intercellular space into the subepithelial space. The host response includes neutrophils, followed by epithelial shedding and the formation of subepithelial microabscesses and purulent exudates. If left untreated, macrophages and lymphocytes replace neutrophil infiltration. Some gonococci can cause asymptomatic infections, called asymptomatic carriers.
Gonococci can grow in anaerobic conditions and when mixed with menstrual blood or adherent sperm, can then infect and invade the lower genital tract (vagina and cervix) and further upstream to other organs (endometrium, fallopian tubes, ovaries).
Transmission routes.
(1) Direct vaginal, anal, and oral mucosal contact transmission occurs during sexual contact. The mucous membranes can also be infected through fingers or other objects. Penile-rectal contact is very susceptible to infection.
Nearly 20% of men who come into contact with a gonococcal-infected woman can be infected in just one encounter, and the infection rate can rise to 60-80% if four or more sexual encounters occur. For every 1 contact with men infected with gonococcus, women have a 50-70% chance of being infected.
(2) Neonatal and pediatric gonococcal infections.
Neonatal gonococcal infections are secondary to conjunctival infections and are transmitted through the birth canal. In addition, direct infection can occur through fetal testing electrodes in the scalp area.
Infection can occur in children through sexual assault or transmission through non-sexual contact in the home or in public places.
(3) Self-inoculation.
Infection occurs through contact with the infected site and then contact with skin or mucous membranes.
Risk factors include.
Unprotected or failed protective measures; multiple sexual partners; gay men; low socioeconomic status; minorities in the United States; comorbid or prior history of STDs; transactional sexual contact; cocaine use; early sexual activity; pelvic inflammatory disease – use of IUDs.
Prognosis.
Early and adequate treatment leads to complete cure and recovery. Most patients respond quickly to cephalosporin antibiotics. Late, delayed or inappropriate treatment may lead to complications.
(1) Male complications.
Urethral stricture, which has become uncommon in the antibiotic era. Other complications include penile lymphangitis, periurethral abscess, acute prostatitis, vesiculitis, prepuce gland and urethral bulb gland infections, which are now rare.
(2) Female complications.
Tubal scarring and infertility are the main complications. 1 episode of pelvic inflammatory disease can lead to infertility in 15% of patients and 3 episodes of pelvic inflammatory disease can lead to infertility in 50-80% of patients. However, infertility is more commonly seen in chlamydial pelvic inflammatory disease and may be related to the obvious symptoms of gonococcal pelvic inflammatory disease and therefore prompt diagnosis and treatment.
Undiagnosed pelvic inflammatory disease can present with acute complications such as tubo-ovarian abscesses, endometritis, perihepatitis, and other chronic complications. Perihepatitis presents with right upper abdominal pain and nausea.
Patients with tubal infections have a 7-10 times higher chance of ectopic pregnancy.
Gonococcal infections in women can also present with gonococcal urethritis or periurethritis or pachymeningitis.
Pelvic inflammatory disease is the most dreaded complication in women at the time of infection, causing female infertility and hospitalization.
(3) Epididymitis and orchitis.
Epididymitis and orchitis can occur in untreated men. The use of a treatment regimen with non-complicated UTIs usually results in good outcomes, but the medication takes longer to administer.
(4) Arthritis.
The most common cause of juvenile arthritis is clinically rare. Other causes of septic arthritis need to be excluded.
(5) Other complications.
Ocular gonococcal infection results in corneal scarring; gonococcal endocarditis leads to heart valve destruction; endocarditis leads to congestive heart failure; gonococcal meningitis leads to central nervous system infection; and oral sex can lead to pharyngitis. Similarly, anal intercourse can cause local spread of infection.
Patient education.
Avoid sexual contact until treatment is completed and refrain from sexual contact until sexual partners have been thoroughly examined and treated. Avoid unprotected sexual contact.
Abstinence is the most effective measure to prevent STDs.
Unprotected sexual contact can lead to infection not only with gonorrhea, but also with other lifelong diseases such as herpes, hepatitis B, and HIV.