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Emergency And Acute Medicine - Gonococcal Disease
Basics Description
Gonococcal disease is the second most frequently reported sexually transmitted infection in the United States, with an estimated 820,000 new cases annually and fewer than half reported. The highest incidence occurs in males and females aged 15–24 years, particularly among African Americans. Rates are increasing among men who have sex with men, especially those who are HIV-positive. Humans are the only known host. Coinfection with Chlamydia trachomatis is common. Infection may involve the urethra, rectum, cervical canal, pharynx, upper female genital tract, and conjunctiva. Urethritis is the most common presentation in men, while infection is often asymptomatic in women.
Etiology
The causative organism is Neisseria gonorrhoeae, a gram-negative aerobic diplococcus.
Diagnosis Signs And Symptoms
Cervicitis is defined by mucopurulent endocervical discharge or easily induced endocervical bleeding and is the most common site of infection. Up to 80% of women are asymptomatic, with nonspecific symptoms such as vaginal discharge, menorrhagia, pelvic pain, dyspareunia, urinary frequency, and dysuria.
Pelvic inflammatory disease develops in up to 20% of untreated cases, most commonly presenting with lower abdominal pain. Other symptoms include dyspareunia, abnormal bleeding or discharge, fever, and onset around menses. Fitz-Hugh–Curtis syndrome occurs in about 10% and presents with right upper quadrant pain. Bartholin abscess may also occur.
Urethritis typically has a 2–5 day incubation period and presents with penile discharge and dysuria; untreated cases may progress to prostatitis or epididymitis, which presents with acute unilateral testicular pain and swelling.
Proctitis is often asymptomatic and may be the only site of infection in many men who have sex with men. Rectal infection occurs in 35–50% of women with endocervical infection and significantly increases HIV acquisition risk. Symptoms include perianal pruritus, mucopurulent discharge, rectal bleeding, pain, tenesmus, and constipation.
Pharyngitis may present with sore throat or exudative tonsillitis.
Disseminated gonococcal infection occurs in 0.5–3% of untreated mucosal infections and presents with the triad of tenosynovitis, dermatitis, and polyarthralgia, often accompanied by fever, chills, and malaise. Dermatitis consists of tender necrotic pustules on an erythematous base. Septic arthritis typically affects the knee. Females are affected more commonly than males, with recent menstruation or pregnancy as risk factors. Rare complications include hepatitis, myocarditis, endocarditis, and meningitis.
Physical examination may reveal cervical friability and edema, uterine or adnexal tenderness in PID, and thick yellow-white urethral discharge with meatal erythema in urethritis.
Essential Workup
In symptomatic men, diagnosis is often clinical with Gram stain, which has high sensitivity. In women, cervical culture is recommended. Testing for chlamydia and syphilis should always be performed.
Diagnosis Tests And Interpretation
Cultures on Thayer-Martin medium remain the gold standard, particularly for blood and synovial fluid. Gram stain demonstrating intracellular gram-negative diplococci is highly sensitive in symptomatic men. Nucleic acid amplification tests using PCR are widely used for urethral, cervical, and urine specimens and frequently test for chlamydia concurrently. Pharyngeal and rectal cultures are indicated in symptomatic or high-risk patients.
In disseminated infection, synovial fluid typically shows neutrophilic leukocytosis, and multiple blood cultures should be obtained. Women with PID require CBC, urinalysis, pregnancy testing, and consideration of pelvic ultrasound to evaluate for tubo-ovarian abscess. Rapid plasma reagin testing is indicated to assess for syphilis.
Differential Diagnosis
Urethritis due to chlamydia, trichomonas, urinary tract infection, or syphilis; septic arthritis from other organisms; connective tissue diseases; poststreptococcal arthritis; viral infections; gout; HIV; secondary syphilis; and Lyme disease.
Treatment Ed Treatment Procedures
Provide IV fluids for dehydration or vomiting. Sexual partners should be treated, including expedited partner therapy where legally permitted. Patients are often treated empirically for chlamydial infection.
Uncomplicated cervical, urethral, or anorectal infection is treated with ceftriaxone 250 mg IM once plus azithromycin 1 g PO once or doxycycline 100 mg PO BID for 7 days.
Pelvic inflammatory disease may be treated as an outpatient with ceftriaxone or another third-generation cephalosporin plus doxycycline with or without metronidazole, or as an inpatient with IV cephalosporin-based or clindamycin-gentamicin regimens.
Pharyngitis is treated with ceftriaxone plus chlamydia coverage.
Epididymitis requires ceftriaxone plus doxycycline for 10 days.
Disseminated gonococcal infection is treated with ceftriaxone 1 g IV or IM daily, followed by oral therapy after clinical improvement.
Neonatal infections, conjunctivitis, meningitis, and endocarditis require weight-based or prolonged IV cephalosporin therapy. Severe cephalosporin allergy warrants infectious disease consultation.
Follow-Up Disposition
Admission is indicated for severe PID, pregnancy, inability to tolerate oral therapy, lack of response to outpatient treatment, tubo-ovarian abscess, or diagnostic uncertainty requiring surgical evaluation.
Patients with uncomplicated genital, pharyngeal, or conjunctival infection may be discharged after treatment.
Issues For Referral
Referral is indicated for infertility evaluation or recurrent infection despite appropriate therapy.
Key Clinical Insights And Common Errors
Always exclude testicular torsion in patients presenting with epididymitis. Disseminated gonococcal infection should be strongly considered in young, sexually active patients with acute, nontraumatic oligoarthritis or tenosynovitis, as delayed recognition can lead to significant morbidity.
Basics Description
Gonococcal disease is the second most frequently reported sexually transmitted infection in the United States, with an estimated 820,000 new cases annually and fewer than half reported. The highest incidence occurs in males and females aged 15–24 years, particularly among African Americans. Rates are increasing among men who have sex with men, especially those who are HIV-positive. Humans are the only known host. Coinfection with Chlamydia trachomatis is common. Infection may involve the urethra, rectum, cervical canal, pharynx, upper female genital tract, and conjunctiva. Urethritis is the most common presentation in men, while infection is often asymptomatic in women.
Etiology
The causative organism is Neisseria gonorrhoeae, a gram-negative aerobic diplococcus.
Diagnosis Signs And Symptoms
Cervicitis is defined by mucopurulent endocervical discharge or easily induced endocervical bleeding and is the most common site of infection. Up to 80% of women are asymptomatic, with nonspecific symptoms such as vaginal discharge, menorrhagia, pelvic pain, dyspareunia, urinary frequency, and dysuria.
Pelvic inflammatory disease develops in up to 20% of untreated cases, most commonly presenting with lower abdominal pain. Other symptoms include dyspareunia, abnormal bleeding or discharge, fever, and onset around menses. Fitz-Hugh–Curtis syndrome occurs in about 10% and presents with right upper quadrant pain. Bartholin abscess may also occur.
Urethritis typically has a 2–5 day incubation period and presents with penile discharge and dysuria; untreated cases may progress to prostatitis or epididymitis, which presents with acute unilateral testicular pain and swelling.
Proctitis is often asymptomatic and may be the only site of infection in many men who have sex with men. Rectal infection occurs in 35–50% of women with endocervical infection and significantly increases HIV acquisition risk. Symptoms include perianal pruritus, mucopurulent discharge, rectal bleeding, pain, tenesmus, and constipation.
Pharyngitis may present with sore throat or exudative tonsillitis.
Disseminated gonococcal infection occurs in 0.5–3% of untreated mucosal infections and presents with the triad of tenosynovitis, dermatitis, and polyarthralgia, often accompanied by fever, chills, and malaise. Dermatitis consists of tender necrotic pustules on an erythematous base. Septic arthritis typically affects the knee. Females are affected more commonly than males, with recent menstruation or pregnancy as risk factors. Rare complications include hepatitis, myocarditis, endocarditis, and meningitis.
Physical examination may reveal cervical friability and edema, uterine or adnexal tenderness in PID, and thick yellow-white urethral discharge with meatal erythema in urethritis.
Essential Workup
In symptomatic men, diagnosis is often clinical with Gram stain, which has high sensitivity. In women, cervical culture is recommended. Testing for chlamydia and syphilis should always be performed.
Diagnosis Tests And Interpretation
Cultures on Thayer-Martin medium remain the gold standard, particularly for blood and synovial fluid. Gram stain demonstrating intracellular gram-negative diplococci is highly sensitive in symptomatic men. Nucleic acid amplification tests using PCR are widely used for urethral, cervical, and urine specimens and frequently test for chlamydia concurrently. Pharyngeal and rectal cultures are indicated in symptomatic or high-risk patients.
In disseminated infection, synovial fluid typically shows neutrophilic leukocytosis, and multiple blood cultures should be obtained. Women with PID require CBC, urinalysis, pregnancy testing, and consideration of pelvic ultrasound to evaluate for tubo-ovarian abscess. Rapid plasma reagin testing is indicated to assess for syphilis.
Differential Diagnosis
Urethritis due to chlamydia, trichomonas, urinary tract infection, or syphilis; septic arthritis from other organisms; connective tissue diseases; poststreptococcal arthritis; viral infections; gout; HIV; secondary syphilis; and Lyme disease.
Treatment Ed Treatment Procedures
Provide IV fluids for dehydration or vomiting. Sexual partners should be treated, including expedited partner therapy where legally permitted. Patients are often treated empirically for chlamydial infection.
Uncomplicated cervical, urethral, or anorectal infection is treated with ceftriaxone 250 mg IM once plus azithromycin 1 g PO once or doxycycline 100 mg PO BID for 7 days.
Pelvic inflammatory disease may be treated as an outpatient with ceftriaxone or another third-generation cephalosporin plus doxycycline with or without metronidazole, or as an inpatient with IV cephalosporin-based or clindamycin-gentamicin regimens.
Pharyngitis is treated with ceftriaxone plus chlamydia coverage.
Epididymitis requires ceftriaxone plus doxycycline for 10 days.
Disseminated gonococcal infection is treated with ceftriaxone 1 g IV or IM daily, followed by oral therapy after clinical improvement.
Neonatal infections, conjunctivitis, meningitis, and endocarditis require weight-based or prolonged IV cephalosporin therapy. Severe cephalosporin allergy warrants infectious disease consultation.
Follow-Up Disposition
Admission is indicated for severe PID, pregnancy, inability to tolerate oral therapy, lack of response to outpatient treatment, tubo-ovarian abscess, or diagnostic uncertainty requiring surgical evaluation.
Patients with uncomplicated genital, pharyngeal, or conjunctival infection may be discharged after treatment.
Issues For Referral
Referral is indicated for infertility evaluation or recurrent infection despite appropriate therapy.
Key Clinical Insights And Common Errors
Always exclude testicular torsion in patients presenting with epididymitis. Disseminated gonococcal infection should be strongly considered in young, sexually active patients with acute, nontraumatic oligoarthritis or tenosynovitis, as delayed recognition can lead to significant morbidity.
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