Body Systems
Neisseria Gonorrhoeae and Its Effects
Case Overview
21-year-old Naser recently hooked up with a new sexual partner. This morning he noticed a burning pain in his urethra during urination, followed by a yellow-white discharge. He decided to visit the student health clinic where the doctor asks Naser about his recent sexual history. He recounts that he had unprotected sexual intercourse with a new partner about one week ago. When asked, the new partner claims no knowledge of having any sexually transmitted infections. The doctor asks Naser to provide a urine sample to send to the Microbiology Laboratory. The laboratory report results positive for Neisseria gonorrhoeae. The doctor prescribes antibiotics for Naser and counsels him on safe sex practices and on the importance of encouraging his new partner to come in for testing too. Naser is advised that he will be contacted by public health to discuss any other sexual partners he might have.
Signs and Symptoms
- Characteristics experienced by the patient
- History of present illness
- Meanings of the laboratory results
Signs and Symptoms
Neisseria Gonorrhea (N. gonorrhea) is a sexually transmitted infection (STI) that can affect both males and females (1).
In males, common symptoms are dysuria, burning sensations, itching in the urethra during urination, itchy or sore throat and pain in the anus, and white, yellow or green discharge from the penis and testicular pain (2).
In women, common symptoms are dysuria, burning sensations, itching in the urethra during urination, itchy or sore throat and pain in the anus, lower abdominal pain, dyspareunia, white or yellow vaginal discharge, abnormal vaginal bleeding, and bartholinitis (2,3).
Common signs for women are Bartholin’s cyst because they are visible can be observed by healthcare professionals (3)
Common signs for men include swollen testicles (2)
It is important to note that N. gonorrhea does not always have symptoms, especially in women where they have a higher chance of being asymptomatic when compared to men (2). This is because gonococcal inflammation occurs at a different location than urination does and is less painful (4).
(5)
Figure 1:
Shows the primary site of infection highlighted in yellow, as well as the different signs and symptoms for men and women listed below.
History of Present Illness
Key elements include: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
To start, Naser noticed urethral pain and yellow-white discharge during urinating in the morning; no mention of further experience with symptoms was made in the case.
An important thing to note, which likely aided in diagnoses, was that Naser had unprotected sexual intercourse with a new partner about one week prior. However, new partner claimed no knowledge of any existing STIs
Symptoms of gonococcal infection present 2-14 days after sexual intercourse which align with Nasers timeline (6).
The doctor did not observe any sign during Nasers check up.
Meaning of Laboratory Results
Gonorrhea is usually diagnosed using Nucleic acid amplification tests (NAATs) (7).
This test Detects gonorrheal DNA in a urine sample and is optimal due to simplicity of the sampling procedure and and the high accuracy of the diagnostic test (7).
The test is examined microscopically to identify N. gonorrhoeae cells with gram staining(7).
The test is also capable of identifying antibiotic susceptibility of the infection.
(8)
Body Systems Affected
- Anatomical sites that could be affected by this infection
- How has normal physiology been disturbed
Anatomical Sites Affected By This Infection
In the case specifically, only Nasers urethra is affected as previously discussed.. However, gonorrhea has the potential to affect a list of other body parts (1)
Women specifically are at risk of gonorrhea spreading to their uterus and fallopian tubes, causing pelvic inflammatory disease (PID); severe cases of this can cause infertility (1).
How Has Normal Physiology Been Disturbed
Male:
IL-8, IL-6, IL-1β and TNF-α are produced causing inflammation upon infection of urethral epithelial cells (1).
Urethral dischargeis associated with polymorphonuclear neutrophils (PMN) recruitment and shedding of urethral epithelial cells.
Degranulation, phagosome maturation and expression of cell surface receptors as a result of porin can induce penile inflammation (1).
Female:
The pathogen can inactivate the complement system. Then, peptidoglycan and LOS stimulate the production of TNF cytokines leading to the shedding of ciliated fallopian tube epithelial cells (3).
If a pregnant women is left untreated, it can result in chorioamnionitis (4).
In the case specifically, the only normal physiological function which was disturbed was the urethra.
Gonorrhea’s phospholipase D promotes CR3 recruitment to the cell surface which causes actin remodelling and membrane ruffling and entry of the pathogen into the host cell (2).
(5)
Figure 2:
Shows a compilation of invasive methods employed by N. gonorrhoeae as well as the various cytokines and agents released by the pathogen and their function.
Treatment
What Antibiotics Might Have Been Given
Empiric treatment recommendations for uncomplicated gonococcal urogenital infection is:
One of Oral Cefixime (800 mg single dose) or Intramuscular Ceftriaxone (250 mg single dose)
PLUS
One of Oral Azithromycin (1 g single dose) or Oral Doxycycline (100 mg twice a day for 7 days) (1, 2, 3, 4).
An alternate treatment for those with cephalosporin allergy can be Oral Azithromycin (2 g single dose) or Intramuscular spectinomycin (2 g single dose) (1, 2, 3, 4)
Antibiotic Method of Treatment
Ceftriaxone works by inhibiting bacterial wall synthesis and N. gonorrhoeae is susceptible to ceftriaxone. (5)
Azithromycin works by inhibiting bacterial protein synthesis.
Doxycycline works by blocking various ribosomal subunits of bacteria and inhibiting protein synthesis (6).
Considerations For Antimicrobial Resistance
When considering antimicrobial resistance, the main treatment that is clinically discussed is azithromycin (3, 6).
This drug is removed from new STI guidelines by the CDC (3, 6).
Instead, it is recommended to take intramuscular ceftriaxone (500 mg single dose) (3, 6)
(7)
Following Up
Notifying Sexual Partners and Follow Up
Usually meant to determine where the infection started, and by identifying that, preventing further spread.
As seen in the case summary, at this stage public health follows up with the individual and discusses sexual partnerships, gets those involved treated, and minimizes the spread of the infection.
Public health and doctors highly recommend following up with sexual partners as they may also be infected and requiring treatment even if they report being asymptomatic (1).
Other Testing
Health professionals recommend being tested for STIs such as Chlamydia and Syphilis as well (2).
It is reported that there is an increased risk of co-infection between the bunch (2)
Other blood borne pathogens should be tested for as well since Gonorrhea also grants increased risk on both acquiring and transmitting HIV (2).
Recommendations For Safe Sex Practices
It is recommended that all those involved in a case of STI infection refrain from sexual activity for a minimum of seven days post antibiotic treatment and up to as long as all symptoms have subsided (3).
(4)
Reinfection
Re-infection is a very possible outcome in the future if Naser is not diligent when engaging in sexual intercourse. There is no immunity to gonorrhea and re-infection can occur by having sexual intercourse with someone who is positive for the infection.
Re-testing is critical three months post primary infection and will check to ensure the initial infection has successfully cleared the host and no re-infection has occurred (5).
It is important to note that permanent damage caused from the disease will never heal (5).
References For Question 1
1. McSheffrey GG, Gray-Owen SD. 2015. Chapter 82, Neisseria gonorrhoeae. In Tang YW, Sussman M, Liu DY, Poxton I, Schwartzman J(ed), Molecular Medical Microbiology, Second Edition (pp. 1471-1485). Academic Press. http://dx.doi.org/10.1016/b978-0-12-397169-2.00082-2
2. Gonorrhea: Causes, Symptoms, Treatment & Prevention. Cleveland Clinic. Last reviewed September 2, 2022. Accessed February 9, 2023. https://my.clevelandclinic.org/health/diseases/4217-gonorrhea
3. Ghanem K. 2022. Marrazzo, J., & Bloom, A, (Eds.). Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-neisseria-gonorrhoeae-infection-in-adults-and-adolescents#H790871163
4. Quillin SJ, Seifert HS. 2018. Neisseria gonorrhoeae host-adaptation and pathogenesis. Nature reviews Microbiology. 16(4). doi:10.1038/nrmicro.2017.169
5. Gonorrhea. Dr Ben Medical. https://dbclinic.com.sg/gonorrhea/. Published June 5, 2021. Accessed March 3, 2023.
6. What Are the Symptoms & Signs of Gonorrhea? Planned Parenthood. Accessed February 9, 2023. https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/gonorrhea/what-are-symptoms-gonorrhea
7. Gonorrhea guide: Screening and diagnostic testing - Canada.ca. Public Health Agency of Canada. Last modified April 28, 2022. Accessed February 9, 2023.
8.Gonorrhea. Learn About Gonorrhea | Chegg.com. https://www.chegg.com/learn/medicine-and-health/medical-terminology/gonorrhea. Accessed March 3, 2023.
References For Question 2
References For Question 3
References For Question 4 + Wiki
1. CDC, C. D. C. (2020, March 31). Just diagnosed? next steps after testing positive for gonorrhea or Chlamydia. Centers for Disease Control and Prevention. Retrieved February 10, 2023, from https://www.cdc.gov/std/prevention/NextSteps-GonorrheaOrChlamydia.htm
2. Canada, P. H. A. of. (2022, April 28). Government of Canada. Canada.ca. Retrieved February 10, 2023, from https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/gonorrhea/screening-diagnostic-testing.html
3. Springer, C., & Salen, P. (2022). Gonorrhea - StatPearls - NCBI Bookshelf. National Library of Medicine. Retrieved February 11, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK558903/
4. Safer sex options. Doin' It. https://www.doinit.ca/safer-sex/safer-sex-options/. Accessed March 3, 2023.
Wiki page citation:
Course:PATH417:2022W2/case2. Course:PATH417:2022W2/Case2 - UBC Wiki. https://wiki.ubc.ca/Course:PATH417:2022W2/Case2. Accessed March 3, 2023.