Introduction
Background
Historically, gonorrhea is one of the first described infectious diseases. It is caused by the gram-negative diplococcus, Neisseria gonorrhoeae. Ocularly, it affects 2 populations, the sexually active adult population and the neonate. Ophthalmia neonatorum (neonatal conjunctivitis) is described in the article Conjunctivitis, Neonatal. This article discusses the adult disease.
Pathophysiology
Conjunctivitis can occur in adults, as well as children, following direct inoculation of organisms (usually as a result of hand-eye inoculation in adults) and can lead to blindness.
Frequency
United States
In the United States, gonorrhea is the second most commonly reported notifiable disease, with 339,593 cases documented in 2005.1 More cases may be unrecognized or unreported. Incidence, once believed to be on the decline because of public health initiatives, has been rising since 1984; however, rates in some demographic segments (eg, homosexuals) have decreased.
Incidence of antibiotic-resistant strains has been rising since the late 1940s. Of greatest concern is the rise in the percentage of cases due to penicillinase-producing N gonorrhoeae (PPNG).
International
Similar to the United States, in most countries, it is a ubiquitous infectious disease. Approximately 200 million new cases of gonorrhea occur worldwide each year.
Mortality/Morbidity
Gonorrhea is a major cause of morbidity throughout the world.
- The most common long-term sequelae of gonorrhea are chronic pelvic pain in women after pelvic inflammatory disease (PID), septic abortion, chorioamnionitis in pregnancy, blindness after either neonatal conjunctivitis or adult conjunctivitis, and infertility of either sex.
- Ectopic pregnancy is a life-threatening complication that may follow scarring of the female upper reproductive tract.
- Disseminated infection may lead to meningitis or endocarditis.
Race
No racial predilection exists, but the disease is most common among urban poor and minority groups.
Sex
Gonococcal infections are 1.5 times more common in men than in women.
- All sexually active populations are at risk, and the level of risk rises with the number of sex partners and the presence of other sexually transmitted diseases (STDs).
- Serious sequelae are more common in women than in men. PID may lead to ectopic pregnancy or infertility, and disseminated gonorrheal infection (DGI) is more likely in women than in men.
Age
- Gonococcal infection is more common in the sexually active age group (ie, 15-35 y).
- Infection in children is a marker for child sexual abuse.
Clinical
History
In all patients presenting with possible STDs, history should include past history of STDs (including HIV), known symptoms of STDs in current or past partners, type of contraception, and any history of sexual assault.
In women, history also should include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.
Physical
- Ocular or periocular manifestations
- Anterior chamber - Cellular reaction, hypopyon, endophthalmitis
- Conjunctiva - Chemosis, acute purulent exudate, hemorrhages
- Cornea - Punctate epithelial keratitis; marginal, sterile stromal infiltrates; epithelial defects; infectious stromal infiltrates; stromal ulcerations; descemetocele; perforation; opacification
- Lids - Erythema, edema
- Genitourinary tract, male
- Mucopurulent or purulent urethral discharge
- Unilateral epididymal tenderness and edema
- Lower genitourinary tract, female
- Mucopurulent or purulent cervical discharge
- Vaginal discharge or bleeding; vulvovaginitis in children
- Upper genitourinary tract, female
- PID
- Lower abdominal tenderness with or without rebound tenderness
- Cervical motion tenderness
- Adnexal tenderness
- Fever
- Upper right abdominal tenderness (with perihepatitis)
- Rectal - Mucopurulent or purulent discharge
- DGI may present with any of the following findings:
- Fever - Usually below 39°C
- Skin changes - Maculopapular, pustular, necrotic, or vesicular rash typically occurs on the torso, limbs, palms, and soles. The rash usually spares the face, scalp, and mouth. Hemorrhagic lesions, erythema nodosum, urticaria, and erythema multiforme occur less frequently. Skin lesions are usually in different stages of development at the time of clinical presentation.
- Joints - Most patients may have polyarthralgia with pain, tenderness, decreased range of motion, and erythema. Less often, purulent arthritis may affect a single joint with severe pain, tenderness, edema, erythema, and decreased range of motion. Tenosynovitis presents as erythema and local tenderness along a tendon sheath, with pain on active or passive range of motion. Tenosynovitis most often occurs in the hands, but it may be found in the tendons of the lower extremities.
- Central nervous system - Patients with gonococcal meningitis may present with meningismus or decreased mental status.
- Cardiac - Patients with gonococcal endocarditis may have a new murmur, tachycardia, and fever. Embolic lesions may be present.
- Muscle - DGI can cause abscess formation within the soft tissues, presenting as localized tenderness, edema, and pain with motion.
Causes
Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual contact. It also may be caused by inoculation of mucosa by contaminated fingers or other objects.
Neonatal infection may follow conjunctival inoculation during birth or direct infection through the scalp at the sites of fetal monitoring electrodes.
- Risk factors
- Sexual exposure to an infected individual without barrier protection
- Multiple sexual partners
- Infants - Passage through the infected birth canal of the mother
- Children - Sexual abuse by an infected individual
- For PID, use of an intrauterine device (IUD)
More on Gonococcus |
 Overview: Gonococcus |
| Differential Diagnoses & Workup: Gonococcus |
| Treatment & Medication: Gonococcus |
| Follow-up: Gonococcus |
| References |
| Next Page » |
References
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Centers for Disease Control and Prevention (CDC). Updated recommended treatment regimens for gonococcal infections and associated conditions - United States, April 2007. CDC. Available at http://www.cdc.gov/std/treatment/2006/updated-regimens.htm. Accessed July 17, 2007.
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Tight RR. Gonococcal conjunctivitis. JAMA. May 14 1982;247(18):2499. [Medline].
Ullman S, Roussel TJ, Culbertson WW, Forster RK, Alfonso E, Mendelsohn AD, et al. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. May 1987;94(5):525-31. [Medline].
Ullman S, Roussel TJ, Forster RK. Gonococcal keratoconjunctivitis. Surv Ophthalmol. Nov-Dec 1987;32(3):199-208. [Medline].
Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. Am J Ophthalmol. Nov 15 1986;102(5):575-83. [Medline].
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Further Reading
Keywords
gonorrhea, Neisseria gonorrhoeae, N gonorrhoeae, hyperacute conjunctivitis, sexually transmitted disease, STD
