Gonococcal Infections Clinical Presentation

In all patients who present with a possible STD, the history should include a past history of STDs (including HIV infection and viral hepatitis), treatment history for known STDs, known symptoms of STDs in current or past sexual partners, type of contraception used, and any history of sexual assault. In women, the history should also include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.

• Female genitourinary tract

  • The most common site of gonococcal infection in women is the endocervix (80%-90%), followed by the urethra (80%), rectum (40%), and pharynx (10%-20%). If symptoms develop, they often manifest within 10 days of infection.
  • Major symptoms include vaginal discharge, dysuria, intermenstrual bleeding, dyspareunia, and mild lower abdominal pain.
  • When gonococcal cervicitis is either asymptomatic or unrecognized, the patient may progress to PID, often in proximity to a menstrual period. PID may also be asymptomatic or silent and occurs in 10-20% of infected women. Symptoms of PID include the following:
    • Lower abdominal pain (most consistent symptom of PID)
    • Increased vaginal discharge or mucopurulent urethral discharge
    • Dysuria (usually without urgency or frequency)
    • Cervical motion tenderness
    • Adnexal tenderness (usually bilateral) or adnexal mass
    • Intermenstrual bleeding
    • Fever, chills, nausea, and vomiting (less common)
  • Acute perihepatitis (Fitz-Hugh-Curtis syndrome) occurs primarily through direct extension of N gonorrhoeae or Chlamydia trachomatis from the fallopian tube to the liver capsule and overlying peritoneum.
• Male genitourinary tract

  • In men, urethritis is the major manifestation of gonococcal infection.
  • Initial characteristics include burning upon urination and a serous discharge. A few days later, the discharge usually becomes more profuse, purulent, and, at times, blood-tinged. Acute epididymitis may also be caused by N gonorrhoeae, especially in men younger than 35 years. This is usually unilateral and often occurs in conjunction with a urethral exudate.
• Sex-independent manifestations

  • Both men and women may exhibit gonococcal infection of the pharynx, rectum, and eye.
  • Gonococcal pharyngitis is most commonly acquired during orogenital contact, with fellatio predisposing to infection more so than cunnilingus. Pharyngitis is often asymptomatic; however, it may present as exudative pharyngitis with cervical lymphadenopathy.
  • Although rectal cultures are positive for gonorrhea in up to 40% of women with cervical gonorrhea (a similar percentage noted in infected homosexual men), symptoms of proctitis are unusual.
  • Eye involvement in adults occurs by autoinoculation of gonococci into the conjunctival sac from a primary site of infection, such as the genitals. The most common form of presentation is a purulent conjunctivitis, which may rapidly progress to panophthalmitis and loss of the eye unless promptly treated. This patient presented with gonococcal urethritis, which became systemically disseminated, leading to gonococcal conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD.
• Neonates

  • In neonates, bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery from an infected mother. However, transmission to the newborn can also occur in utero or in the postpartum period.
  • Symptoms of gonococcal conjunctivitis include eye pain, redness, and a purulent discharge. Neonates may also acquire pharyngeal, respiratory, or rectal infection or disseminated gonococcal infection (DGI).
  • The organism can cause permanent injury to the eye very quickly. Prompt recognition and treatment are essential to avoid blindness. Blindness due to neonatal gonococcal infection is a serious problem in developing countries but is now uncommon in the United States and in other countries where neonatal conjunctival prophylaxis with antimicrobial therapy is routine.
• Disseminated gonococcal infection

  • DGI follows 1%-2% of mucosal gonococcal infections and is caused by hematogenous dissemination of gonococci from the primary site. The symptoms vary greatly from patient to patient. By the time the symptoms of DGI appear, many patients no longer have any localized symptoms of mucosal infection.
  • Risk factors of DGI include the following:
    • Complement deficiency
    • Female sex: Disseminated infection may be more common in women, as gonorrhea in women is often asymptomatic, allowing for dissemination before symptoms occur.^[3]
    • Menses: In menstruating females, the illness is observed shortly after the end of menstruation.
    • Pharyngeal infection and pregnancy: These may also be predisposing factors to gonococcal bacteremia.
    • Specific serotypes: Certain strains of gonorrhea causing asymptomatic genital infections are seen in association with DGI.^[10]
  • The classic presentation of DGI is an arthritis dermatitis syndrome. Joint or tendon pain is the most common presenting complaint in the early stage of infection. Many patients with DGI describe migratory polyarthralgia, especially of the knees, elbows, and more distal joints, and may also have tenosynovitis. The early tenosynovitis most commonly affects the flexor tendon sheaths of the wrist or the Achilles tendon ("lovers' heels"). The dermatitis consists of lesions varying from maculopapular to pustular, often with a hemorrhagic component. Lesions usually number 5-40, are peripherally located, and may be painful before they are visible. Fever is common but rarely exceeds 38°C.
  • The second stage of DGI is characterized by septic arthritis, by which time the skin lesions have disappeared and blood culture results are nearly always negative. The knee is the most common site of purulent gonococcal arthritis.
  • Rare complications of DGI include gonococcal meningitis and endocarditis.
  • Gonococcal meningitis may be clinically indistinguishable from meningococcal meningitis upon presentation, although the course of gonococcal meningitis is usually less rapid than that of meningococcal meningitis.
  • Gonococcal endocarditis is more common in men than in women, with the aortic valve affected most commonly. A subacute onset of fever, chills, sweats, and malaise may indicate the presence of gonococcal endocarditis. Patients with endocarditis may develop atypical chest pain, cough, and dyspnea and may also develop the arthralgias and rash typical of DGI. Gonococcal endocarditis can cause severe valvular damage and death if not recognized and treated rapidly.

Patients with gonococcal infection may have the typical signs and symptoms of gonococcal diseases, especially in the genital tract. Sometimes, however, patients may have no localized signs or symptoms.

• Female genitourinary tract

  • Mucopurulent or purulent cervical discharge
  • Vaginal discharge or bleeding; vulvovaginitis in children
  • Lower abdominal tenderness with or without rebound tenderness
  • Adnexal tenderness (associated with ascending infection)
  • Cervical motion tenderness (associated with ascending infection)
  • Fever
  • Right upper abdominal tenderness (with Fitz-Hugh-Curtis syndrome)
• Male genitourinary tract

  • Mucopurulent or purulent urethral discharge
  • Unilateral epididymal tenderness and edema with or without penile discharge or dysuria
  • Penile edema without other overt inflammatory signs
  • Urethral stricture (uncommon; more often seen in preantibiotic era with urethral irrigation using caustic liquids)
• Rectal

  • Mucopurulent or purulent discharge with or without rectal bleeding
  • Mucopurulent exudate and inflammatory in the rectal mucosa
  • Rectal abscess (less common)
• Eyes

  • Purulent conjunctivitis (usually bilateral in ophthalmia neonatorum but usually unilateral when caused by secondary self-inoculation)
  • Corneal ulceration (in untreated ocular disease)
• Disseminated gonococcal infection

  • Patients with DGI may present with any of the following nonspecific findings:
  • Fever (usually < 39°C)
  • Polyarthralgia, mainly of knees, elbows, and distal joints; rare involvement of axial skeleton
  • Asymmetric oligoarthritis or tenosynovitis of usually two or more joint regions
  • Septic joints, which may be warm, tender, and edematous
  • Skin lesions, characteristically few in number and found mostly on the distal extremities as small papulopustular lesions with an erythematous periphery; may progress to hemorrhagic bullae or necrotic pustular lesions
  • Usually no urogenital symptoms

Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual contact or perinatally.

• Sexual contact

  • The risk of transmission of N gonorrhoeae from an infected woman to the urethra of her male partner is approximately 20% per episode of vaginal intercourse and rises to 60%-80% after 4 or more exposures.
  • In contrast, the risk of male-to-female transmission approximates 50%-70% per contact, with little evidence of increased risk with more sexual exposures.
  • Transmission through penile-rectal contact is fairly efficient.
  • Persons who have unprotected intercourse with new partners frequently enough to sustain the infection in a community are defined as core transmitters.
• Neonatal gonococcal infection may follow conjunctival infection, which is obtained during passage through the birth canal. In addition, direct infection may occur through the scalp at the sites of fetal monitoring electrodes.
• Autoinoculation can occur when a person touches an infected site (genital organ) and contacts skin or mucosa.