J.L is a 17 year old junior that came in with complaints of urinary tract manifestations and increasingly severe urethral burning during urination that has persisted for three days. She has said that her vaginal discharge has been yellow and thick. She also reports mild anal itching but denies any other symptoms. She reported that she had sex for the first time during prom two weeks ago. It was also reported that she and her date did not use a condom. Along with a heightened frequen cy of urination and mild incontinence she also experiences mild erythema and yellow-white discharge, cervical tenderness and edema.
J.L also has a pH of 5.0 which is slightly more ac idic than normal. Her urinalysis shows that she has 10 RBC as well as WBC in her urine which is unusual. She also tested positive for gram-negative diplococci. On further investigation of her results her Nucleic Acid Amplification Test showed her positive for Neisseria gonorrhoeae and Chlamydia trachomatis. J.L's one major risk factor in all of this was the fact that she engaged in unprotected sex.
Gonorrhea is the second most common sexually transmitted disease in the United States today. It accounts for more than three hundred thousand cases annually. There is concern that due to the low rate of reporting cases of gonorrhea, almost the same number (300,000 cases) goes unreported annually. In men Neisseria gonorrhoeae ; the etiologic agent of gonorrheal infections have been incriminated in urethritis while in women cervicitis ; which can progress to pelvic inflammatory disease(PID), ectopic pregnancy, infertility and pelvic pain. Invasive infections include disseminated gonococcal infections(DGI), meningitidis and endocarditis. The latter two are considerably uncommon but they can result in serious morbidity.
Epidemiologically, overall rates of infections have plummeted since the mid-1970s to a rate of approximately 116.2 cases per 100, 000 cases by the end of 2003 . Despite these statistical representations of overall decline in gonorrheal cases, racial disparities still persist and antibiotic resistance has been on the increase. The reasons behind this disparity in reduction is attributable to geographical clustering of the populace, differences in accessing and utilizing health services, sexual partner choices coupled to a set of complex and interrelated socioeconomic influences. Differential reporting by members of the public can also magnify the statistical racial disparity.
Neisseria gonorrhoeae is a Gram- negative , non motile, non spore forming diplococcus belonging to the family Neisseriaceae . It is the principal etiologic agent of gonorrhea. Other pathogenic species in the same family is Neisseria meningitidis. These two species are genetically related but N. meningitidis is not usually taken as an etiologic agent of a sexually transmitted disease. However, it can infect the mucous membranes in the anogenital area among homosexual men . Both bacteria are classified as pyogenic cocci since their infections are characterized with the production of purulent material composed of white blood cells. The genus Neisseria is also composed of other species; Neisseria lactamica, Neisseria cinerea , Neisseria polysaccharea and Neisseria flavescens . These species are comparatively more related to Neisseria gonorrhoeae than the saccharolytic strains like Neisseria sicca , Neisseria subflava and Neisseria mucosa . The latter species are basically non pathogenic normal flora resident in the nasopharyngeal mucous membranes .
Structurally, Neisseria gonorrhoeae are unencapsulated, non motile, pilated organisms that have a pair of kidney beans like appearance. These pili are hair like surface appendages made of helical aggregates of subunit peptide repeats referred to as Palin . These structures are used by the organism to attach onto mucosal and epithelial cell surfaces as well as to confer resistance to pha gocytic action. The pili acts as an important virulence factor. Pili are also antigenic. The existence of at least twenty gonococcal genes that code for pili confer the bacteria with the ability to synthesize and express multiple pili at different times. Neisseria gonorrhoeae also possess gonococcal lipooligosaccharides (LOS) that have shorter and more branched non repeat O-antigenic side chains. The outer membrane proteins(OMPs) confer antigenic diversity among the different strains of Neisseria gonorrhoeae . OMP I functions as a porin complex with OMP III. OMP II; the opacity protein, renders gonococcal colonies less translucent. Together with pili, OMP II, mediate