The usual sites of infection are the 

• urethra in males 
• endocervix in females

2. What other sites may be infected?

 Other sites that may be infected include the urethra in females, 

• urethra in females
• the rectum
• the oropharynx
• the eye
  
  

3. Describe the mechanisms of attachment of Neisseria gonorrhoeae to host cells.

• Initial adherence is mediated by the pili made up of repeated protein subunits capable of phase and antigenic variation. 
• Opa (opacity) proteins are closely related outer membrane proteins and act as adhesins in the second phase or tighter binding. 

4. What elicits the intense inflammatory response (pus) in the urethra? Does the response occur in females?

•  Inflammation is stimulated by lipooligosaccharide and possible peptidoglycan fragments of Neisseria gonorrhoeae. 
• The inflammatory response is also seen in females. Inflammation occurs typically at the endocervix; it is severe in the fallopian tubes when ascending infection occurs.
  
  

5. What is the reservoir of gonococcal disease in the population?

• The reservoir of gonococcal disease in the population is asymptomatic persons. 
  • As many as 50% of women and 5% of men will not experience recognizable symptoms. 
  • In addition, men who do not seek treatment may become asymptomatic carriers.
    
    

6. How would you diagnose this infection? Is a gram stain of the pus sensitive or specific? How useful is the Gram stain in females?

•  Diagnosis is established by Gram stain of the urethral discharge. 
  • Gram stain is more 90% sensitive and 98% specific in men.
  • In women, sensitivity and specificity drop to 5-70%. 
• Urethral swabs in males and cervical swabs in females should be plated on selective media (Thayer-Martin).
  
  

7. How would you treat this patient?

• You treat the patient with amoxicilin. He returns one week later stating that the treatment has had no effect on the discharge.
• Treatment should be started immediately. 
• Antibiotic options are 
  • a single dose of Ceftriaxone 125 mg. IM
  • Cefixime (Suprax) 400 mg p.o. 
  • Ciprofloxacin 500 mg. p.o.
  • Ciprofloxacin 400 mg. p.o.
• Erythromycin, doxcycline and spectinomycin are effective, but resistance is limiting their usefulness: 
• Concurrent treatment of Chamydia trachomatis is recommended as 50% patients with urethritis or cervicitis have concomitant chlamydia infection. Doxycycline 100 mg. Twice daily, or azithromycin 1 gram orally as a single dose, should be given along with one of the above antimicrobials.
  
  

8. What is the most likely cause of treatment failure?

•  The likely cause of treatment failure is penicillin resistance. Penicillinase-producing Neisseria gonorrhea (PPNG) were first described in the Far East, and are now endemic in the U.S. 
  • These strains produce a plasmid encoded beta-lactamase.

9. Why can't we develop a vaccine?

• They are associated with phase and antigenic variation. 
• Besides pili and Opa, gonococcal lipooligosaccharide also undergoes antigenic variation. 
• This complex, high frequency antigenic variation provides specific ligands for different cell receptors which allows the organism to escape from immune surveillance, and makes it very difficult to develop a vaccine.