Gnococcal & Chamydial infection -How to diagnose and Treta??

How to diagnose  , Treat and eradicate Gonococcal  cervicitis ?? Do members have a belief that we often miss the diagnosis of  Chr stage of Gonococcal Cervicitis (as well as chlamydial Cervicitis )at OPD?? What may be S/S in acute cases if reports to your private  clinic or busy OPD??

Ans related to white discharge –its diagnosis at OPD ; If she comes in acute stage then there will be   yellow exudative discharge   pouring   from the   endocervix with   10  or more  polymorpho  nucleocytes per  high power field   on microscopy . In all cases of white discharge one should keep Gono  as a D/D. So in cases of Gono    she will complain, but not always of vaginal   discharge and  postcoital  spotting. A purulent   vaginal discharge on Gram stain in such cases will exhibit intracellular   gram negative diplococci (very diagnostic-may be done at OPD pathology Rom if facilities exist) . When  a patient presents    with this type of cervical   discharge. Gram   stain  may be done if evidence of gonorrhea is present   that is intra cellular   gram  negative  diplococcic   then treatment  should be directed toward    gonococcal disease .

Pathogensis of Gono-Long lasting ill effects?  An    infection of the cervix is analogous to an infection   of the urethra in the male. Thus, many sexually transmitted pathogens(STI)  , such as Chlamydia trachomatis, N gonorrhoeae   or herpes  simplex virus   , may   infect the cervix as well as urethra of both partner . Gonococcal   and chlamydial organisms have   a propensity for the    columnar cells of the endocervix. These patients   may complain of postcoital spotting due to  active and persistent infn in Cx  . However of all the STI cases  of persistent  white discharge. The most   common organism implicated in Mucopurulent cervical  discharge   is C trachomatis     although gonorrhea   may also be a pathogen.

What may be Long term problems/Sequelae?? :-There is a saying that gono primarily attacks the Cx where as Chlamydia targets F tubes. Because    of gonorrhea’s   propensity   to invade the endocervix , woman   almost certainly  will continue to  have some degree of Cx damage in endoCx.  In research settings the   endocervix  may sampled   for culture   or DNA  probe. Gonococcal arthritis    or painful skin  lesions to suggest disseminated  gonorrhea was not uncommon in early twentieth century but with advent of streamlined and  implementation of separate  STD clinics in many Govt hospitals both See & Gnu arte treated early if she (or her husband) reports to hospital, That is why we nowadays rarely come across  such  extra genital Symp or signs related to Gono/Syphilis. Are not seen as is uncommon to see third sage of Treponema . Chlamydia too can perihepatic adhesions. What is the name of those adhesions which  easily can be seen in laparoscopy?

How best to treat??  What treatment for Gono Cervicitis ??. Most   common treatment   for gonococcal    cervicitis   is Ceftriaxone   125 to  250  mg  intramuscularly . Because    Chlamydia  often coexists   with gonorrhea   therapy   with   azithromycin  1 g orally or doxycycline 100  mg twice  daily for 7  to 10 days may also be supplemented  . What drug for gonococci?? Choice of drugs??  Ans:-: Intramuscular   Ceftriaxone is ideal for gonorrhea. But if one is not sure and cant differentiate with concomitant association with Chlamydia then one should add oral   azithromycin  for chlamydial   infection.

 

  Why to add azithromycin as well??? Because   of the frequency of coexisting chlamydial infection , azithromycin  1 g orally   or doxycycline 100  mg orally bid for 7 to 10 days   is also often   given. If eth  Gram  stain of the   cervical discharge   is negative then antimicrobial   therapy directed  at Chlamydia is warranted. Nevertheless   cultures   or tests for both organisms   should be performed. If the symptoms    resolve   no follow up   cultures    need to be   done. Finally, the patient    and partner   should be    counseled  and offered testing for   other sexually transmitted  organisms   such as HIV , syphilis and   hepatitis B and C.

 Gonococcal   and cervicitis may lead to more serious   complications. The organism may ascend  and   infect  the fallopian tubes  causing  salpingitis. The term   pelvic  inflammatory   disease  is usually synonymous   with acute   salpingitis. The tubal  infection in turn predisposes the patient   to infertility and   ectopic   pregnancies due to   tubal occlusion and / or  adhesions, The gonococcal  organism   may lead  to an infectious   arthritis usually involving  the large   joints  and classically  is  migratory. In fact   in the United States   gonorrhea   is the most  common cause  of septic   arthritis in young women . Disseminated  gonorrhea can occur  also affected     individuals   will usually have eruptions of painful pustules   with  an erythematosus base  on the skin. The diagnosis  is made by Gram   stain and culture   of the  pustules.

CHLAMYDIAL cervicitis is the most common cause of  Mucopurulent   cervical   discharge. Although  gonorrhea is also   associated  with a   Mucopurulent discharge, it is less common than Chlamydia. The  mucus  in the Mucopurulent  discharge  is due to involvement of the columnar  glandular cells  of the endocervix.

Neither  gonorrhea nor chlamydial infection typically cause  vaginitis and the discharge whatever noticed is from Cx.. By contrast, bacterial   vaginosis(fishy odour on smelling the speculum as one withdraws the speculum –Yellow frothy is Trichomonal, But if fishy BV ) will speak in favour of BV. But Fungi may be another imp cause of white discharge as is trichomonal(frothy copious) . Candida   infection does  not usually cause a fishy  odor,  and induces  a heterogeneous discharge.

Disseminated gonococcal disease Long term  distal Extra genital sequelae ;   A) Skin lesions:-leads to multiple often painful  pustules on the skin. These  pustules  can  be cultured  and Gram   stained  for diagnostic purposes. Other   signs  of disseminated gonococcal   disease   include   fever, malaise  chills and joint  pain or swelling . Chlamydia is not a common cause of  a disseminated  process however  reinfection  or persistent   infections  are common . B) Gono Phyaryngitis: The diagnosis   of gonococcal pharyngitis is made by swabbing the  throat. The infection is typically located on the tonsils and back of the  throat. A patients who engage in oral   sex are  at increased risk of  acquiring   gonococcal  pharyngitis. There is   no symptoms   are noted by the patient  unless   the disease   disseminates. Chlamydia is not a common cause of   pharyngitis   most likely because unlike   Neisseria gonorrhea   it lacks the pili that  allow  the gonococcal   bacteria   to adhere to the surface  of eh columnar epithelium at the back of the throat.

C) Conjunctivitis, Neonatal in particular:- Both chlamydial infection and gonorrhea may cause conjunctivitis and blindness in a newborn. Such neonatal fin was not uncommon in  early  decades of last   century .Gonococcal   infections usually present between the second ad fifth days of life   whereas chlamydial infections   present between the fifth and fourteenth day of life. Neisseria gonorrhea was once   the most common cause   of blindness in the newborn . Chlamydia   trachomatis   may also cause infantile pneumonia generally between 1 and 3 months of age. 

This patient has salpingitis   common organisms   include   Gonorrhea  Chlamydia  gram negative  rods and anaerobes . Risk  factors  for salpingitis include use of an IUD, previous   infection    with either    Gonorrhea   or Chlamydia  surgery or anything that breaks the cervical   barrier  and   enhances transfer of organisms from the endocervix to the    upper  reproductive tract. Pseudomonas aeruginosa is a gram   negative    nonfermenting bacillus that is  commonly  known to cause   infections associated with hot tubs contaminated    contract lens   solution   patients  on  ventilators  and immunocompromised   patients   . it is    not associated with   infecting   the upper    genital    tract. Treponema   pallidum  is a spirochete   bacterium that causes  syphilis. There  are multiple stages that this chronic   disease  may progress   to if left   untreated. The presenting symptom in the first stage of disease   is a painless    chancre typically located  at the site of   inoculation  and not    lower abdominal tenderness   with dyspareunia. Treatment   of choice   in penicillin. Actinomyces is an organism considered  part of the normal    vaginal   flora  and is associated with intra uterine    device use  but is not commonly  encountered.