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Clinical Summary

Infection with Neisseria gonorrhoeae may occur at any exposed site and typically manifests within 2 to 7 days. Up to 10% of infections in men and 80% in women are asymptomatic. Urethritis, characterized by purulent urethral discharge and dysuria, is the most common manifestation in men. Although women may develop urethritis, cervicitis is more common. Symptoms may include vaginal irritation, discharge, or spotting, particularly with intercourse. Examination reveals a friable cervix, and a mucopurulent endocervical exudate may be present.

Disseminated gonococcal infection (DGI) occurs in 1% to 3% of patients and most commonly in females. Forty percent of DGI presents as monoarticular septic arthritis of the knee, wrist, ankle, or elbow. The other 60% of DGI presents as the arthritis-dermatitis syndrome where, in addition to arthritis, crops of pustules on a purpuric base are also present. Complications of DGI include myocarditis, hepatitis, endocarditis, and meningitis.

Gonococcal conjunctivitis, characterized by chemosis and copious purulent exudate, is most often seen in neonates but may occur at any age. In neonates, symptoms develop within 2 to 6 days of exposure at birth. Complications if untreated include endophthalmitis and perforation of the globe with permanent loss of vision.

Management and Disposition

Urethritis and cervicitis: Treat with single doses of both ceftriaxone 250 mg IM and oral azithromycin 1000 mg. Single-agent treatment is no longer recommended.

Conjunctivitis: Treat adults with ceftriaxone 1 g IM and oral azithromycin 1 g once. Oral doxycycline 100 mg twice daily for 7 days is an alternative. Treat infants and children over 2 months of age with ceftriaxone 25 to 50 mg/kg IM once. For infants less than 2 months old, use cefotaxime 100 mg/kg once. All neonates should receive empiric treatment with erythromycin ophthalmic ointment at birth.

FIGURE 9.11

Male Gonococcal Urethritis. Purulent urethral discharge from a patient with gonococcal urethritis. (Photo contributor: Larry B. Mellick, MD.)

DGI: Treat initially with ceftriaxone 1 g intravenously (IV) plus a single dose of azithromycin 1 g orally. Treat suspected endocarditis or meningitis with higher doses of ceftriaxone (1-2 g twice daily). Admit all patients with DGI for continued parenteral treatment for a minimum of 7 to 10 days followed by 7 to 10 days of an oral third-generation cephalosporin. All sexual partners should be treated empirically. Gonorrhea is a reportable disease.

FIGURE 9.12

Female Gonococcal Urethritis. Gonococcal urethritis in a female patient. Note the purulent urethral discharge. (Reproduced with permission from Morse SA, Holmes KK, Ballard RC, Moreland AA, eds. Atlas of Sexually Transmitted Diseases and AIDS. 4th ed. Saunders Elsevier; 2010. Copyright © 2010 Elsevier, Ltd.)

FIGURE 9.13

Gonococcal Cervicitis. Endocervical purulent exudate in an asymptomatic patient ...

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