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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 31-33

Gonococcal urethritis in present times: Seek and find


Department of Microbiology, Apollo Speciality Hospitals, Vanagaram, Chennai, Tamil Nadu, India

Date of Submission05-Nov-2019
Date of Acceptance30-Dec-2019
Date of Web Publication17-Mar-2020

Correspondence Address:
B Isabella Princess
Junior Consultant, Department of Microbiology, Apollo Speciality Hospitals, Vanagaram, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_70_19

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  Abstract 


Sexually transmitted infections gained importance after the advent of human immunodeficiency virus infection in 1983. The global incidence of gonorrhea in 2008 was 106.1 million, in 2005 was 87.7 million, and in 1999 was 62 million. Laboratory diagnosis of gonorrhea is challenging due to poor facilities in smaller laboratories of developing countries. This along with nonsuspicion might lead to under-reporting of cases from such countries. We report two cases of gonococcal urethritis from a city in South India within a period of 1 year. Two young/middle-aged patients presented to the urology department with complaints of acute-onset painless urethral discharge. On suspicion of gonococcal urethritis, urethral pus was sent for Gram stain which revealed a plenty of polymorphonuclear neutrophils and a plenty of Gram-negative bean-shaped diplococci. The organism was isolated and identified as Neisseria gonorrhoeae. Contact tracing was not possible in both cases, so they were appropriately counseled and treated. Gonococcal urethritis could be under-reported in India. In the era of automation in microbiology and syndromic approach for diagnosis, simple techniques such as Gram stain and culture coupled with good clinical suspicion can clinch the diagnosis of gonococcal urethritis. Since there is a vast difference in antibiotics used for treating gonococcal and nongonococcal urethritis, it is important to diagnose the etiological agent at the earliest for targeted therapy.

Keywords: Ceftriaxone, gonococcal urethritis, gonococci, Gram stain, Neisseria gonorrhoeae, sexually transmitted infection, urethritis


How to cite this article:
Princess B I. Gonococcal urethritis in present times: Seek and find. Apollo Med 2020;17:31-3

How to cite this URL:
Princess B I. Gonococcal urethritis in present times: Seek and find. Apollo Med [serial online] 2020 [cited 2020 Sep 22];17:31-3. Available from: http://www.apollomedicine.org/text.asp?2020/17/1/31/280914




  Introduction Top


Sexually transmitted infections (STIs) gained importance after the advent of human immunodeficiency virus infection in 1983. Ever since, data and surveys on STIs by the World Health Organization have been extensive. The global incidence of gonorrhea in 2008 was estimated to be 106.1 million, Southeast Asian region constituting a major 25.4 million cases.[1] Older reports on global incidence in 2005 was 87.7 million and in 1999 was 62 million, with 27 million cases in Southeast Asian region.[2] The causes of urethritis are broadly classified as gonococcal and nongonococcal urethritis, with most recent reports from India and other parts of the world pointing to a rise in the prevalence of nongonococcal urethritis.[3],[4] Gonococci cannot still be ruled out as a causative agent of urethritis as the incidence rate is on the ascending phase. Notification and reporting systems are well developed in the western part of the world compared to Southeast Asia where these challenges remain a constant. This may negatively impact global figures on the incidence rate of gonococcal urethritis.

Diagnosis of gonococcal urethritis has become challenging since the advent of “syndromic approach” of STIs. However, point-of-care diagnosis of gonococci does help in the management of patients with gonococcal urethritis.[5] The widely available rapid as well as cheaper method for presumptive diagnosis of gonococci is microscopic examination by Gram stain. The sensitivity and specificity of Gram stain are high, especially in men with urethritis.[6],[7] Culture remains the “gold standard” of diagnosing gonococci although challenging due to the fastidious nature of the organism.[8] A challenging laboratory diagnosis of gonorrhea with poor facilities in smaller laboratories of developing countries and nonsuspicion might lead to under reporting of cases from such countries. Knowledgeable and skilled personnel is mandatory to make an appropriate diagnosis of gonococcal urethritis, especially in settings which cannot depend on molecular diagnostic techniques.

We report two cases of gonococcal urethritis diagnosed using microscopy and culture from a city in south India within a period of 1 year. These cases were diagnosed with limited diagnostic modalities which are commonly available in most laboratories of developing countries like India.


  Case Reports Top


Case 1

A middle-aged patient between 30 and 40 years of age presented to the urology outpatient department with complaints of acute-onset painless purulent urethral discharge. On clinical suspicion of gonococcal urethritis, urethral pus was sent for Gram stain examination. Gram stain revealed a plenty of polymorphonuclear leukocytes with a plenty of intracellular as well as extracellular Gram-negative bean-shaped diplococci [Figure 1].
Figure 1: Gram stain of urethral pus showing Gram-negative bean-shaped diplococci

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Gram stain report was immediately conveyed to the clinician, and the patient was treated with intravenous ceftriaxone. In the laboratory, the pus sample was inoculated on blood agar and chocolate agar. After 24–36 h of aerobic incubation, blood agar showed no growth and chocolate agar showed heavy growth of translucent flat colonies. Gram stain from colonies on chocolate agar revealed Gram-negative diplococci which were oxidase positive. The organism was identified as  Neisseria More Details gonorrhoeae based on presumptive (Gram stain) and gold standard (culture) methods with available culture media. Microscopic and culture characteristics (inability to grow on blood agar with growth on chocolate agar) helped in the confirmation of clinical diagnosis.

Case 2

A young teenager presented to the urology outpatient department with the complaints of painless urethral discharge and dysuria of acute onset. Urine culture was done and found to be insignificant. Gram stain of urine specimen showed a plenty of polymorphs and no organisms. Urethral swab on Gram stain revealed aplenty of polymorphs with scarce/scanty Gram-negative bean-shaped diplococci [Figure 2]. The organism failed to be isolated on culture due to the presence of other commensal normal flora. With strong clinical suspicion and Gram stain findings suggestive of gonococcal urethritis, the patient was started on intravenous ceftriaxone.
Figure 2: Urethral swabs showing Gram-negative diplococci

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Contact tracing was not possible in both cases, but the patients were counseled on the mode and possible risk of transmitting infection to their contacts. Adequate counseling was given regarding partner screening and risk of transmitting infection due to unprotected exposure. Both the patients had adequate response to treatment and resolution of symptoms on follow-up.


  Discussion Top


The above-reported cases of gonorrhea are from a 7 year-old tertiary healthcare facility. These cases were reported for the first time with both presentations within a period of 1 year. Since this is a tertiary care facility, these could be delayed presentations resulting due to failed initial treatment from other smaller facilities. Low load of gonococci in the second patient could be due to partial treatment or presence of drug-resistant strain which was recalcitrant to initial therapy. Since both the patients presented on outpatient basis, thorough and detailed history on previous antibiotic prescriptions was not available.

The clinical manifestations of STIs are distinct among men and women with only 0.2% men presenting with urethral discharge.[9] Most patients are asymptomatic, and another majority do not seek medical attention. However, patients with gonococcal urethritis commonly present with urethral discharge and dysuria.[10] Our patients presented with symptoms of urethral discharge signifying the severity of infection. One patient had dysuria, but the documented complications of gonococcal urethritis such as prostatitis, epididymitis, and disseminated infection were not present. Clinical manifestations of both our patients were consistent with previous reports of gonococcal urethritis.

Presumptive and gold standard method of diagnosis of gonococcal urethritis was possible in one of our patients (Case 1). The second patient was diagnosed based only on clinical and presumptive laboratory diagnosis. Another major drawback in laboratory diagnosis of N. gonorrhoeae in settings like ours is the lack of supportive non culture diagnostic tests, such as enzyme immunoassay, polymerase chain reaction, and ligase chain reaction.[11] We were unable to perform rapid carbohydrate utilization test to differentiate N. gonorrhoeae and  Neisseria meningitidis More Details due to unavailability of the same. Acase report by Sood et al. from New Delhi emphasizes the importance of combining culture techniques and molecular diagnostic tests for diagnosing N. gonorrhoeae. These techniques play a major role to distinguish N. gonorrhoeae and N. meningitidis, especially in confirmation of sexual abuse.[12]N. meningitidis is a normal commensal of the pharynx and can also be isolated from urethra, thereby making its identification mandatory to rule out orogenital mode of transmission.[13] This could be a drawback in laboratories lacking availability of supportive diagnostic techniques.

Drugs of choice for the treatment of gonococcal urethritis are penicillin, ciprofloxacin, tetracyclines, ceftriaxone, and cefixime. Various studies have shown high level of resistance to penicillin and ciprofloxacin.[14],[15] Ceftriaxone resistance is not frequently reported, thereby making it an ideal choice for antibiotic therapy in gonococcal urethritis. A recent study from Chennai, India, has also shown good susceptibility of gonococcal isolates to ceftriaxone.[16] Both our patients were treated with ceftriaxone, and good resolution of symptoms was observed. A good counseling on modes of transmission and conveying knowledge on partner screening plays a pivotal role in arresting spread of infection.


  Conclusion Top


Although the incidence of nongonococcal urethritis is on the rise and diagnostic tools have evolved to efficiently detect the etiological agents within a short duration, gonococcal urethritis is still under reported in India. In the era of automation in microbiology and syndromic approach for diagnosis, simple techniques such as Gram stain and culture coupled with good clinical suspicion can clinch the diagnosis of gonococcal urethritis. Since there is a vast difference in antibiotics used for treating gonococcal and non gonococcal urethritis, it is important to diagnose the etiological agent at the earliest for targeted therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections – 2008. World Health Organization, WHO Library Cataloguing-in-Publication Data; 2012.  Back to cited text no. 1
    
2.
World Health Organization. Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections Overview and Estimates – 1999. World Health Organization; 2001.  Back to cited text no. 2
    
3.
Devi SA, Vetrichevvel TP, Pise GA, Thappa DM. Pattern of sexually transmitted infections in a tertiary care centre at Puducherry. Indian J Dermatol 2009;54:347-9.  Back to cited text no. 3
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4.
Thappa DM, Kaimal S. Sexually transmitted infections in India: Current status (except human immunodeficiency virus/acquired immunodeficiency syndrome). Indian J Dermatol 2007;52:78-82.  Back to cited text no. 4
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5.
Verma R, Sood S. Gonorrhoea diagnostics: An update. Indian J Med Microbiol 2016;34:139-45.  Back to cited text no. 5
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6.
Koumans EH, Johnson RE, Knapp JS, St Louis ME. Laboratory testing for Neisseria gonorrhoeae by recently introduced nonculture tests: A performance review with clinical and public health considerations. Clin Infect Dis 1998;27:1171-80.  Back to cited text no. 6
    
7.
Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010;59:1-10.  Back to cited text no. 7
    
8.
Ng LK, Martin IE. The laboratory diagnosis of Neisseria gonorrhoeae. Can J Infect Dis Med Microbiol 2005;16:15-25.  Back to cited text no. 8
    
9.
Thomas K, Thyagarajan SP, Jeyaseelan L, Varghese JC, Krishnamurthy P, Bai L, et al. Community prevalence of sexually transmitted diseases and human immunodeficiency virus infection in Tamil Nadu, India: A probability proportional to size cluster survey. Natl Med J India 2002;15:135-40.  Back to cited text no. 9
    
10.
Gupta CM, Sanghi S, Sayal SK, Das AL, Prasad GK. Clinical and bacteriological study of urethral discharge. Indian J Dermatol Venereol Leprol 2001;67:185-7.  Back to cited text no. 10
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11.
Verma R, Sood S, Manjubala, Kapil A, Sharma VK. Diagnostic approach to gonorrhoea: Limitations. Indian J Sex Transm Dis 2009;30:61-4.  Back to cited text no. 11
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12.
Sood S, Verma R, Mukherjee A, Mahajan N, Das BK, Kapil A, et al. Gram-negative diplococci in vaginal smear mistaken for child sexual abuse. Indian J Dermatol Venereol Leprol 2014;80:260-2.  Back to cited text no. 12
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13.
Givan KF, Thomas BW, Johnston AG. Isolation of Neisseria meningitidis from the urethra, cervix, and anal canal: Further observations. Br J Vener Dis 1977;53:109-12.  Back to cited text no. 13
    
14.
Singh V, Bala M, Kakran M, Ramesh V. Comparative assessment of CDS, CLSI disc diffusion and Etest techniques for antimicrobial susceptibility testing of Neisseria gonorrhoeae: A 6-year study. BMJ Open 2012;2. pii: E000969.  Back to cited text no. 14
    
15.
Khaki P, Sharma A, Bhalla P. Comparison of two disc diffusion methods with minimum inhibitory concentration for antimicrobial susceptibility testing of Neisseria gonorrhoeae isolates. Ann Med Health Sci Res 2014;4:453-6.  Back to cited text no. 15
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16.
Muthusamy S, Elangovan S. A study on prevalence and antibiotic sensitivity testing methods for Neisseria gonorrhoeae isolates among female outpatients of sexually transmitted infection clinic. Int J Health Allied Sci 2017;6:11-4.  Back to cited text no. 16
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