Neisseria gonorrhoeae

(gonococcus)
Pranisha Shakya
B.Sc.MLT Second year
2071/04/08
General Characteristics of Neisseria spp.
 Family: Neisseriaceae
 Aerobic
 Gram-negative diplococci with adjacent sides
flattened (like coffee beans)
 Oxidase positive
 Most are catalase positive
 Indole negative
 Non motile
 Grows poorly on ordinary media
 Acid from oxidation of carbohydrates, not from
fermentation
Neisser-1879

Disease- Gonorrhoea(Flow of seed)

Causes purulent urethral and vaginal

discharge
 Morphology

•Gram negative intracellular diplococcus (within polymorphs)

•Measures 0.6-1 micron

•Delicate organisms, survive 1-2 hours in exudate and 3-4 hours

in culture

•Possesses pili on their surfaces which are antigenitically

different in different strains.
 Cultural Characteristics
• Fastidious organism, requires complex media
to grow.
• Growth is adversly affected by drying and fatty
acids and occurs best at pH 7.2-7.6 and at
temperature of 35-36 deg. C.
• Aerobes but may grow anaerobically also in
addition of 5-10% carbondioxide for primary
isolation.
• Media:
 Chocolate agar, blood agar (non-selective
media)
 Thayer-Martin media with VCN (Selective)
 Modified New york city medium (Selective)
 Martin-Lewis agars(Selective)
 Colony Characteristics
• On chocolate agar after 24hrs incubation,
colonies are small about 1mm in diameter,
grey and translucent.

• After 48hrs the colonies are larger 1.5-2.5mm

in diameter, sometimes with an opaque raised
centre and thin transparent margins which
may be creanated.
• On Thayer-Martin medium growth is slower,
although colonies are similar to those on
Chocolate agar.
• On the basis colonial appearance, gonococci
are divided into four types:
T1 and T2 : virulent and contains pili; small
brown colonies
T3 and T4 : avirulent and nonpiliated;
large granular non-pigmented colonies
 Biochemical reactions
• Oxidase positive
• Catalase positive
• Glucose fermenter
• Lactose non fermenter
• Sucrose non fermenter
• Maltose non fermenter
• Indole negative
Differential Characteristics of Commonly
Isolated Neisseria spp.
 Gonococcal Virulence Factors
1. Antiphagocytic capsule- like negative surface charge

2. Fimbrae- only fimbriated cells (formerly known as colony

types T1 & T2) are virulent

3. Outer membrane proteins (formerly Proteins I, II, & III)

•Por (porin protein) prevents phagolysosome fusion following
phagocytosis and thereby promotes intracellular survival
•Opa (opacity protein) mediates firm attachment to epithelial cells
and subsequent invasion into cells
•Rmp (reduction-modifiable protein) protects other surface
antigens from bactericidal antibodies (Por protein, LOS)

4. Lipopolysaccharide-has endotoxic activity (Lipid A plus core

polysaccharide but no O-somatic antigen polysaccharide side chain)
 Gonococcal Virulence Factors (cont.)
5. The peptidoglycan has pro-inflammatory effect.

6. IgA1 protease

7. Acquisition in last two decades of two types of antibiotic

resistance:
• Plasmid-encoded beta-lactamase production.
• Chromosomally-mediated changes in cellular permeability
inhibit entry of penicillins, tetracycline, erythromycin,
aminoglycosides.
 Pathogenesis of Neisseria gonorrhoeae
 Incubation period: 2-8 days
 Sexually transmitted infection.
 Fimbriated cells attach to intact mucus membrane epithelium.
 Adhesion is so tight that even micturation can not remove the
bacteria.
 Capacity to invade intact mucus membranes or skin with abrasions
• Adherence to mucosal epithelium
• Penetration into and multiplication before passing through
mucosal epithelial cells
• Establish infection in the sub-epithelial layer
 Causes pyogenic infection, most common sites of inoculation:
• Cervix (cervicitis) or vagina in the female
• Urethra (urethritis) or penis in the male
• May infect the rectum and oropharynx due to abnormal sexual
bahaviour
Complications
Prostatitis
Epidydimitis
Salpingitis
Bartholinitis
Endometritis
Pelvic inflammatory disease (PID)
Vulvovaginitis
Disseminated gonococcal infection (DGI)
Opthalmia neonatorum
Conjunctivitis
Pharynxitis
Arthritis
Bacteremia
 Epidemiology of Gonorrhea
 Seriously underreported sexually-transmitted disease
 350,000 reported cases in USA in 1998
 Down from 70,000 cases in 1990

 Asymptomatic carriage is major reservoir.

 Transmission primarily by sexual contact.
 Lack of protective immunity and therefore re-infection,
partly due to antigenic diversity of strains.
 Higher risk of disseminated disease in patients with late
complement deficiencies.
Incidence of Gonorrhea in USA
Differences Between Men & Women with
Gonorrhea
IN MEN:
 Urethritis; Epididymitis
 Most infections among men are acute and symptomatic
with purulent discharge & dysuria (painful urination)
after 2-5 day incubation period.
 Male host seeks treatment early preventing serious
sequel, but not soon enough to prevent transmission to
other sex partners.
 The two bacterial agents primarily responsible for
urethritis among men are N. gonorrhoeae and
Chlamydia trachomatis.
Differences Between Men & Women with
Gonorrhea (cont.)
IN WOMEN:
 Cervicitis; Vaginitis; Pelvic Inflammatory Disease (PID);
Disseminated Gonococcal Infection (DGI)
 Women often asymptomatic or have atypical
indications (subtle, unrecognized S/S); Often untreated
until PID complications develop.
 Pelvic Inflammatory Disease (PID)
• May also be asymptomatic, but difficult y in diagnosis
accounts for many false negatives
• Can cause scarring of fallopian tubes leading to infertility or
ectopic pregnancy
Differences Between Men & Women with
Gonorrhea (cont.)
IN WOMEN (cont.) :
 Disseminated Gonococcal Infection (DGI):
(Result of gonococcal bacteremia)
• Often skin lesions: Petechiae (small, purplish, hemorrhagic
spots), Postules on extremities
• Arthralgias (pain in joints)
• Tenosynovitis (inflammation of tendon sheath)
• Septic arthritis
• Occasional complications: Hepatitis; Rarely endocarditis or
meningitis
 Gonorrhea
Females
50% risk of infection after single exposure
Asymptomatic infections frequently not
diagnosed
Major reservoir is asymptomatic carriage
in females
Genital infection primary site is cervix
(cervicitis), but vagina, urethra, rectum
can be colonized
Ascending infections in 10-20% including
salpingitis, tubo-ovarian abscesses, pelvic
inflammatory disease (PID) , chronic
infections can lead to sterility
Disseminated infections more common,
including septicemia, infection of skin and
joints (1-3%)
Can infect infant at delivery (conjunctivitis,
opthalmia neonatorum)
Males
20% risk of infection after single
exposure
Most initially symptomatic (95% acute)
Major reservoir is asymptomatic
carriage in females
Genital infection generally restricted to
urethra (urethritis) with purulent
discharge and dysuria
Rare complications may include
epididymitis, prostatitis, and
periurethral abscesses
Disseminated infections are very rare
More common in homosexual/bisexual
men than in heterosexual populatiuon
 Laboratory diagnosis
Specimen/s

In Male: Urethral discharge, Discharge after prostatic massage,

Anal canal swab, Oropharynx swab.

In Female: Endocervical swab, Urethral discharge, Anal canal

swab, Oropharynx swab, Vaginal swab, Bartholin’s gland swab.

In both sexes
Ophthalmia neonatorum: Conjunctival swab
Gonococcal septicaemia : Blood
Gonococcal arthritis : Synovial fluid
• Disinfectants should not be used when
preparing the patient for collection of
specimen because small amount may be toxic
and impede the recovery of organism in
culture.
• The swabs should be either inoculated directly
on the growth medium or transported to the
laboratory in amies medium with charcoal and
plated within 6hrs.
• Processing:
• 1. Gram’s stain
• 2. Culture
• 3. Antigen detection
• 4. Antibody detection
• 5. Molecular method: PCR
 Gram’s stain/Microscopy

Gram negative, bean shaped diplococcus, intracellular as

well as extracellular along with large number of PMNs.
 Culture
 Susceptible to drying and cooling, so immediate culture
of specimen onto pre-warmed media with moist
atmosphere containing 5% carbon dioxide.

Media:
 Chocolate agar, blood agar (non-selective media)
 Thayer-Martin media with VCN (Selective)
 Modified New york city medium (Selective)
 Martin-Lewis agars(Selective)

Colony: Small, gray-white, opaque, 4 types (T1 to T4)

Biochemical reaction: Glucose positive

Catalase positive
Oxidase positive
 Other tests
Detection of antigen by
-Direct fluorescence test
-Direct agglutination test

Detection of antibody in blood.

 Prevention & Treatment
 Penicillin no longer drug of choice due to:
• Continuing rise in the MIC
• Plasmid-encoded beta-lactamase production
• Chromosomally-mediated resistance
 Uncomplicated infxn: ceftriaxone, cefixime or fluoroquinolone
 Combined with doxycycline or azithromycin for dual infections with
Chlamydia
 Chemoprophylaxis of newborns against opthalmia neonatorum with
1% silver nitrate, 1% tetracycline, or 0.5% erythromycin eye
ointments
 Treatment of newborns with opthalmia neonatorum with ceftriaxone
 Measures to limit epidemic include education, aggressive detection,
and follow-up screening of sexual partners, use of condoms or
spermicides with nonoxynol 9 etc.
References
• A textbook of Microbiology - P.Chakraborty
• Textbook of Microbiology - D.R Arora and B.
Arora
• A Handbook of Clinical Microbiology – Prof. Dr.
Bharat Mani Pokhrel