Gonorrhoea; MG; Granuloma inguinale Flashcards
Describe the typical presentation of gonorrhoea
Male genital infections can present with:
* Odourless purulent discharge, possibly green or yellow
* Dysuria
* Testicular pain or swelling (epididymo-orchitis)
Females
* Odourless purulent discharge, possibly green or yellow
* Dysuria
* Pelvic pain
Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic.
Pharyngeal infection may cause a sore throat, but is often asymptomatic.
Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination.
Conjunctivitis causes erythema and a purulent discharge.
NB: 50% of women are asymptomatic
How do you distinguish discharge between gonorrhea and chlaymdia? [1]
One of the biggest differences between gonorrhoea and chlamydia symptoms is the type of discharge (fluid) that can come from the penis or vagina - discharge from chlamydia is usually clear or milky, while discharge from gonorrhoea tends to be thicker and can be yellow, white, or green.
Investigations for gonorrhoea? [2]
Nucleic acid amplification testing (NAAT) first-catch urine sample. - first line
Rectal, endocervical, vulvovaginal, urethral and or pharyngeal swabs
TOM TIP: It is worth remembering that NAAT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA. They do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance. This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.
Current UK guidelines for uncomplicated infection of gonorrhoea
When antimicrobial susceptibility is not known prior to treatment:
[1]
When antimicrobial susceptibility is known prior to treatment:
[1]
Current UK guidelines for uncomplicated infection:
When antimicrobial susceptibility is not known prior to treatment:
Ceftriaxone 1g IM stat
When antimicrobial susceptibility is known prior to treatment:
Ciprofloxacin 500mg PO stat
Describe how you follow up a positive gonorrhoeal infection?
All patients should have a follow-up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:
72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT
TOMTIP: A key complication to remember is [] in a neonate. Gonococcal infection is contracted from the mother during birth.
Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.
Describe the risk of untreated gonoccoal infection
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
- Various non-specific skin lesions
- Polyarthralgia (joint aches and pains)
- Migratory polyarthritis (arthritis that moves between joints)
- Tenosynovitis
- Systemic symptoms such as fever and fatigue
Describe what is meant by reactive arthritis
Typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
‘Can’t see, pee or climb a tree’
- arthritis is typically an asymmetrical oligoarthritis of lower limbs
- urethritis
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
What is the name for this manisfestation of reactive arthritis? [1]
circinate balanitis
What is the name for this manisfestation of reactive arthritis? [1]
Keratoderma blennorrhagica
Neisseria gonorrhoeae are what type of bacteria? [1]
gram negative cocci
Which bacteria most commonly causes non-gonococal urethritis? [1]
Mycoplasma genitalium (MG)
How do you investigate for MG? for men [1] and women [1]
nucleic acid amplification tests (NAAT) to look specifically for the DNA or RNA if the bacteria:
- First urine sample in the morning for men
- Vaginal swabs (can be self-taken) for women
NB: The guideline recommends checking every positive sample for macrolide resistance, and performing a “test of cure” after treatment in every positive patient.
Tx for MG? [2]
The BASHH guidelines (2018) recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections:
- Doxycycline 100mg twice daily for 7 days then;
- Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
NB: Test of cure 5 weeks after starting medication is recommended.
Tx for complicated MG? [1]
Tx for MG in pregnancy or breastfeeing people? [1]
Moxifloxacin is used as an alternative or in complicated infections.
Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).
NB: Test of cure 5 weeks after starting medication is recommended.
Treatment of NGU [1]?
[] is one of several causes of genital ulcers. It is a sexually transmitted infection (STI), which is caused by the bacterium Klebsiella granulomatis. The condition is most commonly found in tropical regions.
Granuloma inguinale is one of several causes of genital ulcers. It is a sexually transmitted infection (STI), which is caused by the bacterium Klebsiella granulomatis. The condition is most commonly found in tropical regions.
Describe the clinical features that help determine someone is suffering from granuloma inguinale [1]
Granuloma inguinale is characterised by one or more nodules that transform into painless ulcers.
Patients usually develop a painless papule(s) or nodule(s) that has a ‘beefy red’ appearance due to the high vascularity.
Ulcers;
- They typically ulcerate from the middle and have friable, raised and rolled margin
Tx of granuloma inguinale [1]?
The treatment of granuloma inguinale is a minimum three week course of azithromycin.
An older female patient presents with the following on her vulva:
- white patches
- itch is prominent
- may result in pain during intercourse or urination
Lichen sclerosus
The diagnosis is usually made on clinical grounds
Tx for lichen slcerosus? [1]
Why is it important to follow up these patients? [1]
Dermovate and emollients
increased risk of vulval cancer
Name for this infection? [1]
Tx? [1]
Molluscum contagiosum through molluscum contagiosum virus (MCV)
Treatment:
- Reassure people that molluscum contagiosum is a self-limiting condition.
- Spontaneous resolution usually occurs within 18 months
Treatment is not usually recommended. If lesions are troublesome or considered unsightly, use simple trauma or cryotherapy, depending on the parents’ wishes and the child’s age:
- Squeezing (with fingernails) or piercing (orange stick) lesions may be tried, following a bath.
- Cryotherapy in adults
- Treat eczema that may surround the area using mild topical emolliant
When you would you refer someone if they have a molluscum contagiosium infection? [3]
For people who are HIV-positive with extensive lesions urgent referral to a HIV specialist
For people with eyelid-margin or ocular lesions and associated red eye urgent referral to an ophthalmologist
Adults with anogenital lesions should be referred to genito-urinary medicine, for screening for other sexually transmitted infections
