• gram^-, oxidase⁺, glucose⁺, maltose^- diplococci
• rich growth medium required
• clinical picture
  • m - prurulent discharge, edema, painful urination - prompt treatment
  • f - often cryptic - endocervicitis, discharge, or no symptoms - treatment delayed
• pathogenesis
  • pili for adherence
  • gonobactin for Fe uptake
  • IgA protease
• Other gonococcoal infections
  • disseminated --> meningitis, endocarditis, arthritis
  • conjunctivitis
  • pharyngitis
  • opthalmia neonatorum
• Immunity
  • phase variation: piliated/nonpiliated
  • antigenic variation: changes in pilin protein
    • pilE and pilS
• Diagnosis
  • culture and ID of organisms on Thayer-Martin medium
  • gram^- diplococci in urethral smears
• Treatment - penicillin if no resistance, plus azithromycin for Chlamydia
  • plasmid-borne β-lactamase
  • chromosomal-mediated resistance
  • reports of resistance to spectinomycin, tetracycline, fluoroquinolones

I. non-gonoccoal urethritis

• gram^-, EB and RB, obligate intracellular parasite
• may also be caused by Ureaplasma urealyticum
• Diagnosis - PCR, absence of gram^- diplococci
• Treatment: antibiotics that penetrate cells (not penicillin)

II. Lymphogranuloma venereum

• 1°: penile lesion
• 2°: inguinal adenitis
• fever, chills, headache, joint pain
• associated with sex holidays to tropical regions
• diagnosis - isolation in tissue culture, PCR of male urine/cervical swab
• treatment - Azythro + cephalosporin/ quinolone

• gram^-, highly motile, microaerophilic spirochete
• does not sythesize many compounds - transporters to get from host
• difficult to culture - rabbit testicles, epithelial cells
• virulence
  • attachment via terminal end structure
  • motility - dissemination to lymph and organs
  • invasion of tight jxn b/w epithelium
  • immunevasion - few surface proteins
  • phenotypic variation
• Clinical picture
  • primary: Hunterian chancre
    
    • venereal
    • hard-edged, painless lesion 10 - 90 days after infection (lots of spirochetes)
    • self-healing - clearance by CMI?
    • can also be asymptomatic
  • secondary: rash
    • 25% progress to 2° w/out treatment
    • lots of spirochetes in lesions and blood
    • 60 - 70% self-curing
  • tertiary: gummatous lesions
    • 25 - 50% of 2° progress to 3° w/out treatment
    • destruction of tissue due to body's response to treponemal Ags
    • small number of spirochetes present
    • lesions will still heal with antibiotic, but damage permanent
    • cutaneous and gummatous lesions, cardio, CNS involvement
  • latent
    • in between 1°, 2°, and 3°
    • unknown if transmissable
  • neuro
    • 2° or 3°
    • treponemes in CNS
    • loss of sensory and motor ability
    • Charcot's joint
    • Tabes dorsalis
    • diagnosed w/ CSF tests
  • congenital
    • treponems infect fetus in utero
    • fetal death or newborn with 2°/3°
    • generalized rash, Hutchinson's incisors, interstitial keratiti, gummatous infiltration
    • completely preventable by penicillin therapy early in pregnancy
• diagnosis
  • spirochetes in lesions
  • PCR and RFLP
  • non-treponemal Ag tests (not specific)
    • RPR, VDRL
    • pt serum + cardiolipid --> clump
    • non-specific Ab decline after cure
  • treponemal Ab tests
    • active and inactive (specific Ab remain high after cure)
    • FTA - killed T pallidum + pt serum + fluorescent labeled γ-globulin
    • MATP - RBCs w/ treponemes + pt serum --> clumping
• synergy with HIV
• Treatment
  • penicillin
  • Jarish - Herxheimer rxn
• Other treponemal diseases
  • Yaws
  • Pinta

• small gram^- rod, resembles Klebsiella
• normal flora of intestine
• slow progreeive ulceration of skin and mucous membranes - granuloma inguinal
• 1° lesion is a bubo that ruptures and spreads
• diagnosis
  • ID of organisms in tissue (Donovan bodies in monocytes)
  • requires rich growth medium
• uncommon in US, endemic in tropical areas
• Treatment: streptomycin + tetracyclines

• short gram^- oxidase⁺ catalase^- non-motile rod
• cultivation difficult - grows slowly on complex medium
• causes chancroid or soft chancre - irregular ulcers with soft edges, very painful
• localized to lymph nodes that swell to form bubos
• can be confused with 1° syphilis, LGV, genital herpes
• Diagnosis (exclusion - rule out other STDs)
  • gram stained smears of ulcer exudate or bubo aspirate
  • "school of fish" formation
• Treatment - erythromycin, ceftriaxone

• flagellated protozoan
• causes trichomoniasis - malodorous, brownish discharge, non-itchy
• treatment: metronidazole (Flagyl)

• polymicrobial infection associated with Gardnerella vaginalis and anaerobic Bacteroides spp.
• non-specific vaginitis with at least three of
  • excessive discharge
  • vaginal pH > 4.5
  • fishy, amine-like odor with KOH treatment
  • presence of clue cells (epithelium coated with bacteria)
• treatment: metronidazole, clindamycin

• Types
  • aymptomatic bacteruria
    • bacteria on mucosal surface of bladder
    • no damage to bladder or urethral wall
  • symptomatic bacteruira
    • bacteria penetrate deeper layers of bladder
    • frequent, urgent, painful urination (dysuria), low-grade fever
  • acute pyelonephritis
    • inflammation of renal pelves
    • fever, shaking chills, temp. spikes, flank pain, pus in urine
  • chronic pyelonephritis
    • no symptoms or periodic until renal failure develops
• complications
  • bacteremia
  • endotoxic shock
  • circulatory collapse
  • renal damage or failure
• route of infection
  • ascending from urethra
  • hematogenous spread
• types of organisms
  • community - 95% gram^- (UPEC, Proteus, Enterobacter)
• Predisposing factors - age, sex, pregnancy, diabetes, obstruction, instrumentation
• Diagnosis - "clean catch" - gram stain of unspun urine
  • adults >100,000 gram^-, >10,000 gram⁺
  • children >10,000 gram^+/-
  • infants - any counts from catheterization