The causative agent of gonorrhea microbiology. Gonorrhea

Antigens

Pathogenicity and pathogenesis

Immunity

Gonococcal infections

Taking material for research

Bacterioscopic examination

Bacteriological research

Serological diagnosis

Treatment and prevention

Gonococci - These are gram-negative, non-motile, non-capsular, non-spore-forming diplococci. In smears, the cocci are adjacent to each other with flat surfaces and are similar in outline to coffee beans. It has a cellular structure characteristic of gram-negative microorganisms, and can multiply outside and inside host cells. Has no intraspecific variants.

Neisseriae gonorrhoeae (gonococcus) is the causative agent of gonorrhea, a widespread contagious sexually transmitted infection. The disease was known to the ancient Chinese, Egyptians, and Jews. It got its name from two Greek words gone - seed and rhein - expiration, that is, a disease transmitted by seminal fluid. That's what Galen called it at the beginning of the new era. Gonococci also called diplococci - this name was given to it by the German doctor Albert Neisser, who in 1879 discovered it in the purulent discharge of the urethra, cervix and conjunctiva of the eyes. The pathogen was named after Neisseriae gonorrhoeae.

Gonococci. general characteristics

Gonorrhea is a disease accompanied by discharge from the urogenital tract, initially liquid, watery, and then purulent. The incubation period is short - 3-5 days. In the first days of the disease, gonococci are found freely lying in the serous exudate or attached to epithelial cells. When the discharge becomes purulent, the cocci are phagocytosed and can be seen in the cytoplasm of the pus cells (dolimorphonuclear neutrophilic leukocytes). One cell can contain from 20 to 100 gonococci, which, being absorbed, do not die and remain virulent. In the late stage of the disease, they can be found outside the cells; in the stage of formation of a chronic process, they are often not detected at all.

Gonococci - very fastidious microbes, they do not grow on ordinary nutrient media; it is difficult to cultivate them on enriched media specially prepared for them. They grow better at slightly lower temperatures (up to 35.5°C) in the presence of oxygen and 10% CO 2 .

4 types of colonies have been described:
– gonococci types 1 and 2 are formed by virulent gonococci;
– gonococci types 3 and 4 – non-virulent.
Cocci that form ears of types 1 and 2 have pili - an adhesion factor. It is with pili that the bacterium attaches to the cells of the cylindrical epithelium of the urethra, uterine leukemia, and rectum and is not phagocytosed, but colonizes the cells of these sections (colonization). Attachment is a necessary condition for infection; only bacteria that have pili are considered pathogenic.

Gonococci produce the enzyme indophenol oxidase, which catalyzes the reduction of molecular oxygen independently of hydrogen peroxide. The oxidase test is used to identify colonies in laboratory cultures. Gonococci , belonging to all types, produce an enzyme that breaks down secretory IgA, located in the secretions of the mucosa.

Despite the fact that gonococci are difficult to destroy in the patient’s body, they are extremely unstable in the external environment. They die very quickly in sunlight and when dried. In pus or on linen in a dark, damp place, it can persist for 18 to 24 hours. Very sensitive to disinfectants, especially silver salts. Temperature +60°C kills them in 10 minutes.

Although gonococci sensitive to the effects of modern antibiotics, drug resistance is becoming an increasingly serious problem, especially in the case of penicillinase-producing strains of N.gonorrhoeae. These strains were first discovered in the United States in early 1976, and were imported from Southeast Asia and the Philippines. The gene producing penicillinase (β-lactamase) in gonococci is located in plasmids with nucleotide sequences similar to those that determine resistance to penicillin in some gram-negative enterobacteria. Some gonococci can transmit their 3-lactamase plasmids by the “sexual” (conjugative) route.

Gonococci. Pathogenicity

Gonococci damage the columnar epithelium lining the cervix and rectum, as well as the intermediate (urogenital) epithelium lining the urinary tract. Vaginal infection is not detected, since the epithelium lining the vagina of an adult woman is keratinizing stratified squamous epithelium, resistant to gonococci. Before puberty, the vagina is lined with softer, especially receptive epithelium. Gonorrheal vulvovaginitis in prepubertal girls can be epidemic and difficult to cure. Changes in the epithelium with the end of puberty completely eliminate this form of gonorrhea.

Currently, an important primary site of infection is the conjunctiva of the eye, and this process (gonorrheal conjunctivitis and keratitis) actively damages the eyes. Ophthalmia neonatorum - gonorrheal conjunctivitis of newborns, occurs when the eyes of the fetus become infected during passage through the birth canal. Copious purulent discharge from a newborn's eye can create significant pressure under the eyelids. If the eyelids are forcibly opened, pus may spurt out. Doctors and medical personnel treating these children must carefully protect their eyes. In children or adults, such an infection easily leads to blindness or severe visual impairment due to inflammatory changes in the structures of the eye.

Gonococcal infection from the male urethra can directly spread to other parts of the male reproductive system. In women, it can also invade other parts of the tract, especially the Bartholin's glands and fallopian tubes.

The uterine mucosa is resistant to the effects of gonococci, but the use of contraceptives can facilitate the penetration of gonococci into the endometrium, increasing the risk of complications in the fallopian tubes. Infection of the fallopian tubes usually occurs in the first or second menstrual cycle after infection, but in some cases it occurs later.

Involvement of the fallopian tubes (salpinitis) in the inflammatory process leads to significant twisting and scarring when the disease takes a chronic form.

Scarring of the male urethra can lead to stricture or obliteration of the urethra at one or more focal points.

Sometimes gonococci migrate from the genitourinary tract to the lymphatic system or bloodstream, forming distant foci of infection (for example, endocarditis, perihepatitis and meningitis).

Gonococcemia is associated with various skin lesions from which microorganisms can be isolated. A significant manifestation of extragenital gonococcal infection is purulent destructive arthritis, which is especially common in people aged 15 to 35 years. With an increase in the number of cases of gonorrhea, extragenital lesions become more noticeable.

Gonococci. Sources and routes of infection

Gonococci are never found outside the human body unless they are found on objects most recently contaminated with gonorrheal secretions. Therefore, gonorrheal infections are almost always spread through direct contact, mainly through sexual intercourse. It is extremely rare that gonorrhea is transmitted indirectly through contaminated objects,

Gonorrheal ophthalmia in adults is usually accidental. An infection from the urogenital tract is unintentionally brought into the eyes by the hands of the patient himself or another person.

Vulvovaginitis among children is spread by sharing bedding, baths, toiletries, etc. It usually occurs where children live in overcrowded apartments.

Untreated gonorrheal infections tend to become chronic. In the absence of treatment or improper treatment, women become bacteria carriers for many years after the disappearance of signs of the disease. In 60-80% of infected women, the disease is asymptomatic. In approximately 40% of men, the disease is also asymptomatic.

Gonococci. Laboratory diagnosis of infection

Several microbiological methods are used to establish the diagnosis of gonorrhea. Smears, cultures and oxidase reactions are preliminary tests. To establish an accurate diagnosis of gonorrhea and confirm the results of preliminary tests, the method of fluorescent antibodies and the carbohydrate fermentation reaction are used.

Bacterioscopic diagnostics. Direct smears of genital secretions can be Gram stained. The detection of gram-negative diplococci in purulent cells of genital exudate is a strong argument in favor of the fact that these are gonococci. This is especially true if the discharge is taken from the male urethra, where, in the case of typical acute purulent urethritis, a Gram-stained smear containing clearly visible intracellular diplococci suggests an unequivocal diagnosis.

In women, typical diplococci can be detected in smears of material taken from the Bartholin's glands and Skene's glands at the early stage of the disease. But based on this alone, it is impossible to make even a working diagnosis.

Reasons why:
1. gram-negative diplococci (but not gonococci) are found outside cells;
2. gonococci alone or in pairs are found outside cells;
3. Gram-positive microorganisms with the morphology of gonococci are found in the cells.

All that can be said about Gram-negative diplococci found outside cells is that they may be gonococci. Very rarely, gram-negative dip-lococci that are not gonococci are found inside the purulent cells of genital exudate.

The smear prepared from gonorrheal exudate must be very thin. Gonococci react to Gram staining in such a way that if the smear is thick and uneven in thickness, an erroneous result may be obtained. In the case of chronic gonorrhea, microbes are usually not found in the exudate.

Cultural methods are of particular importance in diagnosing chronic diseases and assessing the effectiveness of treatment. Cultivation of “tender” gonococci is possible only on specially enriched media (blood agar, ascites agar, etc.). The most suitable are special media with the addition of antibiotics that suppress the growth of fungi and bacteria of the genus Proteus, but to which gonococci are insensitive,

Special transport media have been developed that allow suspect cultures to be sent for further identification. In this case, test tubes with screw caps containing the medium and a mixture of air and CO 2 are used. After inoculation of the material, the growth of gonococci is maintained for 48-96 hours.

According to modern recommendations, material suspicious for the isolation of gonococcal culture should be obtained not only from the urogenital tract (endocervical canal, anterior urethra), but also from the anorectal region and pharynx. Rectal gonorrhea can be easily viewed. Careful work with the use of tampons is necessary when examining homosexual men. In women, cervical and rectal swabs are necessary, since in 50% of infected women gonococci are deposited in the rectal area. The infection may remain there even after it disappears from the cervix.

Sterile cotton swabs often contain fatty acids and other substances that inhibit the growth of gonococci. Therefore, it is recommended to use neutral swabs, such as calcium alginate, for collecting samples.

Gonococci can be obtained from the urine of men if the first 10 ml of excreted urine is centrifuged and the sediment is cultured. With a simpler screening method, the first few drops of urine that fall on a dry swab are immediately transferred to the medium. Urine cultures in screening programs help identify the source of infection among asymptomatic men.

The next step in the bacteriological study of gonococci is a qualitative analysis of biochemical reactions and identification of microorganisms using antisera. The presence of a specific K-antigen in gonococci makes it possible to use the method of fluorescent antibodies when gonococci are detected in direct smears or exudate, or in smears prepared on cultures.

Gonococci. Social significance of gonorrhea

Gonorrhea has far-reaching medical, social, psychological and even forensic consequences. The disease has acquired a character close to a pandemic - according to the most probable estimates, from 2.5 to 3 million new cases are registered annually in the world, approximately 1 case every 15 seconds. More than half of the cases are teenagers and young people under 25 years of age. Gonorrhea is registered not only among adolescents, but also among children who have not reached puberty. Any discharge from the vagina or urethra in children should be suspicious.

Although the ratio of cases in men and women is approximately 1:1, there are usually three treated men per woman. Manifestations of the disease in men are more acute and unpleasant, which forces them to seek medical help more often. In women, the disease is often asymptomatic or with mild symptoms. Many of them are diagnosed only as a result of information received from their sexual partners. The “silent” reservoir of asymptomatic women is a primary obstacle to disease control. It is recommended that screening for gonorrhea be considered an essential part of prenatal care, and routine isolation should be performed more frequently during routine gynecological examinations.

The most harmful is the information passed down from generation to generation that gonorrhea is no more dangerous than a runny nose. This false conclusion downplays the danger of gonorrhea and creates the impression that the “cold” is not accompanied by complications.

It has been noted that gonorrhea is the most common cause of infertility in both sexes. In women, sterility is caused by obliteration of the fallopian tubes by scar tissue formed during the resolution of gonorrheal salpingitis. In men, sterility is due to obliteration of the seminal ducts, caused by a similar process of gonorrheal infection and resolution of the inflammatory process with subsequent scarring.

Gonococci. Immunity

Infection with gonorrhea provides little or no immunity to subsequent infections. The antibody response is weak. The apparent immune deficiency may be the main reason why the disease remains endemic in the human population. There is marked sensitivity to re-infection. Relative type-specific immunity to gonorrhea is due to opsonins.

Gonococci. Prevention

The population should be educated about the dangers of gonorrhea and the difficulty of its treatment. Unfortunately, the widespread use of chemotherapy drugs and antibiotics in everyday life has created the impression that treating gonorrhea is not a problem. The danger of self-medication, the use of “folk remedies,” and turning to incompetent persons, self-proclaimed “healers,” should be especially emphasized. Patients should not soil toilets with secretions, and they should be warned about the danger of introducing infection into their eyes with their hands. Neonatal ophthalmia can be prevented using the Crede method. Immediately after birth, the baby's eyelids are washed with sterile water. To wash each eye, use a separate swab, which is passed from the nose outwards. Next, the eyelids are opened and 1-2 drops of a 1% solution of silver nitrate are instilled into each eye, strictly ensuring that the entire conjunctival sac is completely covered with the solution. After 2 minutes, the eyes are irrigated with isotonic saline solution.

Vulvovaginitis in children can be prevented by proper cleaning of bedding, nightwear, wash water and bath water. All children should be screened for gonorrhea before they are allowed to have contact with other children in childcare facilities or hospitals. Doctors and medical personnel using rubber or plastic gloves for palpation and examination of the cervix and vagina should replace these gloves before digital examination of the rectum.

Due to the fact that not only gonorrhea is transmitted sexually, every gonorrheal patient must undergo serological testing for syphilis and HIV infection.

The gonococcal vaccine was obtained by isolating and purifying the pili protein. Its effect is that the antibodies produced by the recipient envelop the villi of any gonococcus that has entered the human body, which prevents the bacteria from fixing on the host cells and, thereby, preventing the development of the disease.

There is a gonococcal vaccine (gonovaccine), which is a suspension of an inactivated culture of gonococci in a 0.9% sodium chloride solution. It is used in diagnosis (establishing a cure for gonorrhea), and as an auxiliary method of treatment for sluggish relapses, for fresh torpid and chronic forms of the disease. Prescribed to men with complicated and women with ascending gonorrhea (after acute inflammatory phenomena have subsided).

Conclusion

2. Gonococci (causative agents of gonorrhea) are diplococci that can be located intra- and extracellularly.

3. Neisseria grow only in an atmosphere containing 10% CO2, and only in specially enriched media.

4. Gonococcus pili are a structure that ensures the attachment of the microbe to the columnar epithelium of the mucous membrane.

5. Gonococci from the primary focus of infection (epithelium of the urethra, cervix, rectum) spread to other parts of the body, including the reproductive organs. With repeated infections, deformation of the fallopian tubes occurs due to the formation of scars. Complete obstruction is possible. In men, scarring leads to a narrowing (structure) of the urethra.

6. One of the forms of manifestation of gonococcal infection in adults and, especially, newborns is a specific purulent inflammation of the conjunctiva. The process sometimes involves the tissues of the eye, which can lead to serious visual impairment.

7. Ophthalmia neonatorum is a gonococcal infection that occurs when a fetus passes through an infected birth canal. For the purpose of prevention, all newborns are injected with silver nitrate into the conjunctival sac of both eyes (Crédé method).

Gonorrhea is an infectious disease caused by gonococci of the genus Neisseria and sexually transmitted.

Acute inflammation of the urethra in men, the urethra and cervix in women is usually accompanied by the discharge of pus. This is what gave Galen the foundation in the 2nd century AD. suggest the term "gonorrhea". Although this name gives a misconception about the essence of the disease (the exact translation is “semen”), it has been preserved, completely replacing the previously used terms “blennorrhea” and “gonorrhoea”. However, infectious diseases with the discharge of pus from the urethra were known long before Galen. Only the discovery in 1879 by the German scientist Neisser of a special microorganism in the pus of a patient with urethritis, which naturally causes inflammation of the genitourinary organs in humans, made it possible to consider gonorrhea as an independent venereal disease.

Etiology. The causative agent of gonorrhea is gonococcus - a gram-negative diplococcus of bean-shaped form, 1.25-1.6 µm long and 0.7-0.9 µm wide. Gonococci stain well with all aniline dyes. In acute processes, stained smears reveal a large number of gonococci inside leukocytes (Fig. 123, 124). In later (chronic) stages of the disease, when the discharge becomes scanty, gonococci are less common, and to detect them it is sometimes necessary to resort to provocation and cultural diagnosis.

In a scanning electron microscope, gonococci appear as spherical or diplococcal formations with a slightly bumpy surface.

When studying ultrathin sections of gonococci, it is possible to identify a cell wall, a cytoplasmic membrane, cytoplasm with numerous ribosomes, mesosomes, and a nucleoid with DNA strands. On the surface of gonococci, thin tubular filaments are revealed - pili, which are associated with their ability to genetically transmit certain properties, in particular resistance to antibiotics. A capsule-like substance identified by electron microscopy ensures the adaptation of the pathogen to unfavorable conditions and its persistence in the patient’s body. The cytoplasmic membrane is related to cell metabolism.

Under unfavorable conditions, L-transformation of gonococci with loss of the outer cell membrane is possible. Gonococci grow on

artificial nutrient media in the presence of human protein (ascitic agar) at a temperature of 37 °C.

Certain strains of gonococci produce penicillinase, which contributes to their resistance to penicillin and its derivatives. In many countries, recently, when treatment fails, gonococci producing penicillinase or β-lactamase are increasingly being isolated.

Epidemiology. Gonococci outside the human body quickly die. Various antiseptic drugs, heating above 56 ° C, drying, and direct sunlight have a detrimental effect on them. Gonococci do not tolerate temperatures below the optimal temperature and die quickly at 18 °C. In pus, gonococci remain viable and pathogenic until the pathological substrate dries (from 30 minutes to 4-5 hours). Infection usually occurs through sexual contact

in direct contact of a healthy person with a sick person (or an apparently healthy carrier). Occasionally, infection occurs not through sexual intercourse, but through infected toilet items and underwear, more often in little girls who become infected from their mothers. During anal or oral intercourse, gonococcal infection of the rectum, nasopharynx, oral mucosa, and tonsils may occur. Eye infection in adults is possible when introducing gonococci with dirty hands. In newborns, eye infection occurs when sick mothers pass through the birth canal.

The increased susceptibility of the mucous membranes of the genitourinary organs, rectum, nasopharynx, mouth, tonsils, conjunctiva is explained by biochemical, hormonal, immune and anatomical and physiological

Rice. 123. Gonococcus (methylene blue stain)

Rice. 124. Gonococcus (Gram stain)

characteristics of the body. Gonococci preferentially infect mucous membranes covered with columnar epithelium.

Immunity. With gonococcal infection, there is both a humoral and cellular response, but immunity does not develop to prevent reinfection. Antigonococcal antibodies found in blood serum belong to different classes of immunoglobulins (IgG, IgM, IgA).

A significant proportion of those who have recovered from gonorrhea become infected with it again and even repeatedly, despite the high titer of specific antibodies in the blood serum and the pronounced sensitization of lymphocytes to gonococci. In addition to reinfection, superinfection is also possible if the gonococcus remains in the body. Relative immunity to a homologous strain of gonococcus is known in “familial gonorrhea,” when gonococci do not cause any noticeable inflammatory reaction in their permanent carriers, but cause an acute illness when infecting third parties. Superinfection with foreign pathogens of regular sexual partners is accompanied by a clinical picture of acute gonorrhea.

Currently, the country has put into practice the International Statistical Classification of the X revision with the following classification of gonorrhea.

A54 Gonococcal infection

A54.0 Gonococcal infection of the lower parts of the genitourinary tract without abscessation of the periurethral and accessory glands Gonococcal:

Cervicitis NOS

Cystitis NOS

Urethritis NOS

Vulvovaginitis NOS

A54.1 Gonococcal infection of the lower genitourinary tract with abscess formation of the periurethral and accessory glands

A54.2 Gonococcal pelvioperitonitis and other gonococcal infections of the genitourinary organs

Gonococcal (oe);

Epididymitis

Inflammatory disease of the pelvic organs in women

Orchitis

Prostatitis

A54.3 Gonococcal eye infection

Gonococcal

Conjunctivitis

Iridocyclitis

Gonococcal ophthalmia of newborns

A54.4 Gonococcal infection of the musculoskeletal system

Gonococcal:

Arthritis

Bursitis

Osteomyelitis

Synovitis

Tenosynovitis

A54.5 Gonococcal pharyngitis

A54.6 Gonococcal infection of the anorectal area A54.8 Other gonococcal infections Gonococcal (s):

Brain abscess

Endocarditis

Meningitis

Myocarditis

Pericarditis

Peritonitis

Pneumonia

Sepsis

Skin damage.

Infection of men with gonococcus, as a rule, leads to the appearance of subjective symptoms that force them to seek medical help. In women, gonococcal infection is often mild or asymptomatic and is detected during examinations of sexual partners or when complications develop. Apparently, this can explain the lower number of women seeking medical help.

This necessitates screening for gonorrhea in women at high risk of infection.

28.1. Gonorrhea in men

The entrance gate for gonococci in men is the urethra. In the first 2 hours, gonococci linger at the site of introduction and can be destroyed using personal prevention methods. On the mucous membrane of the anterior part of the urethra (up to the external sphincter), gonococci quickly multiply, spreading over its surface.

ity, and penetrating between epithelial cells into the connective tissue layer, into the urethral glands and lacunae. Gradually, gonococci penetrate the posterior urethra. In this case, there is a danger of damage to the seminal vesicles, prostate gland, and epididymis. The incubation period for gonorrhea is often 3-5 days, but can sometimes be 1-15 days or more.

Clinical picture. In men, they distinguish between fresh, subdivided into acute, subacute and sluggish (torpid); chronic; latent gonorrhea. All forms of gonorrhea can be accompanied by a variety of local and distant (metastatic) complications.

Gonorrheal urethritis manifested by the release of inflammatory exudate from the urethra and pain. In acute inflammation, significant hyperemia and swelling of the sponges of the external opening of the urethra are noted. A large amount of yellowish-green or pale yellow pus is discharged from the urethra. Sometimes a slight burning or itching precedes mucopurulent discharge. Signs of inflammation quickly increase, and after 1-2 days anterior acute gonococcal urethritis forms. Patients feel pain and pain when urinating. In subacute anterior fresh gonococcal urethritis, the discharge is mucopurulent, not abundant, inflammation of the sponges of the external urethral opening is mild, and subjective sensations are insignificant. With torpid fresh gonococcal urethritis, there are no subjective sensations, the discharge is scanty or almost imperceptible. The sponges of the external opening of the urethra are not changed. Patients in this case often do not seek medical help and are the most dangerous in epidemiological terms.

In the future, with gonorrhea, even without treatment, the inflammatory reaction gradually decreases, subjective disorders weaken. Urethritis passes into the subacute and then into the chronic stage.

If gonococci from the anterior urethra enter the posterior urethra, acute total urethritis (urethrocystitis) occurs. The patient experiences an imperative urge to urinate, at the end of which there is a sharp pain (terminal). The amount of urine is very small. Sometimes a drop of blood appears at the end of urination (terminal hematuria). In some cases, with severe inflammation, fever and malaise are observed.

Diagnostics both anterior and total acute gonococcal urethritis does not present any difficulties. It is based on medical history, a typical picture of the disease, and a two-glass urine sample.

and is confirmed by laboratory detection of gonococci (microscopically and culturally). If the inflammatory process is limited to the mucous membrane of the anterior urethra, then when sequentially releasing urine into two glasses, the urine in the first glass, washing away pus from the urethra, will be cloudy, and in the second – transparent.

With total urethritis, the urine in two glasses will be cloudy, since pus from the posterior urethra flows into the bladder due to incompetence of the internal sphincter (total pyuria).

Chronic gonococcal urethritis develops as a result of transformation of fresh gonorrheal urethritis. The lesion is focal - inflammation of individual areas of the mucous membrane, lacunae and glands. In cases where only the anterior part of the urethra is affected, subjective sensations are mild and sometimes absent. The inflammatory process is detected only when discharge appears or the urethral sponges stick together after a night's sleep. The discharge is scanty, mucopurulent, in the form of a single drop. With chronic damage to the posterior part of the urethra, painful ejaculations, frequent urination and pain at the end of urination are noted. Disorders of the functions of the genital organs are observed: libido decreases, erection weakens, premature ejaculation occurs, and sometimes there is an admixture of blood and pus in the ejaculate. Latent chronic gonorrhea may not be accompanied by subjective sensations. An objective symptom is the sticking of the urethral sponges in the morning, sometimes the discharge may increase (after walking, physical stress, drinking alcohol, sexual intercourse). In some cases, there is so little discharge that it is washed out with urine in the form of separate threads and flakes, noticeable in the first portion of urine in a two-glass sample.

Laboratory diagnosis of gonorrhea. In the diagnosis of gonorrhea, laboratory data are critical. Etiological diagnosis is carried out using bacterioscopic (examination of discharge with obligatory methylene blue and Gram staining) and bacteriological methods (inoculation of discharge on special nutrient media). Diagnosis of gonorrhea is based on identifying the pathogen Neisseria gonorrhoeae in discharge from the urethra, from the cervix, from the rectum, oropharynx, from the conjunctiva, etc. The discharge is applied in a thin layer to a glass slide, dried, fixed with ethanol, then stained with a 1% solution of methylene blue and Gram staining. Stained preparations are viewed in a light-optical microscope at a magnification of 10 100 with immersion.

In a preparation stained with a 1% solution of methylene blue, the nuclei of epithelial cells and polymorphonuclear neutrophils are colored blue, the cytoplasm is blue of varying intensity. Gonococcus is dark blue in color, bean-shaped, located in pairs. The outer surface of the cocci is convex, with their concave side facing each other. The arrangement of gonococci resembles the shape of a coffee bean.

Gonococci are located intracellularly in relation to leukocytes and superficially in relation to squamous epithelial cells. Inside leukocytes, each pair of diplococci is located at an angle to the neighboring one.

The defining differential diagnostic feature is obtained by Gram staining: gonococcus is a gram-negative diplococcus.

When kept briefly in a bleaching solution (a mixture of ethyl alcohol and acetone), gonococci stained with crystal violet give off a purple dye and are stained with a red dye (safranin).

If bacterioscopy reveals typical gonococci, then a cultural examination is not performed. To accurately determine the localization of the inflammatory process in the urethra, a two-glass test is used. More accurate topical diagnosis is possible using urethroscopy, but can only be performed for chronic gonorrhea. In acute disease, urethroscopy can contribute to the spread of infection to the upper parts of the genitourinary system.

Differential diagnosis gonorrheal urethritis with urethritis of another etiology (viruses, yeast-like and other fungi, various cocci, trichomonas, chlamydia, mycoplasma, etc.) due to the great similarity of the clinical picture is possible practically only according to the results of bacterioscopic and bacteriological studies.

Complications. Acute gonorrheal urethritis can be complicated by balanitis, balanoposthitis and inflammatory phimosis, which are similar to processes of non-gonococcal etiology. A rare complication is tizonitis (abscess of the foreskin glands - tizon glands) with moderately painful erythematous swelling near the frenulum of the foreskin. Inflammation of the paraurethral canals (paraurethritis) has the appearance of a pinpoint, slightly infiltrated and hyperemic opening on the urethral sponges. The alveolar-tubular mucous glands (glands of Littre) and lacunae (lacunae of Morgagni) located in the urethra are always affected by gonococci (litreitis and morganitis). With littreitis, peculiar purulent filaments in the form of a comma appear in the first portion of urine,

These are casts of the ducts of the urethral glands. Infection with gonococci of the excretory ducts of the bulbourethral glands (Cooper's glands) - cooperitis usually goes unnoticed. Only with abscess formation do throbbing pains in the perineum, pain during defecation and frequent urination occur. Body temperature rises to 38 °C and above.

Persistent stricture becomes the outcome of chronic gonococcal urethritis. Strictures can be single or multiple, 0.5-1.5 cm long. One of the first symptoms of a stricture is delayed emptying of the bladder.

Gonococcal epididymitis occurs due to the penetration of gonococci into the epididymis from the prostatic urethra through the vas deferens or, bypassing it, through the lymphatic vessels. This is facilitated by antiperistaltic contractions of the vas deferens, which occur as a result of irritation of the inflamed seminal mound, sexual arousal, and physical stress. Gonorrheal epididymitis usually develops acutely. Pain appears in the area of ​​the epididymis and in the groin. The testicle itself remains unchanged. In patients, body temperature rises (up to 40 ° C), chills, headache, and weakness appear. The skin of the scrotum is tense and hyperemic. The epididymis is enlarged, covers the testicle above, behind and below, dense and painful. In subacute and chronic epididymitis, pain is mild, swelling and hyperemia of the skin may be absent, body temperature is normal or subfebrile, and the patient’s well-being does not deteriorate.

Gonococcal testicular infection may occur when inflammation passes from the epididymis to the testicle, but this is rare. More often, the inflammatory process involves the membranes of the testicle, causing accumulations of exudate (acute periorchitis). In such cases, a fluctuating formation is palpated in the affected half of the scrotum, in which the epididymis cannot be identified.

Gonococcal lesions of the prostate gland may be acute or chronic. There are catarrhal, follicular and parenchymal prostatitis. Prostatitis is often combined with inflammation of the seminal vesicles - vesiculitis. If the inflammatory process is limited to the excretory ducts, then catarrhal prostatitis is formed, there are no subjective disorders, and the disease remains asymptomatic. The spread of lesions to the lobules of the gland with the development of pseudo-abscesses in them is characteristic of follicular prostatitis. In this case, the symptoms of the disease are clearly expressed. In the crotch

there is a feeling of heat, pain occurs at the end of urination. Chills and severe malaise may occur. On palpation, the prostate gland is of normal size, but may be enlarged. Among the normal tissue of the gland, painful compactions are palpated.

Acute parenchymal prostatitis is accompanied by severe general disorders with increased body temperature, pain in the perineum and above the pubis, and dysuric disorders. Rectal examination reveals a diffusely enlarged, painful, dense prostate. When purulent melting of the infiltrate occurs, a prostate abscess occurs. In these cases, pathological phenomena sharply intensify until acute urinary retention. Chronic prostatitis has a protracted course with discharge from the urethra, itching and burning. The secretion of the prostate gland is often released after urination (mictional prostatorrhea) or during defecation (defecatory prostatorrhea). Various functional disorders of the genitourinary system appear, weakening of erection, decreased libido, premature ejaculation. In the secretion of the inflamed prostate gland, an increased content of leukocytes is detected, a decrease in the number of lipoid grains, and sometimes their complete absence, and the phenomenon of crystallization of the secretion is disrupted. Gonococci are rarely detected during bacterioscopic examination and more often during bacteriological examination. With any form of gonorrhea, changes in the blood are observed: anemia, leukopenia or leukocytosis, eosinophilia, neutrophilia and monocytosis. ESR is often elevated in acute gonorrhea.

28.2. Gonorrhea in children

Due to the increase in morbidity in adults, cases of gonorrhea in children have increased significantly. Both boys and girls can get gonorrhea, but gonorrhea infection occurs 10-15 times more often in girls than in boys. The development of the gonococcal process in children determines favorable conditions for the life of the pathogen in the genitourinary system. Children aged 5 to 12 years are most often affected. 90-95% of children become infected through extrasexual contact.

Newborns become infected at birth, through contact with the mother's infected birth canal, and also in utero. There are cases of nosocomial infection in maternity wards from service personnel. Infection of children in children's institutions is caused by the shared use of chamber pots and common intimate toilet items. Spread of infection

in children, overcrowding in boarding schools, orphanages, kindergartens, sanatoriums, etc. contributes. Gonorrhea in children can be a consequence of violation of hygiene rules when in contact with adult patients, as well as the use of infected objects.

The frequency of infection with gonococci in girls depends on age, level of immunity and hormonal state. During the newborn period, gonorrhea is rarely observed as a result of passive maternal immunity and maternal estrogenic hormones. At the age of 2-3 years, passive protective maternal antibodies are depleted, estrogen saturation decreases. During this period, the condition of the mucous membrane of the external genitalia and vagina changes. In the cells of the cylindrical epithelium, the glycogen content decreases, the activity of diastase decreases, the vaginal discharge becomes alkaline or neutral, Dederlein's bacilli disappear, and pathogenic microbial flora is activated. Between the ages of 2-3 and 10-12 years, children are susceptible to many infections and can become infected with gonorrhea through extrasexual contact. In subsequent years, due to the activation of the function of the endocrine glands, the level of glycogen in epithelial cells increases, vaginal discharge becomes acidic, and the population of Dederlein bacilli is restored, displacing pathogenic flora.

Clinical picture. Damage to the mucous membranes occurs immediately after contact with gonococci, but subjective and objective symptoms of the disease appear after an incubation period ranging from 1-2 days to 2-3 weeks.

There are fresh gonorrhea lasting up to 2 months, chronic - more than 2 months and latent. Fresh gonorrhea is divided into acute, subacute and torpid. Fresh acute gonorrhea in girls begins with pain, burning and itching in the perineum, increased body temperature and dysuric phenomena. The process involves the labia minora, the mucous membrane of the vaginal vestibule, the vagina itself, the urethra and the lower rectum. In the affected areas, severe swelling, hyperemia of the mucous membrane and copious mucopurulent discharge are observed. The mucous membrane of the external genitalia is sometimes macerated and eroded. With insufficient care, the skin of adjacent areas becomes irritated by purulent discharge, macerates and becomes inflamed. An active inflammatory process may be accompanied by enlargement of the inguinal lymph nodes, the occurrence of polypous growths at the entrance to the vagina and the external opening

urethra. The process often spreads to the vaginal part of the cervix, the mucous membrane of the cervical canal, and the urethra (anterior and middle parts). The external opening of the urethra is dilated, the urethral sponges are swollen and hyperemic. When pressing on the lower wall of the urethra, purulent contents are released. Dysuric phenomena are pronounced, including urinary incontinence. Often the mucous membrane of the lower rectum is involved in the process, which is manifested by edematous hyperemia and mucopurulent discharge detected during defecation.

Acute gonorrhea in older girls can be complicated by inflammation of the excretory ducts of the large glands of the vestibule, paraurethral ducts. Inflamed red dots are clearly visible in the area of ​​the excretory ducts - maculae gonorrhoicae.

In subacute forms of gonorrhea, inflammatory changes are less intense. There is slight edematous hyperemia of the mucous membranes of the vestibule of the vagina, urethra, labia minora and majora with scant serous-purulent discharge. Vaginoscopy reveals clearly limited areas of hyperemia and infiltration on the vaginal walls, and a small amount of mucus in the vaginal folds. In the area of ​​the cervix, erosions are detected against a background of mild swelling and hyperemia. Pus is usually discharged from the cervical canal.

Chronic gonorrhea in girls is detected during the period of exacerbation. Sometimes chronic gonorrhea is discovered during a clinical examination or after parents notice suspicious stains on the child’s underwear. These girls experience slight swelling and hyperemia of the mucous membrane of the posterior commissure of the lips and folds of the hymen. Vaginoscopy reveals the affected last third of the vagina, especially in the posterior part of the fornix, where the mucous membrane is hyperemic and granular - granulosa vaginitis. The urethra is always affected, but the symptoms of inflammation are mild, and dysuric symptoms are insignificant or absent. Chronic gonorrheal proctitis is found in almost all patients. The main symptoms of the disease are slight redness of the sphincter mucosa with erosions or cracks, as well as a network of dilated vessels on the skin of the perineum. In the stool you may notice an admixture of pus and mucus. Rectoscopy reveals hyperemia, edema, and purulent accumulations between the folds. Damage to the paraurethral passages and large glands of the vestibule in chronic gonorrhea is observed.

are given more often than with the fresh form, but the symptoms are usually erased. As a rule, point hyperemia of the excretory ducts of the large glands of the vestibule is detected. Involvement of the overlying parts of the genital organs in the process occurs less frequently, especially at the age of functional rest. Menstruating girls may develop ascending gonorrhea affecting the uterine appendages and pelvic peritoneum. In such cases, the disease is acute, with chills, high body temperature, vomiting, severe abdominal pain and other signs of peritonitis. With ascending gonorrhea in girls, “benign gonococcal sepsis” can form, in which soreness of the uterus and peritoneum in the pelvic area is noted.

Most often, gonococcal infection in pre-adolescent children is the result of sexual abuse.

Treatment: ceftriaxone 125 mg intramuscularly once (for body weight less than 45 kg). Spectinomycin can be used at a dose of 40 mg/kg (not more than 2.0 g) intramuscularly once.

In children weighing more than 45 kg, treatment of gonorrhea is carried out in accordance with adult treatment regimens and taking into account contraindications.

Gonorrhea is much less common in boys than in girls. Boys become infected through sexual contact, and very young children become infected through household contact. Gonorrhea in boys occurs in almost the same way as in adult men, but less acutely and with fewer complications, since the prostate gland, seminal vesicles and glandular apparatus of the urethra are poorly developed before puberty.

Ocular gonorrhea is a common manifestation of gonococcal infection of newborns (gonococcal conjunctivitis). A newborn becomes infected when passing through the birth canal, but intrauterine infection with amniotic fluid is possible. Cases of infection of a child by nursing staff or transmission of infection from an infected newborn to medical staff and other children are very rare. The incubation period ranges from 2 to 5 days. With intrauterine infection, the disease can appear on the 1st day of life. Gonococcal conjunctivitis is manifested by significant swelling of both eyelids, photophobia, and copious purulent discharge from the eyes. Without treatment, inflammation affects not only the conjunctiva, but also the cornea, which can lead to ulceration, followed by scarring and loss of vision. Treatment is carried out with antibiotics with simultaneous instillation of a 30% sodium sulfacyl solution into the eyes

(albucid) every 2 hours. For prophylactic purposes, after birth, all children's eyes are wiped with a sterile cotton swab and a freshly prepared solution of 30% sodium sulfacyl is instilled into each eye. 2 hours after the child is transferred to the children's ward, instillation of a fresh (one-day preparation) 30% solution of sulphacil sodium into the eyes is repeated.

Treatment of gonococcal conjunctivitis carried out with ceftriaxone at a dose of 1.0 g intramuscularly once. Local treatment: 1% silver nitrate solution, 1% tetracycline, 0.5% erythromycin eye ointments.

Gonococcal infection in newborns

Infection of newborns occurs when a mother with gonorrhea passes through the birth canal.

Gonococcal infection manifests itself in a child on the 2-5th day of life and includes ophthalmia of the newborn, rhinitis, vaginitis, urethritis, septic conditions, including arthritis and meningitis.

Treatment of ophthalmia of newborns

Ceftriaxone - 25-50 mg/kg (but not more than 125 mg) intramuscularly or intravenously once a day for 2-3 days. Treatment is carried out with the involvement of neonatologists, ophthalmologists, and neurologists.

In premature infants and children with elevated bilirubin, ceftriaxone is used with extreme caution.

Prevention of ophthalmia in newborns

Prevention of ophthalmia should be carried out on all newborns immediately after birth with one of the following drugs.

Silver nitrate - 1% aqueous solution once.

Erythromycin - 0.5% eye ointment once.

Tetracycline - 1% eye ointment once.

Treatment of complications of neonatal gonococcal infection

Complications of neonatal gonococcal infection include sepsis, arthritis, and meningitis. To establish a diagnosis, a cultural examination of blood, cerebrospinal fluid and other clinical material is necessary for identification, followed by a study of the enzymatic properties of the isolated strains N. gonorrhoeae. Prescribed:

Ceftriaxone - 25-50 mg/kg intramuscularly or intravenously once a day for 7 days (for meningitis 10-14 days).

Cefotaxime - 25 mg/kg intramuscularly or intravenously every 12 hours for 7 days (for meningitis 10-14 days).

Preventive treatment of newborns born from mothers with gonorrhea

Due to the high risk of infection in newborns, it is recommended to carry out treatment even if they do not show signs of gonococcal infection.

Ceftriaxone 25-50 mg/kg (but not more than 125 mg) intramuscularly once.

28.2.1. Establishing the cure of gonorrhea in children

All girls of preschool age attending preschool institutions, after completion of treatment for gonorrhea, remain in the hospital for 1 month to establish cure. During this time, 3 provocations and 3 cultures are done (once every 10 days), after which they are allowed into children's institutions.

1 week after the end of treatment, a thorough clinical examination is carried out, smears are taken from the vagina, urethra and rectum. For menstruating girls, swabs are taken during menstruation.

The criteria for cure are a normal clinical picture and negative results of repeated laboratory tests of genital discharge after 3 provocations. Combined provocation: injection of gonovaccine (150-200 million microbial bodies), lubrication of the vagina and vulva with Lugol's solution in glycerin, instillation of 2-3 drops of 0.5-1% silver nitrate solution into the urethra, lubrication of the lower segment of the rectum with Lugol's solution.

24, 48 and 72 hours after provocation, swabs are taken from the urethra, vagina and rectum. Sowing is done after 72 hours.

In doubtful cases, with a torpid and long-term course of the disease, repeated relapses, repeated bacterioscopic and cultural studies are necessary. The observation period increases to 1.5 months (4-fold provocation).

Follow-up observation continues for at least 3 months. In the 1st month, girls are examined twice, and in the next 2 months - once. If questionable results of the control examination are obtained, the observation period is extended to 6 months.

28.2.2. Prevention of gonorrhea in children

To protect children from gonorrhea, it is necessary to carry out preventive measures in the family, child care institutions, maternity hospitals, and promptly identify pregnant women with gonorrhea.

Rhea, in antenatal clinics. Children must sleep separately from adults, have an individual potty, as well as individual sponges and towels.

When hired to work in children's institutions, staff are examined by a venereologist. Children have their genitals examined before admission and weekly thereafter.

Sick children are hospitalized; if gonorrhea is suspected, the child is isolated and referred for consultation to a venereologist. Children entering child care institutions should be examined by a pediatrician, and if gonorrhea is suspected, by a venereologist. Each child must have his own linen, individual toiletries - a towel, washcloth, chamber pot and sleep in a separate bed.

Children are washed with a stream of warm water using a separate cotton swab on a forceps; in no case should they use common washcloths and sponges. After washing, the genitals are wiped with individual towels or a napkin. The staff of child care institutions must have a separate toilet. Persons with gonorrhea are allowed to work with children after completion of treatment and then a 3-month examination.

Sanitary and preventive work among staff and mothers is of great importance in the prevention of gonorrhea.

28.3. Disseminated gonorrheal infection

Gonococci penetrate the bloodstream, probably in most cases of gonorrhea, which is facilitated by the destruction of the mucous membrane of the urethra and cervical canal. However, gonococci in the blood immediately die under the influence of natural immunity factors. Only in relatively rare cases does hematogenous dissemination of gonococci occur, when they are introduced into various organs and tissues, causing damage to the joints, endocardium, meninges, liver (abscesses, perihepatitis), skin, etc.

Dissemination of gonococci is facilitated by long-unrecognized gonorrhea, irrational treatment, menstruation and pregnancy in women, intercurrent diseases and intoxications that reduce the body's resistance, injuries to the mucous membrane of the urethra or cervical canal during instrumental interventions or sexual excesses. In recent years, gonococcemia has been observed somewhat more often in women.

Disseminated gonorrheal infection occurs in two main forms. Relatively rare, heavy, sometimes lightning-

nasal sepsis, clinically similar to septicemia or septicopyemia caused by other bacteria (staphylococcus, meningococcus, etc.). With this form, a general serious condition, severe fever, tachycardia, chills and heavy sweating, various skin rashes (such as erythema nodosum, vesicular-hemorrhagic and necrotic manifestations) come to the fore. As a rule, polyarthritis with purulent effusion in the joints occurs simultaneously.

More often, a relatively mild course of disseminated gonococcal infection is observed, in which the symptoms of toxemia are mild, the fever is moderate or short-lived, and the clinical picture is dominated by joint damage. This form is sometimes called “benign gonococcal sepsis.” It is likely that in some cases there is transient bacteremia followed by metastatic lesions of the joints in the form of mono- or oligoarthritis and skin rashes, and in others there is a mild form of sepsis due to a peculiar reaction of the body. The “benign quality” of this form of gonococcemia is very relative, since it also causes endocarditis with damage to the aortic and pulmonary valves, meningitis, liver abscess and other serious complications.

Disseminated gonococcal infection does not depend on the condition of the primary focus, which is typical for all forms of sepsis. It does not depend on any particularly virulent strains of the pathogen. On the contrary, many scientists emphasize that with disseminated gonococcal infection (and with gonorrheal arthritis), as a rule, typical pathogens are isolated that are highly sensitive to penicillin and other antigonorrheal drugs.

Thus, gonorrheal arthritis is one of the manifestations of gonococcal sepsis or a consequence of short-term bacteremia, i.e. are caused by the direct penetration of pathogens into the periarticular tissues and the joint cavity. Clinically, they are similar to bacterial arthritis of other etiologies. The affected joint contains a purulent effusion in which the pathogen can be detected. The detection of gonococci in the synovial fluid undoubtedly confirms the diagnosis of gonorrheal arthritis. Gonococci in the genitourinary lesion and typical vesicular-hemorrhagic rashes on the skin allow us to suspect the gonorrheal nature of arthritis. Timely initiation of therapy leads to complete recovery and restoration of function within a few days. However, if treatment is started too late, joint destruction may develop, followed by ankylosis.

Treatment gonococcal infection depends on the clinical picture and anatomical location of the disease, the sensitivity of the strains N.gonorrhoeae to antimicrobial drugs and restrictions on their prescription, combinations of infection with other sexually transmitted diseases, side effects of therapy.

A combined gonorrheal-chlamydial infection is possible, therefore, if it is impossible to diagnose urogenital chlamydia, patients with gonorrhea should be prescribed antimicrobial drugs that are also effective against Chlamydia trachomatis.

28.4. Treatment of uncomplicated gonococcal infection of the lower genitourinary tract

Uncomplicated gonococcal infection is understood as a primary infection of the mucous membrane of the lower genitourinary tract (urethritis in men and women, cervicitis, cystitis, vulvovaginitis in women).

For the treatment of uncomplicated gonorrhea, a single dose of one of the following antibiotics is usually sufficient: ceftri-axone 250 mg intramuscularly, or ofloxacin 400 mg orally, or ciprofloxacin 500 mg orally.

If there are contraindications to the use of these antibiotics, spectinomycin is used intramuscularly in a single dose of 2.0 g for men, 4.0 g for women. The drug is less effective for pharyngeal gonorrhea, but is effective for anorectal gonorrhea.

Fluoroquinolones are contraindicated in children and adolescents under 14 years of age, pregnant and lactating women.

With simultaneous detection of C h. trachomatis or the impossibility of examination for this infection, azithromycin is prescribed at a dose of 1 g once orally or doxycycline 0.1 g twice a day orally for 7 days.

Penicillin drugs have almost ceased to be used in the treatment of gonorrhea throughout the world due to the increasing number of strains N. gonorrhoeae, producing beta-lactamase.

28.5. Treatment of complicated gonococcal infections of the lower and upper genitourinary system

and pelvic organs

Patients are treated in a hospital. Treatment tactics depend on the clinical course of gonorrhea. Thus, with abscess formation of the paraurethral and vestibular glands, along with antimicrobial drugs,

effective in relation to N. gonorrhoeae, pathogenetic, physiotherapeutic and surgical methods of treatment are used.

Etiotropic treatment of complicated gonococcal infections of the genitourinary system and pelvic organs

The main drug is ceftriaxone, prescribed intravenously or intramuscularly at 1.0 g every 24 hours until the clinical manifestations of the disease disappear and for another 24-48 hours after. As alternative medicines, use spectinomycin intramuscularly 2.0 g 2 times a day until clinical manifestations disappear and 24-48 hours after, or cefotaxime intravenously 1.0 g 3 times a day according to the same regimen, or ciprofloxacin intravenously 500 mg 2 times a day until the clinical symptoms of gonorrhea disappear and 24-48 hours after.

Along with this, pathogenetic, symptomatic, and immunomodulatory therapy is carried out according to indications.

28.6. Treatment of pregnant women

Treatment of pregnant women is carried out in a hospital setting at any stage of pregnancy with antibacterial drugs that do not affect the fetus.

The drugs of choice during pregnancy are some cephalosporins, macrolides, and benzylpenicillin. Tetracyclines, fluoroquinolones, and aminoglycosides are contraindicated.

The use of immunomodulatory and biostimulating drugs for gonococcal infection should be justified.

Establishing the criterion for cure of gonorrhea begins 7-10 days after completion of the course of treatment. The criteria for cure are the absence of subjective and objective symptoms of the disease, negative results of microscopic and cultural studies. If clinical and laboratory data indicate persistence of the inflammatory process, a re-examination with mandatory cultural examination and exclusion of concomitant infections is recommended.

Gonorrhea detected after treatment is more often a consequence of reinfection. When establishing a relapse of gonorrhea, a cultural study is necessary to determine the sensitivity of the gonococcus to antibiotics.

In recent years, data have appeared indicating the possibility of reducing the time of clinical and laboratory observation

for women after complete treatment of gonococcal infection. Before prescribing antibacterial drugs for gonorrhea, a serological examination for syphilis should be performed. If it is impossible to perform a serological examination of sexual partners for syphilis, a repeat serological examination of a patient with gonorrhea is carried out after 3 months.

When treating uncomplicated gonorrhea of ​​the lower genitourinary tract with an unknown source of infection, drugs that are also active against T. pallidum, those. having a preventive antisyphilitic effect (ceftriaxone, azithromycin).

Sexual partners of patients with gonorrhea are subject to examination and treatment if sexual contact occurred 30 days before the onset of symptoms of the disease. For asymptomatic gonorrhea, persons who have had sexual intercourse within 60 days before the diagnosis of gonorrhea are subject to examination and treatment.

Children are subject to examination if gonorrhea is detected in their caregivers.

Gonococci.

History of discovery

The causative agent of gonorrhea, an infectious venereal disease with inflammatory manifestations in the genitourinary tract, was discovered by Albert Neisser in 1879. The first cultures were obtained by Leistkow and Leffler (1882), the etiological role was proved by Bumm (1885).

Taxonomy.

Family – Neisseriaceae Genus – Neisseria Species – N. gonorrhoeae

Morphology.

In fresh cultures, gonococci are bean-shaped diplococci, 1.25-1.0 x 0.7-0.8 microns in size, forming a microcapsule. They have no flagella and do not form spores. They stain well with aniline dyes (methylene blue, brilliant green, etc.). Gram staining is negative. They form L-forms, including under the influence of penicillin. Under the influence of chemotherapy, they can quickly change properties and form gram-positive forms. Based on the presence of pili, gonococci are divided into 5 types. Previously they were designated T1-T5, now P +, P ++, P +++... Bacteria of types P +, P ++ are equipped with threads, have a capsule and are virulent, bacteria of other types are avirulent.

The cell membrane (wall) contains up to 60% protein I, on its basis serotyping with gonococci is carried out using the ELISA method. In addition to protein I, there is protein II, which determines the specificity of the clinical manifestations of the disease.

Cultural properties.

By type of respiration - aerobes. Chemoorganotrophs. Demanding on nutrient media. They grow on freshly prepared, moist nutrient media with the addition of native protein (blood, serum, ascitic fluid). Optimum pH 7.2-7.4; temperature - 37 0 C. Most freshly isolated strains require the presence of 4-10% CO 2 in the atmosphere for growth. With further cultivation these properties are lost.

On solid nutrient media, after 24 hours of incubation, gonococci containing protein II in the cell wall form transparent colonies in the form of dew droplets (1-3 mm in diameter) with a smooth edge.

On liquid nutrient media they grow diffusely and form a surface film, which settles to the bottom after a few days.

Biochemical activity.

Gonococci decompose only glucose with the formation of acid, form catalase and cytochrome oxidase - enzymes typical of Neisseria. They do not have proteolytic properties (do not form ammonia, hydrogen sulfide, indole), do not cause hemolysis on blood agar, and do not grow on media containing milk, gelatin and potatoes.

Antigenic structure.

The antigenic structure of gonococci has not been sufficiently studied; it is heterogeneous and changes in daughter populations. It is obvious that the expression of some gonococcal antigens is determined by changes in environmental conditions. This phenomenon is largely due to the fact that the main antigenic load is borne by determinants of pili and surface proteins recognized by immunocompetent cells. Gonococci have a number of mechanisms that reduce the effectiveness of immune reactions, including through changes in the antigenic structure. The main role is played by phase variations, which consist in changing or stopping the formation of some antigenic determinants, and antigenic variations, based on changes in the structure of recognized antigens due to the inclusion of new determinants. For example, gonococcal chromosomes may contain 2 sets of genes encoding the antigenic structure of pili, as well as 8-10 silent genes that usually do not respond to regulatory signals. During DNA recombination, which depends on the sequential connection of homologous genes, silent genes are attached to the resulting copy and acquire regulatory properties, as well as the ability to participate in template synthesis reactions, which leads to the appearance of pili with a new antigenic structure. Gonococcal antigens:

a) capsule antigens;

c) cell membrane proteins – based on them, 16 antigenic serotypes are distinguished;

d) lipopolysaccharides.

Pathogenicity factors .

Toxins. Gonococci do not produce exotoxins. The cell wall contains lipopolysaccharide, an endotoxin that has a toxic effect.

- Structural and chemical components:

a) capsule – has antiphagocytic properties, prevents direct contact of bactericidal substances with the cell wall, masks its antigenic determinants;

b) pili – ensure adhesion of gonococci to epithelial cells, which is crucial in the development of infection;

c) Ig A1 – protease. Gonococci synthesize Ig A1, a protease that acts extracellularly and destroys propine-threonine bonds in the heavy chains of Ig, as well as cleaves the Ig molecule in the sharp part. These effects inactivate anti-adhesion antibodies, which facilitates adhesion of gonococci to epithelial cell receptors and also protects them from antibody-mediated phagocytosis;

d) the ability to synthesize β-lactamases.

Resistance.

Gonococci are unstable in the external environment and die quickly outside the human body. When heated to 56 0 C, they die in 5 minutes; low concentrations of potassium permanganate (1:50) and silver nitrate (1:10000), mercuric chloride, and carbolic acid have a detrimental effect on gonococci. The latter do not tolerate drying or UV irradiation well. They are sensitive to antibiotics (β - lactam, aminoglycosides). However, the increase in the incidence of gonorrhea is also associated with the emergence of penicillin-resistant strains of gonococci.

Epidemiology.

The source of infection is a sick person. The main route of infection is through sexual contact; infection of the fetus is possible when passing through the infected birth canal of the mother. Rare cases of infection have been reported when basic personal hygiene rules are not observed. There is no congenital immunity.

Role in pathology

Gonococci cause gonorrhea in men and women and are the causative agents of neonatal blenorrhea.

Pathogen h

G Onorrhea is an infectious venereal disease manifested by inflammation of the mucous membranes, mainly of the genital tract. The term gonorrhea (from the Greek gone - seed, +rhoia - outflow) was introduced by C. Galen in the 2nd century. AD Currently, gonorrhea is one of the most common infectious diseases. Gonococci mainly infect columnar epithelial cells. In newborns it can cause blenorrhea (conjunctivitis). With extragenital localization, they can affect the rectum and tonsils. They

attached to the cylindrical epithelium of the urethra, vaginal part of the cervix, rectum, conjunctiva of the eye, as well as to sperm and protozoa (Trichomonas, amoeba). Adhesion occurs due to pili and proteins of the outer membrane of the cell wall. A characteristic feature of gonococci is their ability to penetrate leukocytes and multiply in them. The lipopolysaccharide part of the bacterial cell wall has a toxic effect on the human body. Capsular polysaccharides inhibit phagocytosis. Connecting with the villi of the cylindrical epithelium of the urethral mucosa, and in women, the endocervical canal, gonococci penetrate into the cell with the participation of proteins of the outer membrane of the cell wall. This leads to the development of acute urethritis, cervicitis and damage to the cervix in women, inflammation of the appendages (tubes, ovaries); in men, inflammation of the seminal vesicles and prostate gland occurs.

Immunity.

After an illness, immunity is not developed. There is no congenital immunity to gonorrhea; super- and reinfections are possible. The only sensitive organism is man. It is still unclear why the antibodies detected in the patient’s serum (agglutinins, precipitins, opsonins) do not provide protection against re-infection.

Prevention. There are no means of specific immunoprophylaxis, which is due to the high antigenic variability of gonococci. The gonovaccine, on which much hope was placed, turned out to be ineffective. General prevention is based on measures to prevent sexually transmitted diseases. To prevent gonoblenorrhea in newborns, immediately after birth, 1-2 drops of sodium sulfacyl solution or an antibiotic (penicillins, cephalosparins) are instilled into the conjunctival sac (for girls also into the genital opening).

Treatment.

The basis of therapy is antimicrobial therapy. The drugs of choice are sulfonamides and antibiotics that suppress the activity of gonococci (β - lactal antibiotics, aminoglycosides). To treat chronic or complicated forms of gonorrhea, gonovaccine is used.

Microbiological diagnostics.

The most common method is bacterioscopic examination. Isolation of a pure culture is carried out relatively rarely, mainly in case of chronic gonorrhea, when bacterioscopy gives a negative result. In addition, RIF and PCR are currently used. Serodiagnosis for chronic gonorrhea (CGC) is rarely performed

Gonococcus (Neisseria gonorrhoeae) was discovered in 1879 by Neisser. It causes purulent inflammation of the mucous membranes of the genitourinary tract (gonorrhea) and the conjunctiva of the eyes in newborns (blennorrhea). Belongs to the genus Neisseria.

Morphology and biological properties. Gonococci resemble coffee beans or beans. These are paired cocci, concave sides facing each other. Their size is on average 0.7X1.3 microns. In purulent discharge they are located in the cytoplasm of leukocytes, maintaining viability there (the phenomenon of incomplete phagocytosis). In pure culture they look like round or bean-shaped cocci, different in size, randomly located. Paints well with all aniline dyes.

Gram negative. Intracellular location, bean-shaped shape and gram-negative staining constitute a characteristic triad of properties that distinguish gonococci from other diplococci. However, under the influence of drugs and during the chronic course of the disease, they can change: along with gram-negative ones, there are gram-positive gonococci of irregular shape and different sizes. In this case, L-forms of gonococcus can be formed. They are usually spherical in shape and of different sizes: along with large ones, there are very small ones. They do not form spores and are immobile. In the pathological material, a mucous capsule-like substance is formed around the gonococcus. Aerobes. They are very demanding on nutrient media. They grow on media containing native human protein (blood, serum, ascitic fluid), at a pH of 7.2-7.4, with the obligatory addition of vitamins. A prerequisite for cultivation is sufficient humidity of the environment and the presence of CO2. Growth occurs within the range of 30-39°C with an optimum of 37°C. On ascites agar, the colonies are small (1-2 mm), resembling dew drops; Sometimes daughter colonies are formed. The ascites broth gives a slight turbidity and forms a film that settles to the bottom of the test tube. Of carbohydrates, only glucose is broken down. There is no hemolysis on blood agar. Gonococci do not produce exotoxin. When cells are destroyed, they release endotoxin, which when administered intraperitoneally to white mice causes their death.

Sustainability. Gonococcus is not stable in the external environment. At 40°C it dies within 3-6 hours, and at 56°C - within 5 minutes. Does not tolerate cooling. The pus can persist for up to 24 hours. It is especially sensitive to silver salts: in a solution of 1:6000 silver nitrate it dies within 1 minute. It is highly sensitive to penicillin and streptomycin, but during treatment it quickly becomes resistant to them.

Antigenic structure. Heterogeneous, easily changes under the influence of antibiotics, environmental conditions, and the chronic course of the disease. Group carbohydrate C-substance, common with meningococci and type III pneumococcus. Specific typical protein antigens have been identified, which distinguish three types of gonococci.

Pathogenesis and clinic. Gonorrhea only affects humans. Animals are naturally immune to gonococcus. Gonorrhea is usually transmitted through sexual contact. Children become infected through household items (chamber pot, towel, sponge). The incubation period for gonorrhea is 3-7 days, less often 10-15 days. Once on the mucous membranes of the genitourinary tract, gonococcus multiplies and penetrates the submucosal connective tissue. The urethra and cervix are most often affected. The process can spread deeper through the lymphatic tract. Clinically, gonorrhea is manifested by pain when urinating, a feeling of heaviness in the lower abdomen, discharge of pus from the urethra and vagina, and other symptoms. Occasionally, gonococcus can spread through the bloodstream to various organs, settling in joints and heart valves. Possible sepsis. With neonatal blenorrhea, purulent inflammation of the mucous membrane of the eyes occurs.

Immunity. Humans do not have innate immunity to gonococcus. Previous illness does not protect against re-infection. Phagocytosis in gonorrhea is incomplete: gonococci are not only preserved in leukocytes, but multiply and can be transferred by them to various organs.

Microbiological diagnostics. Examine the discharge of the urethra, vagina, cervix, and in case of blenorrhea - purulent discharge of the conjunctiva of the eye. In case of chronic gonorrhea, urine is also examined. The main method of laboratory diagnostics is microscopy of the material being examined. The presence of a characteristic triad of signs provides grounds for making a laboratory diagnosis of gonorrhea. However, a single examination of patients is sometimes insufficient. To improve diagnosis, patients who do not have gonococcus are recommended to carry out a provocation (injection of gonovaccine, smearing the lesions with 1% Lugol's solution on glycerin), and then daily bacteriological examination of the discharge from the lesions for 3-7 days. In the case of a chronic infection, as well as in acute gonorrhea treated with antibiotics, the microscopic method may not give positive results, so they resort to microbiological examination of the pathological material.

Inoculate on freshly prepared serum, blood or ascites agar. Along with this, starting from the 3rd week of the disease, a serological study is carried out: a complement fixation reaction (Bordet-Giangou reaction) is performed with the patient’s blood serum and gonococcal antigen. Sometimes they resort to a skin allergy test with a gonococcal vaccine. However, this reaction can be positive for many years after the illness.

Prevention and treatment. Prevention comes down to sanitary education among the population, timely identification and treatment of patients. Specific prevention is not carried out. To prevent blenorrhea in newborns, 1-2 drops of a 30% albucid solution are injected into the conjunctival sac.

Antibiotics (penicillin, streptomycin, etc.) and sulfonamide drugs are used for treatment. Their correct administration cures gonorrhea. For chronic gonorrhea, gonococcal vaccine is also used.