Case24-Ngonnorr - Case 24 Lydyard, Peter; Cole, Michael;...

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Case 24 Neisseria gonorrhoeae A 15-year-old heterosexual male was brought to the emergency room by his sister. He gave a 24-hour history of dysuria and noted some ‘ pus -like’ drainage in his underwear and the tip of his penis (Figure 1). Urine appeared clear and urine culture was negative, although urinalysis was positive for leukocyte esterase and multiple white cells were seen on microscopic examination of urine. He gave a history of being sexually active with five or six partners in the past 6 months. He claimed that he and his partners had not had any sexually transmitted diseases. His physical exam was significant for a yellow urethral discharge and tenderness at the tip of the penis. A Gram stain of the discharge was performed in the emergency room (Figure 2). He was given antimicrobial agents and scheduled for a follow-up visit 1 week later. He was asked to provide the names and addresses of his sexual partners to the Health Department so that they could be examined and treated if necessary. One of the sexual partners, a 15-year-old female who reported having had sexual relations with her boyfriend frequently over the last 6 months, was asymptomatic until 2 days before coming to the hospital when she developed fever, shaking chills, and lower abdominal pain. Her symptoms worsened and she presented with fever of 42 C, generalized abdominal pain, and a swollen right knee, with blood pressure 120/80 and pulse 150/min and regular. The date of her last menstrual period, which was described as normal, was 1 week before admission. The patient was oriented as to time, person, and place. Physical examination was unremarkable except for tender abdomen and rigidity, and decreased bowel sounds; the right knee was red, hot, tender, and swollen. Pelvic examination showed some white discharge of the cervical os (Figure 3) A swab was obtained from her cervix for culture (Figure 4). Her right knee was tapped. Laboratory findings: ± hemoglobin: 12 g dl –1 ± white blood cell (WBC) count: 26000 m l –1 ± differential: 70 PMN, 5 bands, 25 lymphocytes ± urinalysis: specific gravity, 1.010; protein, 2+; sugar, negative; WBC, 8–10 per HPF; no casts. Figure 1 (top left). Gonorrhoeae infection in the male. Creamy purulent discharge from the urinary meatus . In many cases infection is asymptomatic, but may cause painful urination or a purulent discharge, as seen here. In severe cases it may also cause inflammation of the testicles and prostate gland, and infertility. Treatment is with antibiotics. Figure 2 (top right). Gram stain of penile discharge showing intracellular gram-negative diplococci. Figure 3 (bottom left). Cervicitis with purulent discharge. Figure 4 (bottom right). Gram stain of a cervical smear showing extracellular and intracellular gram-negative diplococci. © Lydyard, Peter; Cole, Michael; Holton, John; Irving, Will; Porakishvili, Nino; Venkatesan, Pradhib; Ward, Kate, Jan 01, 201
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Case24-Ngonnorr - Case 24 Lydyard, Peter; Cole, Michael;...

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