CASE 7:

Sick at Sea
GROUP MEMBERS:
Dhada Sumanta Kumar
Jorge Mariano
Yadav Shashikant

 A 21 years old sailor, Ralp, appeared at morning sick

bay on the USS Columbia just three days at sea. Ralp
told the hospital corpsman that he had a dose of clap.
Ralp had interscourse with a prostitute in the City the
night before shipping out and balmed her for this
infection.
Yesterday he beganto have a painful urination (dysuria)
and in the evening began to have a urethral discharge.
A cursory physical examination found no other
symptoms of the disease. Blood pressure, temperature,
pulse rate and respirations were all within normal
range.
The urethral discharge was dominated by neuthrophil,
many which contained gram negative diplococcic.

The
navy
doctor
tentatively
agreed
with
Ralpsoriginal diagnosis and stated that although he
was prescribing antibiotics, further tests would be
needed to confirm the diagnosis and his present choice
of antibiotics.

QUESTIONS:

1. Why arent gram negative

intracellular diplococci in urethral
discharge considered as positive proof
of gonorrhea?

Answer:
The genus Neisseria consists of gram-negative, aerobic
cocci. Two Neisseria species are pathogenic for humans-Neisseria gonorrhoeae (commonly called gonococcus), the
causal agent of gonorrhea; and Neisseria meningitidis
(commonly called meningococcus), a frequent cause of
meningitis.
Gonococci and meningococci are nonmotile diplococci, and
cannot be distinguished from each other under the
microscope.
However they can be differentiated in the laboratory by
their sugar utilization patterns, and by the sites of their
primary infections.
Both bacteria are classified as pyogenic cocci, because
infections by these organisms are also characterized by the
production of purulent (pus-like) material made up largely of
white blood cells.

2. What tests provide positive

identification of N.
gonorrhoeae?
Answer:
Growth conditions for cell culture: N. gonorrhoeae
grows best under aerobic conditions, and most
strains require enhanced CO2. N. gonorrhoeae
ferments glucose, but not maltose, lactose, or
sucrose while N. meningitidis does ferment maltose.
All members of the genus are oxidase-positive as
shown by a test in which the colonies turn pink and
then black when flooded with one percent dimethylor tetramethyl-p-phenylenediamine solution.
The oxidase test is used to identify neisseriae, but
does not distinguish between gonococci,
meningococci, and nonpathogenic neisseriae.

 Selective media: Gonococci, like pneumococci,

are very sensitive to heating or drying.
Cultures must be plated promptly, or if this is not
possible, transport media must be used to extend
the viability of the organism to be cultured.
Thayer-Martin medium or a chocolate agar
supplemented with several antibiotics that
suppress the growth of nonpathogenic neisseriae
and other normal and abnormal flora is normally
used to isolate gonococci.
The use of this medium is important for cultures
that are typically obtained from sites such as the
genitourinary tract or rectum, where there is
normally an abundance of flora.
In nonselective medium, the normal flora
overgrows the gonococci.

3.What antibiotic do you think

was prescribed?

Answer:
Penicillin is no longer recommended for the
treatment of gonorrhea.
However, most organisms still respond to treatment
with third-generation cephalosporins;
Many patients with gonorrhea about ten to twenty
percent of males, and thirty to fifty percent of
female have coexisting chlamydial infections.
Therefore, doxycycline is given because,doxycline is
a tetracycline effective against chlamydia and is
often included as part of the treatment regimen for
gonorrhea.
Other drugs such as tetracycline, aminoglycosides,
macrolides, and fluoroquinolones are also used.

4. What is the meaning of the

abbreviation PPNG?
Answer:
Penicillin-resistant organisms are
called PPNG--penicillinase-producing
N. gonorrhoeae.

5. Is antibiotic resistance of
gonococci a plasmid mediated
characteristics?
Answer:
Yes, the Penicillin-resistant organism
contain contain plasmids that carry
the gene for Beta-Iactamase of the
TEM encoded in a transposable
element type such as is seen in E.
coil and H. influenzae.

6. What are the complications

of untreated or improperly
treated gonorrhea?
Answer:
These organisms may cause a
localized infection with the
production of pus, or may lead to
tissue invasion, chronic
inflammation, and fibrosis.

7. Are these complications

more severe in males or
females?

Answer:
Yes, The complications are more
severe in males because a higher
proportion of females than males are
generally asymptomatic.

These individuals act as the

reservoir
for
maintaining
and
transmitting gonococcal infections.

8. What form does neonatal

gonorrhea take? How is it treated
and prevented?

Answer:
Ophthalmia neonatorum is an infection of the
conjunctival sac that is acquired by a newborn
during passage through the birth canal of a
mother infected with gonococcus.
If untreated, acute conjunctivitis may lead to
blindness.
For many years, routine prevention was
performed immediately after birth by the
instillation of a dilute solution of silver nitrate
into the eye.
Today, clinicians prefer the use of erythromycin
in place of silver nitrate, because the antibiotic
also eradicates Chlamydia trachomatis.

9. How do gonococci establish

their infection?
Answer:
Pili and OMP II facilitate the adhesion of the
gonococcus to epithelial cells of the
urethra, rectum, cervix, pharynx, or
conjunctiva, and thus make possible
colonization.
Pili also enable the bacterium to resist
phagocytosis.
In
addition,
both
gonococci
and
meningococci produce an IgA protease that
cleaves IgA1 thus helping the pathogen to
evade immunoglobulins of this subclass.

 10. Explain why there is so little immunity to

repeated gonococcal infection?
Answer:
Pili: These hairlike surface appendages are made of helical
aggregates of repeating peptide subunits, called pilin.
Pili enhance attachment of the organism to host epithelial and
mucosal cell surfaces, and confer resistance to phagocytosis.
They are therefore among the most important virulence factors.
At least twenty gonococcal genes code for pilin, most of which
are not expressed at any given time because they lack
promoters 1.
By shuffling and recombining chromosomal regions of these
genes, a single strain of N. gonorrhoeae can at different times
synthesize multiple pilins that have different amino acid
sequences.
This process, known as gene conversion, allows the organism to
produce antigenically different pilin molecules over time.
In addition, if a gene is moved into an expression locus so that
the reading frame is shifted, 2 then no pilin is made or that is,
the organism is nonpiliated. This is called phase variation.
Gene conversion and phase variation are two mechanisms by
which the gonococcus can avoid the host's immune response,
and thereby cause repeated infections in the same individual.

11. What is the status of

vaccine development against
gonorrhea?
Answer:
Effective vaccines exist for Neisseria
meningitidis serogroups A and C, but
not for Neisseria gonorrhoeae.

12. What other sexually

transmitted bacterial diseases
are also possible in patient
with gonorrhea?
Answer:
More than one sexually transmitted
disease may be acquired at the same
time, for example gonorrhea in
combination with syphilis (Treponema
pallidum infection), chlamydia, human
immunodeficiency virus, or hepatitis B
virus.

13. Do colony type difference

of N. gonorrhoeae related to
virulence?

Answer
No, Because the virulence depends
upon the pilin of the Gonococci and
not that of the colony type.
There are about hundredths of pilin
in one gonococci.

14. What are the protein I and

protein II of N. gonorrhoeae?

Answer:
POR protein (Protein I) extends through the
gonococcal cell membrane.
It occurs in trimers to form pores in the surface
through which some nutrients enter the cell.
It may impact intracellularkilling of gonococci
within neutrophils by preventing phagosomeslysosomes fusion.
OPA protein (protein II) functions in adhesion of
gonococci within colonies and in attachment to
host cell especially cells that express
carcinoembryonic membrane.

15. Does nonvenereal

transmission of gonorrheoae
occur?
Answer:
Yes, N. gonorrhoeae is usually
transmitted during sexual contact, or
more rarely, during the passage of a
baby through an infected birth canal.
It does not survive long outside the
human body because it is highly
sensitive to dehydration.