Introduction

Gonorrhea is one of the oldest known human illnesses, and references to sexually acquired urethritis can be found in ancient Chinese writings, the biblical Old Testament (Leviticus), and other works of antiquity (Table 4). Galen (AD 130) introduced the term "gonorrhea" ("flow of seed"), implying interpretation of urethral exudate as semen. The causative organism was described by Neisser in 1879 and was first cultivated in 1882 by Leistikow and Loffler (10). Untreated infections were understood to resolve spontaneously over several

TABLE 4 Gonorrhea: Key Points

Overview

The most common reportable infectious disease, causing symptomatic or asymptomatic localized infections including urethritis, cervicitis, proctitis, pharyngitis, and conjunctivitis after an incubation period of 2-8 days Disseminated infections occur either by extension to adjacent organs (pelvic inflammatory disease, epididymitis) or by bacteremic spread (skin lesions, tenosynovitis, septic arthritis, endocarditis, and meningitis)

Pathophysiology of gonorrhea

Neisseria gonorrhoeae are Gram-negative cocci, usually seen in pairs with the adjacent sides flattened

Gonorrhea is usually acquired by sexual contact. Gonococci adhere to columnar epithelial cells, penetrate them, and multiply on the basement membrane Transmission from the pharynx to sexual contacts is rare

Adherence is facilitated through pili and opa proteins. Gonococcal lipopolysaccharide stimulates the production of tumor necrosis factor, which causes cell damage Gonococci may disseminate via the bloodstream. Strains that cause disseminated infections are usually resistant to serum and complement In the head and neck, pharyngeal gonococcal infection is significant, because it is the principal origin of gonococcemia

Symptomatology (by location of infection)

Pharyngeal gonococcal infection is most often asymptomatic

Diagnosis

Gonorrhea cannot be diagnosed solely on clinical grounds

Pharyngeal culture on selective medium is often required to differentiate N. gonorrhoeae from other Neisseria species and evaluate antimicrobial resistance A nonamplified DNA probe test is available but is not as sensitive as culture Serologic tests are not recommended for uncomplicated infections

Treatment

Recommended treatment for uncomplicated infections is a third-generation cephalosporin or a fluoroquinolone plus an antibiotic (e.g., doxycycline) effective against possible coinfection with Chlamydia trachomatis Sex partner(s) should be referred and treated No effective vaccine yet exists Condoms are effective in preventing gonorrhea

Prognosis

Isolated pharyngeal infection is rare, complications occur infrequently if ever, and most cases resolve spontaneously within a few weeks or in response to therapy for genital or rectal infection weeks or months, but reinfection was recognized to occur. Many therapies were tried, but truly effective treatment did not become available until the advent of the sulfonamides in the 1930s and penicillin in 1943. Growth of fundamental knowledge about the organism and the host response to infection was slow for 80 years, but a remarkable surge of new information began in the 1970s, and, currently, as much is known of the molecular biology of the gono-coccus and the pathogenesis of gonorrhea as that of any bacterial pathogen. Public health control efforts have met with variable success, and gonorrhea remains a prime example of the influence that social, behavioral, and demographic factors can have on the epidemiology of an infectious disease despite highly effective, readily available antimicrobial therapy. Although the most common portal of entry is the genitourinary tract, head and neck manifestations of infection include gonococcal pharyngitis, gingivitis, stomatitis, and glossitis. Gonococcal pharyngitis is an uncommon but well-described manifestation. Gonorrhea remains a major public health problem worldwide, is a significant cause of morbidity in developing countries, and may play a role in enhancing transmission of HIV.

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