NEISSERIA GONORRHOEAE

Morphology
&
characteristics

Culture
characters

- morphology and staining of identical to

those of N. Mengitidis
- Gm ve diplococci

Aerobe but most strains require CO2

37
Enriched media : choc agar
Selective media : Thayer-Martin (choc +
VCN) valuable in isolating gonococci
from heavilt contaminated sites
Colonies are small, smooth, glistening
and semi transparent

TREPONEMA PALLIDUM
small slender delicate spiral filament
having 6-12 coils that are small, sharp,
of same size and regularly spaced
actively motile by means of endoflagella
have cork-screw like motility, and
bending movement
method of T. Pallidum demo :
1. TP is weakly refractile, so must be
examined under dark ground
illumination for its typical morpho
and motility
2. TP is v thin, has no affinity to aniline
dyes, so it cannot be stained by
ordinary methods, but can be
visualized by IF staining technique

NEVER BEEN CULTURED

Reiter strain
- non pathogenic variant of TP that has
been cultured anaerobically, on a special
medium composed of serum albumin +
several a.a. + vitamins + minerals
- Reiter strain shares a group Ag with
pathogenic strain of TP
Nichols strain
- isolated from CSF of a neurosyphilitic
patient
- propagated in rabbits by intratesticular
injection and weekly passage
- used in serological tests

Biochemical
Reactions

Oxidase +ve
Can produce acid from glucose
(distinguished from meningococcus
which utilize maltose)

HAEMOPHILUS
DUCREYI

CHLAMYDIA TRACHOMATIS
genital tract infection caused
by serotypes D while K and
lymphogranuloma venereum
(LGV) is caused by serotypes
L, L, L
most genital infections in
are asymptomatic, while in

UROGENITAL
MYCOPLASMAS
they include :
1. M. Hominis
2. Ureaplasma
urealyticum
- has urea splitting actvt,
require essential
presence of 10% urea
in media

mostly symptomatic
at high risk for chlamydial
infection include female sex
partners of men with nongonococcal urethritis (NGU)
caused by Chlamydia
35-50% of NGU are caused
by CT. epididymitis mayb
associated
Up to 15% of procitis in
homosexual men caused by
CT

*in a large no of adults,

lower urogenital tracts
are asymptomatically
colonized by both
species

Antigenic
structure &
virulence
factors

Pathogenesis
& clinical
findings

antigenically heterogenous (>100

serotypes are known)
virulence factors :
1. PILI
virulent gonococci are piliated to :
- mediate resistance to phagocytosis
- adhere to epithelial cells
2. OUTERMEMBRANE PROTEIN
play role in
- attachment of organisms to cells
- basis for serotyping the gonococci
3. LIPOLIGOSACCHARIDE (LOS)
as endotoxin
4. IgA PROTEASE
can split IgA present in mucosal surface

1.
2.
3.
4.

Strict human parasite

Acute/ chronic infection
No healthy carrier exist
Attacks mucous membrane
(genitourinary tract, eye, rectum,
throat)

2. Reagin
- directed against cardiolipin which is
liberated during process of tissue
destruction or breakdown produced
by invasion of Treponema
Cardiolipin
- acts in conjunction with spirocheteal
protein to stimulate production of
reagin so they are grouped as auto-Ab
- commercially prepared for use in
serological tests by alcoholic
extraction of beef heart. Small
proportions of lecithin and cholesterol
also added to this Ag to increase its
sensitivity to reagin
Acquired Syphilis
natural infection limited to human host
transmitted thru close sexual contact,
and rarely in occupational exposure
and infection of medical personnel
1ry stage
spirochetes multiply locally at site of
entry, some spread to regional LNs, then
reach to blood stream

acute suppuration

tissue invasion

chronic inflammation
5. Transmitted thru sexual intercourse

Have poorly defined Ags

But spirochete stimulate
development of 2 types of Abs :
1. Anti-treponemal Abs
specific Ab directed against TP itself;
or group of Abs directed against to a
group of Ag shared by all
Treponemas

2-10 weeks after infection, papule

develop at site of infection

breaks down to form an ulcer with a

clean, hard base (hard chancre)
- evident up to 6 weeks but always heal

causes veneral
disease call soft
chancre
(chancroid),
characterized by
:
Development
of a ragged,
swollen tender
ulcer on the
genitalia
Enlarged and
painful regional
LNs

Reiters Syd
a complication of NGU,
characterized by urethritis +
conjunctivitis + uveitis +
polyarthritis + mucocutaneous
lesions
LGV
a chronic STD caused by CT
serotypes L, L, L
genital tract and rectum of
chronically infected persons
serve as reservoirs
begins with genital ulcer
followed by
lymphadenopathy of
regional LNs producing
painful fluctuant buboes

M. Hominis
: associated with
pyelonephritis, cystitis,
salpingitis, tubo-ovarian
abcesses, post-abortal or
post-partum fever and
may cause abortion
: does not causes
disease
U. urealyticum
: associated with lung
disease in premature,
low birth weight infants.
minimal evident to cause
infertility

in
urethritis + yellow
creamy pus + painful
urination, may extend
to

epididymis and
prostate

discharge becomes
scanty in the form of
a morning drop
if untreated,

fibrosis, sometimes
lead to urethral
strictures

in
infection in
endocervix,
extending to
urethra and
vagina +
mucopurulent
discharge

progress to FT,
Pelvic
Inflammatory
Disease (PID)
*infertility occurs
in 20% of women
with gonococcal
salpingitis

** chronic
cervicitis /
procitis are often
asymptomatic
6. Gonococcal bacteremia is rare
but may occur leading to skin lesion
and suppurative arthritis
7. Gonococcal endocarditis is uncommon
severe infection
8. Gonococcal ophthalmia neonatorum
(infection of the eye of the newborn,
acquired during passage through
infected birth canal)
The initial conjunctivitis rapidly
progresses, if untreated, results in
blindness.

spontaneously
2ry stage
occurs 2-10 weeks after 1ry stage
generalized symptoms of infection:
o non-itchy macula-papular rash
anywhere on the body
o mucous patches mainly in
oropharynx, and ulcerate with
serpentine tracks
o generalized lymphadeopathy
o moist pale papules (condylomalata)
in moist warm areas such as peri-anal
region, vulva, scrotum, axilla, mouth
o some patients may develop chorioretinitis, hepatitis, nephritis,
periostitis, or syphilitic meningitis
Latent stage
o on about 30% cases, the untreated
infection becomes latent
o patient appears clinically well but
continues to have a syphilitic
infection which controlled by
immunological factors for 15 yrs
before late syphilis become evident
Late stage
o development of granulomatous
lesion (gumma) in skin, SC tissues,
bones, joints, mucous membrane of
URT and liver
o degenerative changes in CNS and CVS
complications
Congenital Syphilis
syphilitic can transmit TP to her
foetus thru placenta, some die thru
miscarriage or still birth if at delivery,
while others develop signs of
congenital syphilis
adequate treatment of mother during
pregnancy can prevent congenital
syphilis

that gradually enlarge and

rupture forming fistulae
untreated LGV may
progress to strictures or
genital elephantiasis due to
blockage of lymphatic
drainage

: NGU (about 10%)

Immunity

Lab Diagnosis

Repeated gonococcal infections are

common
Protective immunity to reinfection does
not appear to develop bcoz the
antigenic variation
ACUTE STAGE
Specimen
: urethral discharge
: urethral discharge and cervical
secretion
A. Smears
- methylene blue stain
- Gram stain
Gm ve diplococci ICly in
polymorphonuclear leukocytes + few
EC organisms
*this is sufficient to diagnose
gonorrhoea
B. Culture
urethral discharge / cervical swab is
inoculated on choc blood agar (CO2
enriched aerobic atmosphere, 37 for
48 hrs)
*colonies identified by:
Oxidase test (+ve)
Gm stained film (Gm ve
diplococci)
Production of acid from
glucose
Coagglutination test
** culture is done during acute stage for
several reasons:
1. To confirm diagnosis
2. To isolate the organism, to
determine its sensitivity to
diff antibiotics
3. When medico-legal
proceedings are involved

1RY STAGE
Specimens :
- exudates from a chancre, penile/ female
genital chancre shud be squeezed gently
using gloved hand to obtain a serous
exudates
- bleeding shud be avoided coz RBCs may
mask spirochetes as they are almost
same size
Detection of Treponema:
1. A drop of exudates placed on a slide
and covered by a coverslip then
examined by dark ground
microscopy to demo typical motile
TP
2. Exudates is spread on a slide, air
dried, fixed and stained with
fluorescein-labeled anti-treponemal
serum examined by means of IF
microscopy for typical fluorescent
spirochetes
3. NA probe and PCR techniques
Serology
cardiolipin Abs maybe ve
but fluorescent treponemal (FTA)
mayb +ve earlier bcoz it can detect
IgM anti-treponemal Abs

Specimen
scraping the
ulcer base
A. Smears
* stained by
Gms method
showing Gm ve
rods,
ICly in pus cells
and
ECly together
with 2ry invaders
B. Culture
choc agar + isovitalex +
vancomycin,
incubated in air
+ CO2
require X factor
but not V

1. Cytologic examination
cell scrapings stained with
Geimsa stain for presence
of chlamydial inclusion
bodies
2. Isolation in cell culture
cycloheximide treated Mc
Coy cells are used
commonly
*most sensitive method
3. Direct Ag detection
employs fluorescein
isothiocyanate +
monoclonal Abs to CT for
the detection of
elementary bodies in
smears (direct IF staining)
chlamydial Ags can be
detected by ELISA
4. NA probe and PCR
for detection of NA of CT
5. Serology
- Abs to genus-specific Ag by
complement fixation
- type specific Abs by micro IF
assay
* serologic testing has
limited value in adults coz
cannot differentiate
between current or past
infection
** high titre of IgM or rising
Ab lvl suggest recent
infection

Specimens
only upper genitourinary
specimens are value
bcoz both species
frequently colonize
lower genitourinary tract
for both sexes
: urethral swabs or
urine after prostatic
massage
* fetal membrane swabs
and semen as a pasrt of
investigating infertility
**specimens are put in
stuarts transport
medium and sent to lab
Isolation
o swabs are spread on
plates of standard
media for
mycoplasma (moist
atm + 5-10% CO2 at
37) and inspected
for characteristic
fried-egg appearance
(by a magnification
of 40x)
o ureaplasma require
10% urea in media,
they demo their
urease activity in
liquid media

C. Ag detection and NA probe

(direct non culture tests)
- ELISA : to detect gonococcal Ag
- Gene probe : to detect gonococci
directly in patients specimens in 2 hrs
*useful for screening specimens where
culture facilities are not available :
CHRONIC STAGE
Gm stained smear is of no value in
chronic conditions coz
- Gm ve diplococci may be v few in
number OR totally absent,
- presence of 2ry bacterial invaders
So, culture is necessary
Specimen
: morning urethral drop / prostatic
secretion
: swab from the cervix uteri
Culture
inoculated in Thayer-Martin medium (CO2
enriched atmosphere, 37 , 48 hrs)
*colonies identified as in the acute stage

2RY STAGE
Specimens : exudates from skin lesions,
mucous patches or condyloma lata shud
be examined for the presence TP in a
similar way to 1ry stage ;
1. dark ground microscopy
2. IF microscopy
3. NA probe
4. PCR technique
Serology
both cardiolipin and anti treponemal
shows strongly +ve results
LATENT STAGE
1. Serum samples :
serological test for syphilis are always
+ve but cardiolipin Ab mayb ve in
patients with old syphilis or partially
treated while treponemal Ab remains
+ve
2. CSF samples:
cardiolipin and treponemal Ab test
for syphilis are usually +ve in CSF in
patients with active neurosyphilis

*** detection of IgM to CT

useful in diagnosis of
neonatal infection
- single sitre of >64 is a good
evidence for active
neonatal infection

containing urea and

phenol red and
result in ammonia
production that
alters pH and
changes the colour
of the medium
colonies on agar are
tiny and also show
fried-egg appearance
o growth inhibition
with specific anti
sera can be used for
differentiation of
genital mycoplasmas
Serodiagnosis
rarely used

SEROLOGICAL TESTS FOR SYPHILIS

CARDIOLIPIN AB TEST
(NON TREPONEMAL AG TEST)

- non-specific but quantitative

- principle : utilize cardiolipin + small proportion of cholesterol and lecithin
as a complete Ag bcoz cardiolipin is a soluble extract, it will remain dispersed
in liquid and aggregates only when it reacts with the appropriate Ab at opt conc
and forms Ag-Ab complexes within few mins if suspension is shaken
Veneral Disease
Research Lab test
(VDRL)
-on glass slideAg is emulsified in
special buffered saline +
patients heat
inactivated serum on
ring

Rotating machine for 4

minutes

Ag will flocculate if
reagin is present

Rapid Plasma Reagin Test (RPR) -on a

plastic cardRapid coz cud be performed on
unheated patients serum or plasma
mixed with carbon containing
cardiolipin Ag on the card

Rotating machine for 8 mins

Aggregates of carbon particles will

appear as black clumps against a white
card (rapidly visualized)

Points to be considered in relation to cardiolipin Ab test

1. become +ve 10-14 days after appearance of chancre (mayb ve in 1ry syphilis)
2. simple and accurate, so used as screening tests or 1st line procedures for
routine diagnosis
+ve results shud be confirmed by repetition of the test and use of a test to detect
Treponemal Ab
3. also can be used to monitor treatment bcoz quantitatively the titer reagin will
gradually increase with the progress of the disease, only declines or disappears
after recovery and in late syphilis
4. disadvantage : occurrence of false +ve result in malaria, measles, infectious
mononucleosis, leprosy, SLE, recent immunization with certain vaccines and drug
addiction

TREPONEMAL AB TEST

Fluorescent treponemal Ab testabsorbed (FTA-Abs)

1. Patients serum allowed to react
with reiter strain to absorb out
treponemal Ab leaving the
specific Ab against TP
2. Indirect IF test is done, by using
killed whole TP as Ag to react
with the unabsorbed specific Ab
against TP earlier
*this test usually remains +ve for
many years after effective
treatment of early syphilis so it
cannot be used to judge the
efficacy of the treatment

TP-particle agglutination test

(TP-PA)
Performed in microdilution
plate with diluted patients
serum
Gelatin particles sensitized
with TP Ags and react with
the Abs against TP
A mat of agglutinated
particles indicate +ve
result
This test is similar to the
FTA-Abs test in specificity
and sensitivity

Treatment

N. Gonorrhoeae
Penicillins are not recommended for
the primary treatment of
uncomplicated infection coz they
chromosomally mediated and plasmid
mediated resistance
Broad spectrum
used in 1ry
of 3rd gen of
therapy
cephalosporins
uncomplicated
(ceftriaxone)
gonococcal
Fluoroquinolones
infections
(ciprofloxacin)

Treponema Pallidum
for all stages:
a single injection of benzathine
penicillin (2G/IM) per week for 3
successive weeks
if patient is allergic, give the
following
1. erythromycin or
2. tetracycline or
3. cephalosporins

H. ducreyi
Ceftriaxone
(IV) or
Cotrimoxazole
or
Erythromycin

Chlamydia Trachomatis
acute condition : tetracycline
and erythromycin given for 2
weeks
trachoma treatment : topical
and systemic sulphonamides
PREVENTION
CT infections are difficult
bcoz population with
endemic disease frequently
suffer from poor sanitation
and limited access to medical
care
Blindness associated by
prompt treatment of early
disease and prevention of
subsequent re-exposure
Chlamydial conjunctivitis
and genital infections by
the use if safe sexual
practice and prompt
treatment of both
symptomatic and their
contacts
neonatal inf by examination
and treatment of the
parents

Urogenital Mycoplasma
they are resistant to
erythromycin but
susceptible to
tetracycline