1. What diagnostic work-up would you recommend?

 Pus and secretions from the urethra, cervix, conjunctiva, rectum, throat, or
synovial fluid for culture and smear
 Blood culture in systemic illness.
 Gram Stained Smear & Specimen Culture on enriched selective media
 Nucleic Acid Amplification Test

2. Explain the value of the following tests:

a. Gram stain- (presumptive diagnosis) gram negative dipplococci w/in pus cells or
polymorphonuclear leukocytes (PMNS)
 Urethral exudate from men have a sensitivity of about 90% and a
specificity of 99%. Additional diagnostic testing is not necessary when
the stain result is positive.
 Endocervical exudates have a sensitivity of about 50% and a
specificity of about 95% when examined by an experienced
microscopist, still requires nucleic acid amplification tests (NAATs) or
cultures to confirm.
 Conjunctival exudates.
 The direct Gram stain of body fluids for either N. gonorrhoeae or N.
meningitidis is best accomplished using a cytocentrifuge to concentrate
small numbers of organisms 100-fold

 Avirulent strains (i.e., pili types 3-5) may be present in specimens as

extracellular diplococci; these are not pathogenic.
 Pharyngeal specimens should not be Gram stained, because
nonpathogenic, commensal Neisseria spp. may be present, and the
presence of these organisms is not diagnostic of infection.

b. Enzyme immunoassay
 Not useful as diagnostic aids for several reasons:
 gonococcal antigenic heterogeneity
 delayed development of antibodies in acute infection
 high background level of antibodies in the sexually active
population.

c. Bacterial culture on selective media

i. Thayer Martin
 This medium is a chocolate agar with an enrichment
supplement (IsoVitaleX), and the antimicrobials colistin (to
inhibit gram-negative bacilli), nystatin (to inhibit yeast),
and vancomycin (to inhibit gram-positive bacteria)

ii. Martin Lewis

  similar to MTM except that anisomycin, an antifungal
agent, is substituted for nystatin and the concentration of
vancomycin is increased

iii. Modified Thayer Martin

 Composition is similar to Thayer Martin but is modified to
include trimethoprim (to inhibit the swarming observed
with Proteus spp.)

iv. New York City Agar

 transparent clear-to yellow medium containing lysed horse
blood, horse plasma, yeast dialysate, and the same
antimicrobials as MTM.
 Also permits growth of genital mycoplasmas (Mycoplasma
hominis and Ureaplasma urealyticum)

d. Nucleic acid amplification test: preferred test. For direct detection of N.

gonorrhoeae in genitourinary specimens,

Advantages:
 Excellent sensitivity and specificity in symptomatic, high-prevalence
populations.
 Better detection
 More rapid results
 Ability to use urine as a specimen source

Disadvantages:
 Poor specificity of some assays because of cross-reactivity with
nongonococcal Neisseria species.
 Not recommended for use for the diagnosis of extragenital
gonococcal infections or for infection in children.
 Does not test treatment efficiency because nucleic acid may persist in
patient specimens for up to 3 weeks after successful treatment.

Non-amplified DNA probe assay

 PACE 2 (Hologic, Inc., Bedford, MA), has a chemiluminescent
detection system for direct detection of gonococcal ribosomal
ribonucleic acid (rRNA) in genital and conjunctival specimens.
 This test is rapid because results are available in 2 hours and it is
suitable for screening many patients simultaneously
 Gen-Probe Accuprobe test targets rRNA after lysis of bacteria; the
rRNA is detected using a single-strand chemiluminescent
deoxyribonucleic acid (DNA) probe. The hybrids are then detected
in a luminometer.
  Digene CT/GC Dual ID HC2 (HC2; Qiagen, Valencia, CA) detects
RNA-DNA hybrids using antibody-mediated recognition of the
hybrids and visualization of a chemiluminescent substrate.

Amplified assays
 More sensitive than nonamplified assays
 These tests are suitable for large-scale screening programs, but
none are admissible as evidence in medicolegal cases.
 N. gonorrhoeae DNA can be found in a specimen for up to 3 weeks
after a successful treatment regimen therefore these methods
should not be used to assess rates of cure.
 Examples of it are:
o AMPLICOR
o COBAS AMPLICOR PCR (Branchburg, NJ)
o Hologic Gen-Probe Aptima Combo 2 transcription-mediated
amplification (Bedford, MA)
o ProbeTec ET (Becton Dickinson, Sparks, MD).

e. Serology
 Serum and genital fluid contain immunoglobulin G (IgG) and IgA
antibodies against gonococcal pili, outer membrane proteins, and LPS.
 Antibodies to gonococcal pili and outer membrane proteins in inffective
individuals can be detected by immunoblotting, radioimmunoassay, and
ELISA tests. However, the aforementioned test are not useful for
diagnosis
 Some IgM of human sera is bactericidal for gonococci in vitro