In young adults, hematogenous gonococcal infection is one of the most common causes of acute arthritis. Arthritis may be the sole manifestation of disseminated gonococcal infection. Skin lesions are few and are found on the extremities, frequently around a joint, and are pustular or hemorrhagic, rarely bullous. Gram-stained smears of material contained in the pustules may reveal gram-negative diplococci within polymorphonu-clear neutrophils. Tenosynovitis classically involves tendons of the hand or foot. The primary (mucosal) site of gonococcal infection is often asymptomatic. If disseminated gonococcal infection is suspected, culture of blood and secretions from the pharynx, rectum, and urethra or cervix should be obtained.







Content 12

Content 9



Specific microbiologic diagnosis of infection with N. gonorrhoeae should be performed in all persons at risk for or suspected to have gonorrhea; a specific diagnosis can potentially reduce complications, reinfections, and transmission. Culture and NAAT are available for the detection of genitourinary infection with N. gonorrhoeae (394); culture requires endocervical (women) or urethral (men) swab specimens. NAAT allows for the widest variety of FDA-cleared specimen types, including endocervical swabs, vaginal swabs, urethral swabs (men), and urine (from both men and women). However, product inserts for each NAAT manufacturer must be carefully consulted because collection methods and specimen types vary. Culture is available for detection of rectal, oropharyngeal, and conjunctival gonococcal infection, but NAAT is not FDA-cleared for use with these specimens. Some laboratories have met CLIA regulatory requirements and established performance specifications for using NAAT with rectal and oropharyngeal swab specimens that can inform clinical management. Certain NAATs that have been demonstrated to detect commensal Neisseria species might have comparable low specificity when testing oropharyngeal specimens for N gonorrhoeae (394). The sensitivity of NAAT for the detection of N. gonorrhoeae in urogenital and nongenital anatomic sites is superior to culture, but varies by NAAT type (394,505-508). In cases of suspected or documented treatment failure, clinicians should perform both culture and antimicrobial susceptibility testing because nonculture tests cannot provide antimicrobial susceptibility results. Because N. gonorrhoeae has demanding nutritional and environmental growth requirements, optimal recovery rates are achieved when specimens are inoculated directly and when the growth medium is promptly incubated in an increased CO2 environment (394). Several non-nutritive swab transport systems are available that might maintain gonococcal viability for up to 48 hours in ambient temperatures (534-536).

Because of its high specificity (>99%) and sensitivity (>95%), a Gram stain of urethral secretions that demonstrates polymorphonuclear leukocytes with intracellular Gram-negative diplococci can be considered diagnostic for infection with N. gonorrhoeae in symptomatic men. However, because of lower sensitivity, a negative Gram stain should not be considered sufficient for ruling out infection in asymptomatic men. Detection of infection using Gram stain of endocervical, pharyngeal, and rectal specimens also is insufficient and is not recommended. MB/GV stain of urethral secretions is an alternative point-of-care diagnostic test with performance characteristics similar to Gram stain. Presumed gonococcal infection is established by documenting the presence of WBC containing intracellular purple diplococci in MB/GV smears.


Content 4

Content 3

Content 11


Update August 12, 2018

USMLE Reviewer (Subscription Required)