Clinical Manifestations

In the head and neck, pharyngeal gonococcal infection is asymptomatic as a rule, although rare cases present with exudative pharyngitis and cervical lymphadenopathy. Symptomatic patients usually present with findings suggestive of tonsillitis. The tonsils are enlarged with a white-yellow exudate arising from the crypts. Patients may show evidence of oropharyngeal trauma, particularly on the soft palate or uvula. Fever (8%) and lymphadenopathy (9%) are uncommon findings (11). Organisms are found within the cellular debris at the base of crypts. 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. In addition, transmission of pharyngeal infection to other sites is inefficient. Gonococcal oropharyngitis is common among homosexuals and among children who are victims of sexual abuse. Infection follows orogenital contact. For asymptomatic patients, evidence suggests that the presence of N. gonorrhoeae in the oropharynx may be self-limited. This does not justify withholding treatment, however, because dissemination from the pharynx can still occur. Dissemination occurs in roughly 1% to 3% of cases, typically in patients asymptomatic relative to the pharyngeal or urogenital infection (10). Manifestations of dissemination can include low grade fever, migratory polyarthralgias involving the large joints, septic arthritis, or dermatitis.

Bacterial conjunctivitis may affect one or both eyes. Presenting symptoms may include red, injected (hyperemic) conjunctiva; discharge may be watery or purulent. Matted eyelids are common. Pseudomembranes may be present; they do not cause bleeding when removed. True membranes occur, as well; these are fibrin coagulated exudates attached to inflamed conjunctiva, which cause bleeding if removed. This differentiation between pseudomembranes and true membranes is not as important as once thought, because both have similar etiologies (i.e., infection with p-hemolytic Streptococcus, Gonococcus, C. diphtheriae). N. gonorrhoeae is commonly considered first for neonatal conjunctivitities, that is, those occurring within the first month of life. When conjunctivitis occurs within the first two to five days of life, Neisseria must be considered. If infection with this organism is suspected, early treatment is imperative to prevent rapid corneal ulceration and penetration. Gonococcal conjunctivitis is a sight-threatening infection when it occurs in the neonatal period, because the Gram-negative intracellular diplococci can easily penetrate the cornea. Corneal ulceration may occur within hours. Signs of Neisseria conjunctivitis include a hyperacute, purulent, yellow-green discharge. Conjunctivitis beyond the newborn period follows direct spread of the gonococcus, usually via fingers contaminated with genital secretions. It rarely results from gonococcemia. Conjunctivitis is often severe with chemosis, eyelid edema, and ulcerative keratitis; and presentations may mimic orbital cellulites.

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