Introduction
Gonorrhea is a sexually transmitted disease caused by a bacteria Neisseria gonorrhoeae. Those who have multiple sexual partners and unprotected sex are vulnerable to this infection. Illicit drug users are at a higher risk than non users. This disease can affect the anus, eyes, mouth, genitals or throat. Gonorrhea can be diagnosed and treated successfully (Adam, 2011). This essay will discuss differential diagnosis related to the patient’s symptoms. The diagnostic tests, standards of care and treatment of Gonorrhea will be discussed.
Case Study
Miss Walker is a 27 year old female that presents to the office with complains of purulent vaginal discharge and painful urination for three days. She had been sexually involved with a male partner, Patrick for six months. They usually have unprotected vaginal intercourse three times a week. The sexual intercourse was gradually becoming painful. Miss Walker states that Patrick was also complaining of purulent urethral discharge and dysuria. She got involved in a vaginal and oral intercourse with another man last month. She also complains of a sore throat and severe pain in her lower abdomen. Miss Walker is on healthy diet and does not use illicit drugs. Her HIV & AIDS test was negative which she had taken three months ago. She had never had such symptoms before.
Differential Diagnosis
Gonorrhea
The presence of gonorrhea infection was suspected because of the many symptoms which were present in the patient. Her explained experience of two sexual partners was the biggest risk as well as the time duration. Positive Pathophysiologic findings were the presence purulent vaginal discharge and dysuria. The patient also had a sore throat and was complaining of frequent urination. There was also burning pain while urinating. The intensifying pain during sexual intercourse and fever were also signs that she could be suffering from gonorrhea (Adam, 2011).
Chlamydia
In relation to her sexual behavior, it is possible she could be suffering from Chlamydia. Multiple partners increase the chances of contracting Chlamydia. Key Positive pathophysiological findings of the patient were Painful sexual intercourse and burning pain while urinating were also symptoms of Chlamydia. Chlamydia symptoms also include rectal discharge or pain and liver inflammation (Adam, 2011).
Vaginal Yeast Infection
Yeast infections are caused by fungus known as Candida. Positive pathophysiological findings of vaginal yeast infection are abnormal vaginal discharge, painful urination, pain during intercourse and vaginal and labial itching. Yeast infection mostly develops when one is using antibiotics or during pregnancy. It is also common in those people with diabetes and overweight people (Health, 2011).
Bacterial Vaginosis
Bacterial vaginosis is common in women at child bearing age. It occurs when the harmful bacteria in the vagina increase than the “good” bacteria. Having multiple sexual partners increase the risk of infection. It is characterized by discharge, odor, and pain, itching or burning (CDC, 2010). Positive pathophysiologic findings in this patient are purulent discharge and painful urination. This makes it possible that the patient could be suffering from this disease. The discharge is characterized by amine odor (NCBI, 2005).
Epidemiology of Differential Diagnosis
Gonorrhea is a common disease in large cities. People with low levels of education and low social economic status have been seen to be at a higher risk of the disease. Gonorrhea affects more than 700,000 people in the U.S. (Adam, 2011).
Chlamydia is the most common sexually transmitted disease. However, most of the people with this disease do not have any symptoms. Only 25% of men and 30% of women have symptoms of the disease.
Vaginal yeast infection is very common. Most women suffer from it at some time of their lives. Candida albicans is the fungal causative agent. It often occurs in the vagina, mouth, digestive tract and skin. Small amounts of this fungus do not cause disease or symptoms (Health, 2011).
Bacterial vaginosis is most common in women of child bearing age especially in pregnancy. It is estimated to affect 1, 080,000 women every year in the U.S (CDC, 2010). It occurs in 35% women who attend sexually transmitted infections clinics, of which 15%-20% are pregnant women. It is also associated with infections after termination of pregnancies, insertion of intra-uterine devices and hysterectomy (NCBI, 2005). It is caused by an overgrowth of harmful bacteria in the vagina.
Diagnostic Tests
Gonorrhea
Gonorrhea is diagnosed by Nucleic Acid Amplification Test. This test is useful in diagnosing the cause symptoms and in screening of sexually active people. It is the most preferred method (Identification, 2008). This is because molecular tests are very sensitive and specific. The test involves amplification of DNA which is found in Neisseria gonorrhoeae. Multiple copies of genetic material, DNA and RNA are generated so as to produce adequate levels of the target to be detected (Chemistry, 2011).
In men Urethral discharge gram stain tests can also be used. Gram stain tests detect the presence of bacteria and can help in immediate prescription before the other longer tests are completed (Chemistry, 2011). From research done to compare the urine Leukocyte Esterase test to a nucleic Acid Amplification test, the nucleic acid amplification test sensitivity and specificity were 60 % and 96.2% respectively (Wood et al., 2007). Cost information of the test was unavailable.
Chlamydia
A definitive diagnosis of Chlamydia is necessary because of its resemblance with gonorrhea and they require different antibiotics for their treatment. The most preferred method for testing Chlamydia is Nucleic Acid Amplification Test (NAART). The test is advantageous because it is more sensitive and specific than the conventional culture. It is based on Amplification of DNA which is present in Chlamydia Trachomatis. Direct Fluorescent Antibody stain method can also be used to detect Chlamydia Antigens. DNA probe, which looks for Chlamydia DNA can also be used. However, these have lower sensitivity than NAART (Chemistry, 2011). NAART sensitivity and specificity was shown to be 45.8% and 97.4% respectively from a research carried out in the year 2000 in the U.S. (Wood et al., 2007). Cost information of the test was unavailable.
Bacterial Vaginosis
Bacterial Vaginosis can be diagnosed by clinical criteria or laboratory test. In clinical criteria, a health care provider examines the vagina. The most widely accepted criteria are Amsel criteria. This criterion requires that three of the four criteria given be met to confirm Bacterial Vaginosis. Firstly, the vaginal PH must be higher than 4.5. Secondly, clue cells must be present in the vaginal fluid and release amine odor on addition of 10% of Sodium Hydroxide on the vaginal fluid confirms Bacterial Vaginosis infection.
Gram stain method for a laboratory test is also appropriate. The test uses unfixed vaginal smear where after staining, the slide is read and the number of Morphotypes are evaluated. A score of 0-3 is considered normal. Four to six is intermediate while seven to ten is defined as Bacterial Vaginosis. 32% of intermediate score patients proceeds to Bacterial Vaginosis. This method is preferred because of its accuracy. Other tests include gas liquid chromatography, vaginal cultures and liquid preparation Papanicolaou smears (NCBI, 2005). Cost information of this test was not available.
Vaginal Yeast Infection
This disease is diagnosed by microscopic examination of vaginal secretions. This does not specify the particular fungus that is the cause of infection. Cultures are used in identification of the specific fungi. A nutrient media that support growth of fungal and inhibits bacteria growth is used. If yeasts cells are found, this is a confirmation of vaginal yeast infection. Susceptibility testing is then done to determine the best antifungal treatment (Chemistry, 2011). This test is specific but takes weeks to be completed. Vaginal swab can also be used to perform Potassium hydroxide (KOH) prep test. This test dissolves all the non fungal elements. Yeast cells and fungal hyphae are observed on a microscope slide. Calcoflour test could also be used where stain binds to fungal element in a sample and fluoresces under UV light. Both KOH prep and Calcofluor tests are rapid but not specific (Chemistry, 2011). Cost and sensitivity information was unavailable.
Standard of Care for Gonorrhea Diagnostic Test
Quality standards of care should be maintained while performing gonorrhea diagnostic test NAART. The diagnostic tests should differentiate between different sexually transmitted diseases. This prevents overtreatment of the patients. Technical and infrastructure requirements should be taken care of by provision of adequate resources in hospitals and clinics. All equipment used in the test for example those used for PCR should be in good order. Health care providers should also ensure that tests results are given to the patient within the shortest time possible. This would reduce the number of patients who fail to return to the health care providers because of delayed reports as well this enhances timely medication to the patient (Rosser et al., 2009). Sample handling should be done with care. Technicians should ensure that the samples are well labeled and that they acquire sufficient amount of the sample and use of the right quantity of the sample during the test (Services, 2010). They should also ensure proper preservation of these samples. This will ensure proficiency and quality assurance.
Treatment of Gonorrhea
Gonorrhea treatment should focus on treatment of the patient and the sexual partners of the patient. The gold standard is single shot of Ceftriaxone (Rocephin) 125mg or single dose of Cefixime which are orally taken are recommended for treatment of gonorrhea. A single dose of Azithromycin (Zithromax) 2g may be used for people with severe allergic reactions to Ceftriaxone. These are recommended by Centers for Disease Control and prevention. In the past, Penicillin was the major antibiotic for gonorrhea treatment but is no longer effective because it does not always cure the disease. It is advisable to test for Chlamydia if one is diagnosed with gonorrhea. This is because people with gonorrhea often have Chlamydia. Patients should also have a follow up after one week of treatment if they experience joint pain, skin rash, pelvic or belly pain. Sexual contacts of the patient should be contacted and treated to prevent spread of the disease (ADAM, 2011).
Sex education should be enhanced to help in prevention. People should have a monogamous relationship to reduce the risk of infection. Use of condoms while having sex is also a preventive measure (ADAM, 2011). According to CDC (2011), use of the male latex condoms has been proved to be quite effective in preventing most of the sexually transmitted diseases. It is however required that the condoms be used consistently on a regular basis whenever there is a sexual intercourse. It is also warned that the condoms must be used correctly and not just consistently (CDC, 2011).
Complications
It is vital that one is aware of the complications that can be brought about by untreated gonorrhea. Gonorrhea has been known to cause serious health condition if not treated. The Pelvic Inflammatory disease (PID) is known to be caused by untreated gonorrhea in women. It is estimated that almost three quarters of a million women contact PID every year in the US alone. The effects of PID are known to be disastrous to the human body:
The symptoms may be quite mild or can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled “pockets” that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube. (CDC, 2011, p. 1)
Conclusion
Gonorrhea is a sexually transmitted disease that requires specific and sensitive diagnostic test. Health care providers should ensure they provide necessary equipment and encourage people to be screened. Diseases which share most symptoms require differential tests so as to avoid wrong diagnosis. Right diagnosis helps in provision of the right treatment.
References
Adam, B. (2011). Gonorrhoea. Web.
CDC. (2010). Bacterial Vaginosis. Web.
CDC. (2011). STD-Facts. Web.
Chemistry, A. A. (2011). Gonorrhea. Web.
Health, N. I. (2011). Vaginal Yeast Infection. Web.
Identification. (2008). Identification of N. gonorrhoeae and Related Species. Web.
NCBI. (2005). The Lab Diagnosis of Bacteriaal Vaginosis. Web.
Services, D. H. (2010). Nucleic Acid Amplification Testing for Chlamydia and Gonorrhea. Web.
Rosser et al. (2009). Gonorrhea. Web.
Wood et al. (2001). Comparison Military Medicine.172(7) p. 770.