Gonorrhea pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
Overview
Gonorrhea is a sexually transmitted disease (STD) caused by Neisseria gonorrhea. It can infect mucus-secreting epithelial cells both in men and women. Established routes of transmission of the Neisseria gonorrhoeae bacterium include vaginal intercourse, rectal intercourse, fellatio, cunnilingus, and perinatal. The main pathogenicity of the Neisseria gonorrhea stems from the ability of its surface pili to attach to the surface of the urethra, fallopian tubes, and endocervix.[1][2][3] Anotehr virulence factor of gonorrhea is porin. The two main porin serotypes include PorB.1A strains (resulting in a disseminated gonococcal infection) and PorB.1B strains (resulting in local genital infections).[4][5][6]
In pregnancy, gonococcus can be transmitted to the fetus at the time of delivery. This results in infection of the conjuctiva. This appears 1 to 4 days after birth as severe discharge with marked swelling and redness of the eyelids and conjunctiva. Additionally, development of disseminated gonococcal infection is the result of Neisserial organisms' dissemination into the blood due to a variety of predisposing factors such as change in PH, pregnancy, menstruation, PorB.1A strains, and complement deficiencies.[7][8][9][10]
Pathophysiology
Gonorrhea is a sexually transmitted disease (STD) that is caused by Neisseria gonorrhea, a gram-negative intracellular diplococcus, oxidase-positive bacterium that utilizes glucose, but not sucrose, maltose, or lactose. It can infect mucus-secreting epithelial cells in both men and women.
Transmission
Established routes of transmission of the Neisseria gonorrhoeae include:
- Male to female via semen (transmission rate is estimated to be 50%-70% per episode)
- Female vagina to male urethra (transmission rate is estimated to be 20% per episode)
- Rectal intercourse
- Fellatio and, less commonly, cunnilingus can result in pharyngeal gonorrhea
- Perinatal
Virulence factors
Established virulence factors of Neisseria gonorrhoeae include:
- The main pathogenicity of the Neisseria gonorrhea stems from the surface pili by following mechanisms:[1][2][3]
- Mediate attachment to the surface of the urethra, fallopian tubes, and endocervix
- Preventing phagocytosis by neutrophils
- Opa proteins (opacity-associated protein) are surface proteins that help gonococcus binds to receptors on immune cells[11][12][13]
- Down-regulate activated CD4+ T cells (prevent an immune response)
- Inhibit B-cell antibody production (unable to establish immunological memory against gonorrhea)
- Porin, two main serotypes of which have been identified:[4][5][6]
- PorB.1A strains
- Bind to complement inhibitory molecules, resulting in a diminished inflammatory response (disseminated gonococcal infection)
- PorB.1B strains
- Cause local genital infections only
- PorB.1A strains
- Lipooligosaccharides (LOS)[14][15]
- LOS binds to human asialoglycoprotein receptor (ASGP-R) expressed on sperm cells and urethral epithelial cells
- Gonococcal ribosomal protein L12[16][17]
- Allows attachment to and invasion of an endometrial cell line via interaction with the lutropin receptor (LHr), which lead to pelvic inflammatory disease (PID) or disseminated gonococcal infection (DGI) in women
- Release of IgA1 proteases[18][19]
- The exact pathogenesis is not fully understood, but it is thought that IgA protease may play a role gonococcal infection in women
In pregnancy, gonococcus can be transmitted to the fetus at the time of delivery. This results in infection of the conjuctiva. This appears 1 to 4 days after birth as severe discharge with marked swelling and redness of the eyelids and conjunctiva.
Development of disseminated gonococcal infection is the result of Neisserial organisms' dissemination into the blood due to a variety of predisposing factors such as:[7][8][9][10]
- Host factors
- Change in pH
- Pregnancy
- Menstruation
- Change in pH
- Virulence factors of the organism itself
- PorB.1A strains
- Result in serum resistance
- PorB.1A strains
- Failures of the host's immune defenses
- Complement deficiencies
Host Factors
Host factors play an important role in mediating entry of gonococci into nonphagocytic cells by following methods:[20][21]
- N. gonorrhea activates phosphatidylcholine specific phospholipase C and acidic sphingomyelinase and release of diacylglycerol and ceramide
- Accumulation of ceramide results in apoptosis
- Apoptosis may cause disruption of epithelial integrity
- Disturbed epithelium facilitate entry of gonococci into sub epithelial tissue
- Additionally, gonococcus can survive in neutrophils and macrophages by preventing the formation of degradative phagolysosomes[22]
- Inflammatory cytokines may be released as a result of toxic effect of LOS
- Complement activation may result in chemotactic factors release which contributes to inflammation
Associated Conditions
HIV infection
Gonorrhea is associated with increased susceptibility to the transmission and acquisition of HIV infection by the following mechanisms:[23][24][25]
- Increased HIV expression and viral production by activation of HIV infected CD4 (transmission)
- Altered HIV specific CD8 cell response (acquisition)
HIV RNA concentrations in semen are eightfold higher among those with gonococcal urethritis.
References
- ↑ 1.0 1.1 Sparling PF (1966). "Genetic transformation of Neisseria gonorrhoeae to streptomycin resistance". J Bacteriol. 92 (5): 1364–71. PMC 276432. PMID 4958881.
- ↑ 2.0 2.1 Swanson J (1973). "Studies on gonococcus infection. IV. Pili: their role in attachment of gonococci to tissue culture cells". J Exp Med. 137 (3): 571–89. PMC 2139381. PMID 4631989.
- ↑ 3.0 3.1 Wolfgang M, Lauer P, Park HS, Brossay L, Hébert J, Koomey M (1998). "PilT mutations lead to simultaneous defects in competence for natural transformation and twitching motility in piliated Neisseria gonorrhoeae". Mol Microbiol. 29 (1): 321–30. PMID 9701824.
- ↑ 4.0 4.1 Young JD, Blake M, Mauro A, Cohn ZA (1983). "Properties of the major outer membrane protein from Neisseria gonorrhoeae incorporated into model lipid membranes". Proc Natl Acad Sci U S A. 80 (12): 3831–5. PMC 394146. PMID 6407021.
- ↑ 5.0 5.1 Ram S, Cullinane M, Blom AM, Gulati S, McQuillen DP, Monks BG; et al. (2001). "Binding of C4b-binding protein to porin: a molecular mechanism of serum resistance of Neisseria gonorrhoeae". J Exp Med. 193 (3): 281–95. PMC 2195916. PMID 11157049.
- ↑ 6.0 6.1 Ram S, McQuillen DP, Gulati S, Elkins C, Pangburn MK, Rice PA (1998). "Binding of complement factor H to loop 5 of porin protein 1A: a molecular mechanism of serum resistance of nonsialylated Neisseria gonorrhoeae". J Exp Med. 188 (4): 671–80. PMC 2213355. PMID 9705949.
- ↑ 7.0 7.1 WATRING, WATSON G., and DANIEL L. VAUGHN. "Gonococcemia in pregnancy." Obstetrics & Gynecology 48.4 (1976): 428-430.
- ↑ 8.0 8.1 Angulo, Juan M., and Luis R. Espinoza. "Gonococcal arthritis." Comprehensive therapy 25.3 (1999): 155-162.
- ↑ 9.0 9.1 Bohnhoff M, Morello JA, Lerner SA (1986). "Auxotypes, penicillin susceptibility, and serogroups of Neisseria gonorrhoeae from disseminated and uncomplicated infections". J Infect Dis. 154 (2): 225–30. PMID 3088132.
- ↑ 10.0 10.1 O'Brien JP, Goldenberg DL, Rice PA (1983). "Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms". Medicine (Baltimore). 62 (6): 395–406. PMID 6415361.
- ↑ Jerse AE, Cohen MS, Drown PM, Whicker LG, Isbey SF, Seifert HS; et al. (1994). "Multiple gonococcal opacity proteins are expressed during experimental urethral infection in the male". J Exp Med. 179 (3): 911–20. PMC 2191399. PMID 8113683.
- ↑ Boulton IC, Gray-Owen SD (2002). "Neisserial binding to CEACAM1 arrests the activation and proliferation of CD4+ T lymphocytes". Nat Immunol. 3 (3): 229–36. doi:10.1038/ni769. PMID 11850628.
- ↑ Pantelic M, Kim YJ, Bolland S, Chen I, Shively J, Chen T (2005). "Neisseria gonorrhoeae kills carcinoembryonic antigen-related cellular adhesion molecule 1 (CD66a)-expressing human B cells and inhibits antibody production". Infect Immun. 73 (7): 4171–9. doi:10.1128/IAI.73.7.4171-4179.2005. PMC 1168567. PMID 15972507.
- ↑ Harvey HA, Jennings MP, Campbell CA, Williams R, Apicella MA (2001). "Receptor-mediated endocytosis of Neisseria gonorrhoeae into primary human urethral epithelial cells: the role of the asialoglycoprotein receptor". Mol Microbiol. 42 (3): 659–72. PMID 11722733.
- ↑ Harvey HA, Porat N, Campbell CA, Jennings M, Gibson BW, Phillips NJ; et al. (2000). "Gonococcal lipooligosaccharide is a ligand for the asialoglycoprotein receptor on human sperm". Mol Microbiol. 36 (5): 1059–70. PMID 10844691.
- ↑ Spence JM, Clark VL (2000). "Role of ribosomal protein L12 in gonococcal invasion of Hec1B cells". Infect Immun. 68 (9): 5002–10. PMC 101722. PMID 10948117.
- ↑ Tsampalas M, Gridelet V, Berndt S, Foidart JM, Geenen V, Perrier d'Hauterive S (2010). "Human chorionic gonadotropin: a hormone with immunological and angiogenic properties". J Reprod Immunol. 85 (1): 93–8. doi:10.1016/j.jri.2009.11.008. PMID 20227765.
- ↑ Lin L, Ayala P, Larson J, Mulks M, Fukuda M, Carlsson SR; et al. (1997). "The Neisseria type 2 IgA1 protease cleaves LAMP1 and promotes survival of bacteria within epithelial cells". Mol Microbiol. 24 (5): 1083–94. PMID 9220014.
- ↑ Hobbs MM, Sparling PF, Cohen MS, Shafer WM, Deal CD, Jerse AE (2011). "Experimental Gonococcal Infection in Male Volunteers: Cumulative Experience with Neisseria gonorrhoeae Strains FA1090 and MS11mkC". Front Microbiol. 2: 123. doi:10.3389/fmicb.2011.00123. PMC 3119411. PMID 21734909.
- ↑ Duncan JA, Gao X, Huang MT, O'Connor BP, Thomas CE, Willingham SB; et al. (2009). "Neisseria gonorrhoeae activates the proteinase cathepsin B to mediate the signaling activities of the NLRP3 and ASC-containing inflammasome". J Immunol. 182 (10): 6460–9. doi:10.4049/jimmunol.0802696. PMC 2722440. PMID 19414800.
- ↑ Mosleh IM, Huber LA, Steinlein P, Pasquali C, Günther D, Meyer TF (1998). "Neisseria gonorrhoeae porin modulates phagosome maturation". J Biol Chem. 273 (52): 35332–8. PMID 9857075.
- ↑ Johnson MB, Criss AK (2013). "Neisseria gonorrhoeae phagosomes delay fusion with primary granules to enhance bacterial survival inside human neutrophils". Cell Microbiol. 15 (8): 1323–40. doi:10.1111/cmi.12117. PMC 3713093. PMID 23374609.
- ↑ Cohen MS, Hoffman IF, Royce RA, Kazembe P, Dyer JR, Daly CC; et al. (1997). "Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. AIDSCAP Malawi Research Group". Lancet. 349 (9069): 1868–73. PMID 9217758.
- ↑ Laga M, Manoka A, Kivuvu M, Malele B, Tuliza M, Nzila N; et al. (1993). "Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study". AIDS. 7 (1): 95–102. PMID 8442924.
- ↑ Malott RJ, Keller BO, Gaudet RG, McCaw SE, Lai CC, Dobson-Belaire WN; et al. (2013). "Neisseria gonorrhoeae-derived heptose elicits an innate immune response and drives HIV-1 expression". Proc Natl Acad Sci U S A. 110 (25): 10234–9. doi:10.1073/pnas.1303738110. PMC 3690901. PMID 23733950.