gonococcal peritonitis
Introduction
Introduction to gonococcal peritonitis Gonorrhea refers to various purulent infections caused by Neisseria gonorrhoeae (Neisseria gonorrhoeae). It is a classic common sexually transmitted disease. The primary infection site of Neisseria gonorrhoeae is mainly male urethra or Female endocervix, causing purulent inflammation of the genitourinary tract. Infection can be spread from the male urethra to the epididymis, testis and prostate, or from the female cervix to the fallopian tube, ovary, peritoneum, pasteurized gland, urethra and rectum, pharynx, rectum and conjunctiva can also be used as the primary infection site Affected. Neisseria gonorrhoeae can cause disseminated gonococcal infection (DGI), antibiotic treatment with penicillin as the first, severe peritonitis, can be injected intraperitoneally with 0.5% metronidazole solution. If non-surgical treatment is ineffective or it is difficult to rule out other surgical acute abdomen, it should be immediately surgically explored. basic knowledge The proportion of sickness: 0.4%-0.6% (the incidence rate of multi-sex partners is about 0.4%-0.6%) Susceptible people: no special people Mode of infection: non-infectious Complications: gonococcal infection meningitis
Cause
The cause of gonococcal peritonitis
Secondary infection (65%):
Neisseria gonorrhoeae peritonitis is secondary to gonococcal infections in other parts of the patient, such as acute pelvic peritonitis, most of which are followed by acute gonococcal salpingitis, and the fallopian tube exudate flows into the abdominal cavity through the umbrella end, causing localized pelvic inflammation. Sudden gonococcal peritonitis is caused by vaginal gonococcal dissemination; acute diffuse peritonitis is caused by rupture of gonococcal gonococcal, ovarian gonococcal abscess or pelvic gonococcal abscess.
Primary infection (35%):
The pathogen of gonococcal peritonitis is gonorrhea, which was discovered by Neisser in 1879, so it is also known as Neisseria gonorrhoeae. It is oval or kidney-shaped and arranged in pairs. Its size is 0.6-0.8m. One is stored in the cytoplasm of polymorphonuclear leukocytes, and Gram stain is negative. It does not grow on ordinary medium, and can grow on chocolate blood agar medium or Thayer-Martln medium containing vancomycin, colistin and nystatin under 3% to 10% CO2.
Pathogenesis
Humans are the only natural host of Neisseria gonorrhoeae, mainly invading mucosal tissues and causing local inflammatory reactions: extensive congestion, edema, serous exudation, followed by suppuration, connective tissue hyperplasia.
Neisseria gonorrhoeae infection involves different stages, including adhesion, invasion, intracellular survival, and induction of host responses. In vitro tissue and organ culture studies have shown that Neisseria gonorrhoeae adheres to non-ciliated epithelial cells through a variety of adhesins, through a muscle involved The internalization of the actin filaments and microtubules enters the epithelial cells, transcytosis and exocytosis through the basal layer into the subepithelial layer. Neisseria gonorrhoeae usually colonize the epithelial layer and induce inflammation, occasionally Bacterial invasion into the bloodstream causes disseminated infection. During infection and transmission, Neisseria gonorrhoeae needs to adapt to the host environment and evade the host's defense function. The mechanism of gonococcal adaptation and immune evasion includes antigenic variation of surface components, utilization of host components, and resistance. Unfavorable environment and phagocytic attack.
The main virulence factors of Neisseria gonorrhoeae include:
1. Pili have the ability to phase and antigen mutation, pili involved in the adhesion and invasion of Neisseria gonorrhoeae, and is the target of host immune defense.
2. Porin (PorB) plays an important role in gonococcal invasion, intracellular survival, serum resistance and antibiotic susceptibility.
3. Opaque protein (Opa) mediates adhesion and invasion of several different eukaryotic cells.
4. Rmp protein has strong immunogenicity, and its antibody can block the killing effect of normal and immune serum on Neisseria gonorrhoeae. It is of great significance in disseminated gonococcal infection. Rmp is also involved in the invasion of gonococcal epithelial cells.
5. Lipo-oligosaccharide (Los) In addition to participating in various physiological membrane functions, it affects the adhesion and invasion of bacteria, induces inflammatory reactions and resists the defense of the soil.
6. A bacterial exopeptide endonuclease secreted by IgAl protease gonococcal, using human serotype and secretory IgAl as substrates. Recent studies have shown that IgA2 protease is important for the survival of Neisseria gonorrhoeae in cells.
Prevention
Neisseria gonorrhoeae prevention
Gonorrhea is mainly a disease that is directly transmitted through sexual intercourse. Gonococcal peritonitis is often caused by gonococcal infection in other parts. Therefore, prevention must start from the basic link.
1. Promote healthy sexual habits, change bad sexual behavior, and avoid non-marital sexual contact.
2. It is recommended to use condoms in sexual life to prevent cross-infection of gonorrhea.
3. Daily necessities should be used exclusively, such as bath towels, underwear, washing pots, etc., to avoid intra-family transmission when gonococcal infection occurs.
4. Patients with acute gonorrhea in the family should be treated with isolation, such as avoiding sexual life, disinfecting the wash basin, underwear, bath towels, etc., and tracking, checking and treating sexual partners within 1 month. .
Complication
Neisseria gonorrhoeae peritonitis Complications Neisseria gonorrhoeae infection
Neisseria gonorrhoeae can reach the body with blood flow, causing disseminated gonococcal infections, such as gonococcal arthritis.
Neisseria gonorrhoeae dermatitis, gonococcal tenosynovitis, gonococcal endocarditis, gonococcal meningitis and gonococcal perihepatitis.
Symptom
Neisseria gonorrhoeae peritonitis symptoms common symptoms peritoneal irritation abdomen tension urinary frequency abdominal tenderness leucorrhea peritonitis dysuria urinary urgency purulent secretion abdominal pain
1. Lower abdominal pain unilateral or bilateral lower abdomen pain, a small amount of metastatic lower abdominal pain, but lighter than other peritonitis, frequent urination, urgency, dysuria, urinary tract burning, in the past six months often have similar symptoms, there are Unclean sexual contact history.
2. Peritoneal irritation signs palpation abdominal tenderness, the following abdominal or right lower abdomen mainly, with rebound tenderness, abdominal muscle tension.
3. After the gingival fullness of acute pelvic peritonitis, the gynecological examination may have severe tenderness, the posterior fornix is full, the cervical activity is poor, and the attachment touches the inflammatory mass, which is obvious to the right.
Examine
Examination of gonococcal peritonitis
1. Peripheral blood leukocyte count > 15 × 109 / L, neutrophils increased.
2. Bacteriology examination
(1) Secretory examination:
1 urethra (male) or vaginal discharge microscopic examination: there may be a large number of red polymorphonuclear leukocytes, in some cells phagocytosis of Neisseria gonorrhoeae, Neisseria gonorrhoeae is Gram-negative, oval or round, often double-aligned, The contact surface of the two bacteria is flat or slightly concave. The length of the bacteria is about 0.7 m and the width is about 0.5 m. However, the size of the two bacteria may vary. Most polymorphonuclear leukocytes do not contain gonococcal bacteria, but many white blood cells often contain 1 pair. Several pairs, even dozens of Neisseria gonorrhoeae, are often located in the cytoplasm.
In patients with long-term or treated gonorrhea, the number of gonococcus in the secretion smear is small, sometimes single, quadruple and octagonal, and often located outside the cell.
Urinary tract secretion specimen preparation method: wash the urethra mouth with a swab dipped in sterile isotonic saline, then use the fingers to squeeze the pus from the back and forward, use a cotton swab to pick up the pus and gently apply it to the load. On the slide, heat-fixed after natural drying, dyeing (usually Gram staining, also can be dyed with methylene blue), microscopic examination.
2 abdominal secretion examination: abdominal puncture drainage, pus yellow-white, thin, small amount, no odor, smear can find gonorrhea or PCR cocci, DNA test positive.
3 notes:
A. The diagnostic criteria for gonorrhea can be seen as intracellular Gram-negative dicocci, so the smear should be gentle, and the cotton swab should not roll on the slide to prevent the cells from rupturing or deforming, and the bacteria escape from the cells, resulting in Diagnostic confusion.
B. The smear thickness is appropriate, the smear is too thick, which may cause insufficient decolorization time, and the Gram-negative bacteria also appear purple. When a large number of dyed tablets, it is best to use known Gram-positive bacteria (such as Staphylococcus) and negative bacteria ( Such as Escherichia coli) for comparative observation.
C. When fixing the smear, it is only necessary to quickly pass the flame 2 to 3 times to avoid excessive cell deformation caused by heating. Generally, the smear is not overly hot on the back of the hand.
(2) Neisseria gonorrhoeae culture: Neisseria gonorrhoeae culture is the only method recommended by WHO for gonorrhea screening and also the gold standard for diagnosis.
It is usually cultured on blood agar or chocolate agar medium. To suppress the bacteria, an appropriate amount of antibacterial substances such as polymyxin B (25 g/ml) and vancomycin (3.3 g/ml) may be added.
After culturing on the blood plate for 24 to 48 hours, the gonococcus can form round, convex, moist, smooth, translucent or off-white colonies with petal-like edges and a diameter of 0.5-1.0 mm. Viscosity, if continued cultivation, the colony area increases, the surface becomes rough, and the edge shrinks. If the smear is taken from the colony, the size of the bacteria and the depth of dyeing are different, and the arrangement is also inconsistent. % of the bacteria are typical diplococcus, and the other 75% are monococci, quadruple or octagonal.
When using a liquid medium, Neisseria gonorrhoeae grows on the surface of the liquid with slight turbidity and particle precipitation.
Attention should be paid to the collection and inspection of culture specimens:
1Deep material: When taking the male urethra, the small cotton swab should be inserted into the urethra 2~4cm, and the secretion with mucosal cells should be taken out. When taking the material from the female cervix, the diffuser should be moistened with warm water first. Do not use liquid paraffin and other lubricating oil), then insert the cotton swab into the cervical canal 1.0~1.5cm, rotate and stay for 10~30s. Sometimes, in order to increase the positive rate, two specimens can be taken at the same time for cultivation, but the workload is also increased accordingly. .
2 timely inspection, inoculation: Neisseria gonorrhoeae sensitive to environmental changes, cold tolerance, dry tolerance, so the specimen should be sent immediately after leaving the body, if the laboratory is far away, the specimen can be inoculated in Stuart or Amies transport medium Or immersed in 1% glucose meat immersion, heat preservation on the way.
(3) Oxidase test: It is one of the important preliminary diagnostic tests for Neisseria gonorrhoeae. Neisseria gonorrhoeae can produce oxidase during the growth process, and oxidase reagent (0.5% to 1% hydrochloric acid) is added to the colonies cultured for 24 to 48 hours. Dimethyl p-phenylenediamine or tetramethyl-p-phenylenediamine hydrochloride aqueous solution), the colony turned purple or even black positive, but the oxidase test positive is not completely Neisseria gonorrhoeae.
In order to ensure the accuracy of the oxidase test results, three problems should be noted in the operation:
1 The oxidase reagent should be fresh: the normal oxidase reagent (dimethyl-p-phenylenediamine hydrochloride or tetramethyl-p-phenylenediamine hydrochloride) is light red. If the reagent turns gray or black, it means that it has failed. The solution should be stored in a brown glass bottle protected from light and used for about 1 week.
2 Avoid the use of iron inoculating loop: the contact of oxidase reagent with iron ions will produce red chemical changes, resulting in "positive" illusion. Therefore, vaccination should avoid the use of old iron wire or electric furnace wire, etc. The contact between the inoculating loop and the reagent should be checked for red.
3 When you need to keep the strain, you should pick a little turn when the colony has not completely turned black. When the colony turns black, most bacteria will die.
(4) Catalase test: Neisseria gonorrhoeae can produce catalase, which can rapidly decompose hydrogen peroxide into water and oxygen, and bubbles appear to be used for preliminary identification of Neisseria gonorrhoeae.
1 Method: Pick a colony on the inoculating ring and place it on a clean glass slide. Take 1 drop of 30% (V/V) hydrogen peroxide solution on the surface of the suspected colony. A large amount of bubbles are generated within 1 s, which is a positive reaction. Slow reaction or weak bubble formation is a negative reaction.
2 Note: Some non-pathogenic Neisseria can also be positive, and negative reactions can exclude Neisseria gonorrhoeae.
(5) Direct immunofluorescence test: fluorescein-labeled gonococcal antiserum (monoclonal antibody) is dropped on suspect bacteria, and when gonococcal (antigen) is encountered, the antibody binds to the antigen, and an apple is observed under a fluorescence microscope. The green fluorescent cells are detected rapidly by this method, and the dead bacteria can also have a positive reaction.
(6) Enzyme reaction: Neisseria gonorrhoeae has special enzymes, which can make the coloring substrate of some enzymes develop color, which is distinguished from other Neisseria species and clinically used for identification of Neisseria gonorrhoeae.
Choose to do abdominal B-ultrasound and abdominal plain film examination.
Diagnosis
Diagnosis and differentiation of gonococcal peritonitis
Diagnostic criteria for acute gonorrhea:
1. History Other parts of the body have a clear history of gonococcal infection, or a history of unclean sexual intercourse, or a history of gonococcal infection in the spouse, or a history of gonococcal infection in the parents of the child, or a history of sharing items with patients with gonorrhea at home.
2. Clinical manifestations of urinary or reproductive organs, such as urethral redness, purulent discharge (or purulent vaginal discharge). There are frequent urination, urgency, dysuria and other bladder irritation signs, abdominal pain, abdominal tenderness, rebound tenderness, muscle tension and other peritoneal irritation. General discomfort and so on.
3. Laboratory examination of secretions revealed microscopic granulocytic cells with Gram-negative diplococcus, and Gram-negative, oxidase-positive dicocci were isolated from selective medium.
