Gonococcal rhinitis

Symptoms and Diagnosis of Gonococcal Rhinitis

Clinical Presentation

Gonococcal rhinitis typically manifests with a pronounced inflammatory response of the nasal mucous membrane. Key symptoms and signs include:

• Profuse Nasal Discharge: This is a hallmark feature. The discharge is often initially watery but rapidly becomes thick, purulent (pus-like, yellowish or greenish), and sometimes blood-tinged. It is typically very abundant.
• Nasal Congestion and Obstruction: Significant swelling of the nasal mucosa leads to difficulty breathing through the nose, which can be particularly problematic for obligate nasal-breathing infants, leading to feeding difficulties and respiratory distress.
• External Nasal Swelling and Erythema: The inflammatory process can extend to the skin of the external nose, causing redness and swelling. The area around the nasal openings (nares) may become excoriated and inflamed.
• Conjunctivitis: Inflammation of the conjunctiva (the lining of the eyelids and white part of the eye) may co-occur, especially in newborns (as part of a broader neonatal gonococcal infection).
• Local Lymphadenopathy: Swelling and tenderness of the regional lymph nodes (e.g., submandibular or cervical nodes) may be present.
• Systemic Symptoms: Fever, irritability, and poor feeding may be observed, particularly in infants.

The intense inflammation can lead to crusting and difficulty clearing secretions. Without prompt treatment, complications such as septal perforation, sinus involvement, or spread to other sites can occur, though these are rare with modern antibiotic therapy.

Diagnostic Procedures

Diagnosis of gonococcal rhinitis relies on a combination of clinical suspicion and laboratory confirmation:

1. Clinical Examination: Observation of the characteristic symptoms, particularly the profuse purulent discharge and mucosal inflammation.
2. Microscopy: A Gram stain of the nasal discharge can reveal gram-negative intracellular diplococci, which are characteristic of *Neisseria gonorrhoeae*. This provides a rapid presumptive diagnosis.
3. Culture: A swab of the nasal discharge should be sent for culture on selective media (e.g., Thayer-Martin agar) to isolate and identify *N. gonorrhoeae*. This is the gold standard for diagnosis and also allows for antibiotic susceptibility testing.
4. Nucleic Acid Amplification Tests (NAATs): These highly sensitive and specific molecular tests can detect gonococcal DNA or RNA in nasal secretions. NAATs are increasingly used for diagnosing gonococcal infections at various sites.
5. Evaluation for Other Sites of Infection: In newborns, if gonococcal rhinitis is diagnosed, a thorough evaluation for gonococcal infection at other sites (eyes, pharynx, joints, disseminated infection) is crucial. In adults, evaluation for genital, pharyngeal, or rectal gonorrhea should be performed. Screening for other sexually transmitted infections (STIs) is also recommended in adults and in mothers of infected infants.

It is important to differentiate gonococcal rhinitis from other causes of purulent rhinitis, such as common bacterial rhinosinusitis. The absence of *Neisseria gonorrhoeae* on laboratory testing and typically less severe external nasal swelling would favor a diagnosis of non-gonococcal rhinitis. Streptococci and other bacteria may also be found in the discharge of gonococcal rhinitis, representing co-infecting or superinfecting organisms.

 

Treatment of Gonococcal Rhinitis

Prompt and effective treatment is essential for gonococcal rhinitis to prevent complications and further transmission. The mainstay of treatment is systemic antibiotic therapy.

Antibiotic Therapy

The choice of antibiotics should be guided by current local antibiotic susceptibility patterns for *Neisseria gonorrhoeae*, as resistance to some antibiotics (e.g., fluoroquinolones, and historically penicillin and tetracycline) is widespread.

• Newborns and Infants: Typically treated with a single dose of ceftriaxone (intramuscularly or intravenously). Alternatives might include cefotaxime. Hospitalization may be necessary for severe cases or if disseminated infection is suspected.
• Adults: Current guidelines usually recommend dual therapy with a single intramuscular dose of ceftriaxone plus a single oral dose of azithromycin. This combination helps treat gonorrhea effectively and also covers potential co-infection with *Chlamydia trachomatis*. Specific regimens may vary based on local resistance patterns and guidelines.

It is crucial to complete the full course of antibiotics as prescribed, even if symptoms improve.

Local Nasal Care

Supportive local care can help manage symptoms and promote comfort:

• Gentle Suctioning/Clearing of Secretions: Especially important in infants to maintain airway patency.
• Saline Nasal Sprays or Drops: Using sterile physiological saline solution can help to loosen and clear tenacious secretions and soothe the inflamed mucosa. Spray application is generally preferred over nasal washes or irrigation in infants to minimize the risk of middle ear infection (otitis media) by preventing fluid from being forced into the Eustachian tubes. A 3% boric acid solution was historically mentioned but is not a standard current recommendation for nasal irrigation due to potential toxicity if absorbed or ingested.
• Topical Treatments (Historical): Historically, topical applications such as lubrication with 1% silver nitrate solution or insufflation (blowing) of antiseptic powders were sometimes used after the acute phase. However, these are generally not part of modern treatment protocols, as systemic antibiotics are the primary treatment. Silver nitrate can be irritating and staining.

Management of Contacts

• Mothers of Infected Newborns: The mother of an infant diagnosed with gonococcal rhinitis (and her sexual partner(s)) must be evaluated and treated for gonorrhea.
• Sexual Partners of Infected Adults: All sexual partners of an adult diagnosed with gonococcal rhinitis should be notified, tested, and treated for gonorrhea.

Follow-up testing ("test-of-cure") may be recommended in some cases to ensure the infection has been eradicated, especially if non-standard treatment regimens were used or if symptoms persist.

 

Differential Diagnosis of Purulent Rhinitis in Newborns

In newborns presenting with profuse purulent nasal discharge, several conditions should be considered in the differential diagnosis:

Condition	Key Differentiating Features
Gonococcal Rhinitis	Often presents within first 2 weeks of life; profuse purulent, sometimes bloody discharge; marked mucosal inflammation; maternal history of gonorrhea; confirmed by Gram stain, culture, or NAAT for *N. gonorrhoeae*.
Chlamydial Rhinitis/Pneumonia	May present at 2-12 weeks of age; often associated with staccato cough and conjunctivitis; nasal discharge may be less profuse than gonococcal; confirmed by NAAT for *Chlamydia trachomatis*.
Common Bacterial Rhinitis/Sinusitis	Caused by typical respiratory pathogens (e.g., *Streptococcus pneumoniae*, *Haemophilus influenzae*, *Moraxella catarrhalis*); may follow a viral URI; *N. gonorrhoeae* absent on testing.
Viral Upper Respiratory Infection (Common Cold)	Discharge often initially clear and watery, may become thicker and colored later; usually associated with other cold symptoms like cough, mild fever.
Congenital Syphilis ("Snuffles")	Persistent, often bloody or mucopurulent nasal discharge starting in early infancy; associated with other signs of congenital syphilis (rash, bone changes, hepatosplenomegaly). Serological tests for syphilis are positive.
Nasal Foreign Body	Usually unilateral, foul-smelling, purulent discharge; more common in older infants and toddlers.
Chemical Rhinitis	Irritation from topical medications or environmental exposures; usually watery discharge and less purulence unless secondarily infected.

 

Prevention and Public Health Implications

Prevention of gonococcal rhinitis in newborns is closely linked to the prevention and treatment of gonorrhea in pregnant women:

• Prenatal Screening: Routine screening for gonorrhea in pregnant women, especially those at high risk, allows for treatment before delivery.
• Treatment of Infected Mothers: Prompt and effective treatment of gonorrhea in pregnant women prevents perinatal transmission.
• Neonatal Prophylaxis: While primarily aimed at preventing gonococcal ophthalmia neonatorum (eye infection), erythromycin ophthalmic ointment applied to newborns' eyes shortly after birth can also have some effect against nasal colonization if the bacteria are susceptible, though it's not specifically indicated or fully effective for preventing rhinitis. Systemic treatment of the infant is required if maternal infection was untreated or if the infant is symptomatic.
• Safe Sexual Practices: In adults, practicing safe sex (e.g., consistent condom use) and regular STI screening can prevent gonococcal infections that could potentially lead to autoinoculation of the nasal passages.

Gonococcal rhinitis, like other manifestations of gonorrhea, is a reportable disease in many jurisdictions, contributing to public health surveillance and control efforts.

 

When to Seek Medical Attention

Medical attention should be sought immediately if:

• A newborn or infant develops profuse, purulent nasal discharge, especially if accompanied by feeding difficulties, respiratory distress, or eye discharge.
• An adult develops unusually severe or purulent nasal discharge, particularly if there is a known or suspected exposure to gonorrhea.
• Symptoms of rhinitis are accompanied by redness or swelling of the external nose or conjunctivitis.

Early diagnosis and treatment are crucial to prevent complications and ensure a good outcome.