October 23, 2015

Clinical Vignette 49

A photograph from a Gram stain of a urethral swab.

Gram stain from a urethral swab.

Gram stain from a urethral swab.

The young man, recently married, had presented with penile discharge and a burning sensation during micturition for 2 days. He denied promiscuity.

Question: What is the diagnosis and what is an appropriate course of management?

[Update 30 Oct 2015]

The Gram stain shows Gram-negative diplococci within neutrophils. The diagnosis in this case is gonorrhoea. In Singapore, all isolates to date are susceptible to ceftriaxone, with variable (and high) resistance to fluoroquinolones and other antimicrobial agents. Hence a single intramuscular injection of ceftriaxone is the treatment standard.

However, it is important to be cognisant of two fundamental principles in the management of sexually transmitted diseases (STDs):

  • It is possible (and quite common) to have more than one STD at the same time.
  • The partner(s) should also be tested and treated to break the chain of transmission.

In this case, it is therefore good to test (routinely done at Kelantan Clinic) for the presence of Chlamydiae trachomatis, as well as to speak to the patient about screening for HIV. The patient should also be encouraged to ask his wife (and any partners – the history provided by patients is sometimes unreliable with regards to STDs, and it is crucial to be non-judgmental) to come for testing and treatment if possible.

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