Analysis of the cervical exudate would be informative. The specimen is collected by swabbing the endocervix. In an inflamed cervix, this may cause a small amount of bleeding, which is termed friability and is characteristic of Chlamydia, but can be seen in any cause of cervicitis. A cell count can demonstrate the presence of leukocytes, confirming the presence of cervicitis. This is a non-specific finding. Gram stain and culture is useful to demonstrate the causative organism of gonorrhea.
Also, tests for Chlamydia can be performed on the swab and are indicated. Chlamyida trachomatis is the causative agent of Chlamydial disease. This organism resembles bacteria, but is an obligate intracellular pathogen, so cell culture techniques are required to grow it for identification in the laboratory. This is a more difficult task than the simple bacterial culture technique needed for gonorrhea. Cell culture is useful, but may not be cost-effective and is beyond the scope of many laboratories. Non-culture methods of antigen detection are most commonly used in practice today. These include antigen detection by ELISA or direct fluorescent antibody.
Gram stain in this case reveals the characteristic encapsulated gram negative intracellular diplococci of gonorrhea. The organism is seen within the cytoplasm of inflammatory cells. Gonorrhea is cultured on a laboratory medium called chocolate agar. In this case the culture shows the causative organism, Neisseria gonorrhoeae, several days later. ELISA for Chlamydial antigens is negative.
Synovial fluid from the painful knee was obtained and shows neutrophils. The gram stain is also positive for gram negative diplococci.
On the basis of the gram stain and the clinical findings, the patient is placed on an aggressive antibiotic regimen.
Weeks later she is afebrile and has no arthritis. However, she still has significant pelvic pain. Gynecological examination reveals the cervix and vagina to be healing well, but there is still marked tenderness in the region of both adnexae. After a detailed work-up and prolonged discussion, the patient consents to total hysterectomy.
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