Figure 3.

The reproductive cycle influences Gc infection of women and mice. (A) Culture rates from women with gonorrhea and the opacity phenotype of cervical isolates from infected women with respect to stages of the menstrual cycle (Koch, 1947; Johnson et al., 1969; James and Swanson, 1978; McCormack and Reynolds, 1982). In one study, women with gonorrhea were hospitalized without treatment and in four of four women, positive cultures were followed by five to six consecutive negative cultures during the secretory phase; cultures became positive again at menses (Koch, 1947). Gonococcal PID and disseminated gonococcal infection most frequently occur at or shortly after menses (Holmes et al., 1971) and Gc from fallopian tubes from women with salpingitis were reported to be Opa⁻ (Draper et al., 1980). (B) Cartoon depicting the cyclical recovery pattern seen in intact mice following inoculation with mostly Opa⁻ variants of strain FA1090. Within a day after inoculation with mostly Opa⁻ Gc, Opa⁺ variants predominate (early phase). This phase is followed by a period in which mostly Opa⁻ variants are isolated (mid-phase) and then a second Opa⁺ phase (late phase). A high percentage of isolates express multiple Opa proteins in the late phase. In mice that remain infected for more than 8 days, a second mid-phase is observed. The rise and fall of the Opa⁺ population corresponds to fluctuations in the total number of Gc recovered. This pattern is not seen in Ov⁻ mice. Hostile factors may reduce colonization during the mid-phase or perhaps Opa⁺ variants are less accessible for culture due to tissue invasion (Simms and Jerse, 2006; Cole et al., 2010).