A 32-year-old female trader presented to a hospital in the Ashanti region of Ghana, with 3-weeks history of generalised malaise and fever. Prior to her presentation, she was treated in a neighbouring hospital as a presumed case of enteric fever. On direct questioning, the patient had no known history of chronic underlying medical condition.
On examination, she weighed 73.2 kg, was slightly pale and febrile with a temperature of 38.5 °C. Examination of her body systems including the cervix and vagina were all normal. Based on the clinical findings, a provisional diagnosis of enteric fever was made.
Preliminary laboratory test for HIV and malaria were all negative. Her full blood count showed a low haemoglobin concentration of 8.7 g/dL and raised white cell count of 12.4 × 103 cells/µL.
Liver function test showed high aspartate transaminase (AST) of 151 U/L and alanine transaminase (ALT) of 74 U/L. Her CD4 count was 1899 cells/mm3 and CD4/CD3 ratio was 0.71. Pending results for microbiological investigations, the patient was empirically administered with 500 mg of ciprofloxacin 12 hourly daily.
Blood and urine were collected for microbiological cultures. Blood sample was collected into Beckton Dickinson(BD) adult aerobic blood culture bottle (BD, Baltimore, US) and incubated in Bactec Machine at 35 °C (9050, BD).
The blood culture yielded a fastidious bacterium with small sized and creamy non-haemolytic colonies. Gram stain of the colonies showed Gram negative diplococci. Oxidase and catalase tests proved positive. The identity of the bacteria was determined by first using Analytic Profile Index (API) specific for Neisseria spp. and Haemophilus spp. (API NH, Biomerieux) and then confirming with 16S PCR method. The API kit showed a 100% consistency with N. gonorrhoeae.
For molecular identification, the 16S rRNA gene sequence of this bacterium was determined according to the procedure described previously . Briefly DNA was extracted from the pure culture using Spherolyse extraction kit (Hain Lifesciense GmbH, Germany). The 16S rDNA was amplified using primer pair 8F and 1492R and the resulting sequence was checked using DECIPHER (version 2.2.0).The final sequence generated was deposited in NCBI GenBank under the MF509590 and exhibits 99% (1440/1442) sequence identity to N. gonorrhoeae strain NCTC 8375 (NR_026079.1).
Antimicrobial susceptibility testing was performed on the isolate using the Kirby Baur disc diffusion method and following the Clinical and Laboratory Standards Institute guideline  The isolate showed resistance to ciprofloxacin, cotrimoxazole and penicillin but sensitivity to ceftriaxone, chloramphenicol and azithromycin. The patient’s prescription was amended to include ceftriaxone and azithromycin and her condition improved clinically.