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Sexually transmitted infections

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Title: Sexually transmitted infections


1
Sexually transmitted infections
  • Mary Horgan M.D.
  • Cork University Hospital

2
Major STD syndromes
  • Genital ulcer disease
  • Urethritis/cervicitis
  • Vaginitis/vaginosis
  • Exophytic processes
  • Ectoparasitic infestations
  • Systemic STD syndromes

3
Genital ulcer disease
  • Genital herpes (HSV)
  • Syphilis (T. pallidum)
  • Chancroid (H. ducreyi)
  • Lymphogranuloma venereum (rare)
  • Granuloma inguinale (rare)

4
Genital ulcer disease
  • Conditions characterised by ulcers which are
    usually sexually transmitted
  • Multiple causes can co-exist

5
Staging of syphilis
  • Primary
  • Secondary
  • Latent
  • Early latent
  • Late latent 1 year
  • Late (tertiary) - includes neurosyphilis

6
Primary syphilis
  • The first manifestation of infection
  • Characterized by development of chancre
  • Incubation period
  • average 3 wks. from time of exposure
  • range 9 - 90 days
  • Chancre occurs at site of bacterial invasion

7
Chancre characteristics
  • Indurated
  • Painless
  • Raised border
  • Red, smooth base
  • Scant serous secretions
  • Indolent, punched out appearance

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Chancre characteristics
  • Regional lymphadenopathy is common
  • inguinal nodes if genital lesions present
  • cervical nodes if oropharyngeal lesions present
  • Chancre usually (but not always) precedes
    development of secondary symptoms
  • Chancre typically resolves in 3 - 6 weeks without
    treatment

10
Secondary syphilis
  • Evidence of systemic spread of infection
  • Characterized by rash, other skin and mucous
    membrane lesions
  • Typically develops 3 - 6 weeks following
    development of primary lesions (chancre)

11
Rash characteristics
  • Maculopapular eruption
  • classic palmar -plantar distribution
  • may occur on face, back, trunk, arms, legs
  • Rash may also manifest as
  • macular or erythematous eruption
  • papular lesions
  • pustular lesions (infrequent)
  • annular lesions

12
Rash characteristics
  • Mucous patches affecting mucous membrane
    surfaces
  • Facial nickel and dime lesions
  • Patchy alopecia (hair-loss)
  • moth-eaten appearance

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14
Systemic signs and symptoms
  • Flu-like syndrome
  • Weight loss
  • Anemia, elevated ESR
  • Lymphadenopathy
  • Hepatosplenomegaly

15
Latent syphilis
  • Serologic evidence of infection without clinical
    manifestations
  • positive blood test for syphilis
  • no primary or secondary lesions
  • no evidence of tertiary disease
  • Early vs. late latent syphilis
  • early infection of less than 1 years duration
  • late infection of greater than 1 years
    duration

16
Treatment Recommendations
  • Early syphilis
  • all primary infections
  • all secondary infections
  • early latent infection (
  • Benzathine PCN-G (Bicillin-LA) 2.4 million units
    IM single dose

17
Treatment Recommendations
  • Late disease
  • Late latent syphilis (1 years duration)
  • Benzathine PCN-G (Bicillin-LA) 2.4 million units
    IM q week x 3 doses

18
Treatment Recommendations
  • Penicillin-allergic patients
  • Doxycycline 100mg po BID x 14 days
  • (28 days if late disease), OR
  • Tetracycline 500mg po QID x 14 days
  • (28 days if late disease)

19
Neurosyphilis
  • The manifestations of CNS syphilis were readily
    recognized by physicians practicing 30 or 40
    years ago. However they are unfamiliar to many
    physicians today given the relative rarity of
    this condition

20
Neurosyphilis
  • Asymptomatic
  • no clinical manifestations
  • defined by presence of CNS abnormalities
    including
  • WBC 5/mm3, mostly lymphs
  • elevated protein
  • reactive CSF-VDRL
  • may progress to overt neurosyphilis

21
Parenchymatous neurosyphilis
  • General paresis
  • also known as paretic neurosyphilis, dementia
    paralytica, and general paralysis of the insane
  • T. pallidum directly invades the cerebrum
  • early symptoms memory loss, irritability,
    personality changes, headache, insomnia
  • late symptoms defective judgment, emotional
    lability, lack of insight, confusion,
    disorientation, delusions, paranoia, seizures

22
Parenchymatous neurosyphilis
  • General paresis
  • neurologic findings include
  • Argyll Robertson pupils
  • slurred speech
  • expressionless face
  • tremors

23
Congenital syphilis
  • Acquistion of syphilis by the fetus or newborn
    infant
  • Vertical transmission from mother
  • Transplacental (during pregnancy)
  • Perinatal acquisition (at time of birth)
  • Significant cause of spontaneous abortion (up to
    50 in infected mothers)

24
Congenital syphilis
  • Early clinical signs and symptoms include
  • hepatomegaly
  • splenomegaly
  • anemia, jaundice
  • skin rash / petechiate
  • persistent nasal discharge (snuffles)
  • abnormal bone development (osteochondritis)
  • pseudoparalysis

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Cardiovascular syphilis
  • Cause of thoracic aortic aneurysm
  • aortic valvular insufficiency
  • Also may involve coronary arteries
  • Pathogenesis is through endarteritis of the vasa
    vasorum of aorta
  • Lesions may erode through chest wall or rupture
    spontaneously

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Treatment of tertiary syphilis
  • Treatment of gummatous lesions will prevent
    further destruction
  • Treament will not restore tissue which has
    already been destroyed

29
Laboratory tests for syphilis
  • Confirm clinical suspicion of disease
  • Screen populations at risk
  • Monitor response to therapy
  • Determine treatment failure and need for lumbar
    puncture

30
Types of laboratory tests
  • Direct examination of lesion material
  • darkfield microscopy
  • Serologic testing of blood samples
  • non-treponemal tests (screening)
  • treponemal tests (confirmatory)
  • Other
  • direct fluorescent antibody (DFA)
  • histologic staining (biopsy)

31
Darkfield microscopy
  • Extremely specific for T. pallidum
  • Test of choice for moist genital ulcers
  • Offers immediate diagnosis
  • Opportunity for immediate treatment

32
Serologic tests for syphilis
  • A blood test
  • Detects antibody in serum
  • Requires blood sample centrifugation
  • Requires laboratory processing
  • Follow universal precautions at every step

33
Syphilis - Non-treponemal tests
  • Used for screening large samples
  • Cardiolipin-cholesterol-lecithin antigen
  • Sensitive but not 100 specific
  • Two tests commonly available
  • Rapid Plasma Reagin test (RPR)
  • Venereal Disease Research Laboratory test
    (VDRL)

34
Non-treponemal test sensitivity
  • Test 1o 2o EL LL
  • VDRL 78 100 95 71
  • RPR 86 100 98 73

35
False-positive RPR / VDRL
  • General population 1-2
  • IV drug users 10
  • Transient false-positive
  • pregnancy
  • febrile illnesses
  • Chronic false-positive
  • autoimmune disorders, aging

36
Syphilis - Treponemal tests
  • Used for confirmation of infection
  • Detects antibodies against T. pallidum cellular
    components
  • More expensive, more specific
  • Commonly available tests include
  • Fluorescent Treponemal Antibody Absorption
    (FTA-ABS)
  • Microhemagglutination Assay (MHA-TP)
  • T. pallidum particle agglutination (TP-PA)

37
Interpreting treponemal tests
  • 86 of syphilis cases remain reactive for life
  • Not used to monitor efficacy of treatment or
    reinfection
  • 1 false-positive rate in general pop.
  • Negative test on CSF excludes neurosyphilis

38
Syphilis serology
  • Problems
  • How do you ascertain who is infectious?
  • How do you ascertain who should be tracked for
    partner notification?

39
Summary
  • Neurosyphilis, congenital syphilis and tertiary
    syphilis are difficult to diagnose
  • These conditions cause serious long-term
    morbidity and mortality
  • High index of suspicion for syphilis is required
    when dealing with populations at risk

40
Genital herpes
  • 90 of primary infection is subclinical
  • Most common in adolescence and young adults
  • Neonatal infection via birth canal
  • disseminated
  • CNS
  • skin, eye, mouth (SEM)
  • occurs with primary secondary infection

41
Genital Herpes
  • Primary infection first exposure to HSV type 1
    or 2
  • Initial infection first exposure to HSV-2 but
    previous infection with HSV-1
  • some antibody cross protection
  • generally not as severe as primary infection
  • Recurrent infection known prior outbreaks
  • usually precipitated by stress, trauma,
    pregnancy, menses, fever, systemic illness

42
Genital herpes primary infection
  • Usually painful with prodrome
  • Incubation period 2-20 days (mean 6d)
  • Duration 1-3 weeks
  • Presents as painful vesicles or ulcers
  • Initial infection is usually associated with
  • lymphadenopathy
  • fever, headaches
  • myalgias
  • urethritis, cervicitis
  • urinary retention

43
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44
Genital infectionrecurrent infection
  • 80 have recurrences but frequency varies
  • Usually at same site as primary infection
  • Less severe than primary infection

45
Genital herpes Diagnosis
  • Clinical features
  • Viral culture
  • HSV PCR

46
Genital herpes treatment
  • Acyclovir or derivatives are drugs of choice
  • Available in oral, parenteral and topical forms
  • Primary infection
  • ACV 400mg tid for 10 days
  • Recurrent infection
  • ACV 400mg tid for 5 days
  • Chronic suppressive therapy consider for 6
    episodes/year with
  • ACV 400mg bd for one year

47
Urethritis/cervicitis
  • Gonorrhoea (N. gonorrhoeae)
  • Chlamydia trachomatis
  • Mycoplasma hominis
  • Ureaplasma urealyticum

48
The urethra
  • Common pathway for urine and semen
  • Columnar epithelial lining
  • Primary site of infection for GC and chlamydia
  • Possible site of infection for
  • mycoplasma hominis
  • Trichomonas
  • Ureaplasma

49
Urethritis
  • Inflammatory response of urethra
  • infection of urethra
  • WBC is primary inflammatory response
  • organisms may also be seen
  • Symptoms
  • dysuria
  • discharge (purulent or mucoid)
  • WBC

50
Urethral specimen collection
  • Patient should not void for 2hours before
    specimen collection\
  • Swab inserted 1-2cm into distal urethra and
    rotated 1-2 turns
  • Smear swab onto glass slide
  • Inoculate swab onto chocolate and NY agar
  • Second swab for chlamydiazyme

51
Cervicitis
  • Cervicitis is the female counterpart of
    urethritis
  • inflammatory response of cervix
  • reflects infection of T zone
  • WBC is primary inflammatory response and
    organisms may be seen as in GC

52
Cervicitis
  • Caused by
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Mycoplasma hominis
  • Ureaplasma
  • Trichomonas
  • Characterised by
  • discharge
  • dysuria
  • dyspareunia

53
Other causes of cervical inflammation
  • HSV
  • Trichomonas
  • Candidiasis
  • Foreign body
  • Ectopy, OCP and menses

54
Endocervical swab collection
  • Visualise cervical os
  • Insert swab and rotate several times
  • Observe colour of swab
  • Smear swab lightly on glass slide
  • Inoculate on chocolate and NY agar
  • Second swab for chlamydiazyme as above

55
Chlamydia trachomatis
  • Common cause of cervicitis and urethritis
  • Obligate intracellular organism
  • May cause
  • PID and sequelae
  • Reiters syndrome
  • Neonatal eye infection and pneumonia
  • Diagnosis by
  • culture
  • non-culture techniques
  • urine-based screening

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Treatment of Chlamydia trachomatis
  • Treat with
  • Azithromycin 1G po one dose
  • If no access to microscopy treat for coinfection
  • See CDC recommendations for alternatives for
  • allergies
  • pregnancy
  • reinfection
  • less expensive regimens

58
Gonorrhoea
  • Gram - intracellular diplococci
  • Cause urethritis, cervicitis, proctitis and
    pharyngitis
  • Disseminated gonococcal infection
  • Associated with PID and its sequelae
  • Neonatal infection e.g. conjunctivitis

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60
Treatment of GC
  • Effective therapy includes a regimen that covers
    coinfection with chlamydia and GC
  • Treat with
  • Ciprofloxacin 500mg one dose
  • Azithromycin 1G one dose
  • For alternatives see CDC guidelines on www.cdc.gov

61
Evaluation of sex partners
  • Treat regular and potential source partners as
    per index case
  • Symptomatic patients
  • refer all patients within past 30 days
  • Asymptomatic patients
  • refer all patients within past 60 days
  • Treat all partners who have objective evidence of
    infection
  • Full STD screen should be done on all patients

62
Vaginitis/vaginosis
  • Bacterial vaginosis
  • Trichomoniasis
  • Yeast vaginitis

63
Bacterial vaginosis
  • Malodorous vaginal discharge /- pruritis
  • Homogenous, non-viscous milky white D/C
  • Caused by gardnerella, mycoplasma and anaerobes
  • Absence of normal flora like lactobacillus
    appears to correlate with its development
  • Not sexually transmitted but more common in
    sexually active women

64
Bacterial vaginosis
  • Vaginal pH 4.5
  • Positive whiff test
  • fishy odour on addition of 10 KOH
  • Presence of clue cells on microscopy
  • Homogenous discharge on examination

65
Bacterial vaginosis
  • Infection may induce preterm labour
  • Treatment
  • Metronidazole 400mg bd for 7 days
  • avoid during first trimester of pregnancy
  • No indication to treat sexual partner

66
Trichomoniasis
  • Caused by a protozoa, Trichomonas vaginalis
  • Profuse, purulent, malodorous discharge
  • May be associated with dysuria and irritation
  • Examination shows petechiae on cervix
    (strawberry cervix)

67
Trichomoniasis diagnosis
  • Motile trichomonads on saline wet prep of vaginal
    exudate
  • Vaginal pH 4.5
  • Culture (not routinely done)

68
Trichomoniasis treatment
  • Metronidazole 2.0G one dose
  • Sexual abstinence until symptoms resolve
  • Treatment of sexual contacts is necessary since
    the infection is sexually transmitted

69
Vulvovaginal candidiasis
  • Usually not a sexually transmitted infection
  • 66 caused by Candida albicans
  • Presents with
  • vulval pruritis
  • vaginal discharge
  • dysuria

70
Vulvovaginal candidiasis diagnosis and treatment
  • pH
  • Fungal elements on 10 KOH prep
  • Treat with
  • intravaginal imidazole cream or pessary
  • Fluconazole 150mg one dose

71
Pelvic Inflammatory Disease
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