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Term 5: Infectious Disease > 5/26- Sexually Transmitted Diseases > Flashcards

5/26- Sexually Transmitted Diseases Flashcards

1
Q

Minimum evaluation requirements for someone with even 1 STD

A
  • Syphilis- RPR
  • Chlamydia (urethral/cervical swab)
  • Gonococci
  • HIV antibody
  • Hep B antibody
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2
Q

Why is compliance with therapy for STDs notoriously poor?

A
  1. Much denial around diseases (contributing to behavior)
  2. Most persons who acquire are likely not in full control of their own health issues (excluding innocent bystanders)
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3
Q

What is the best documented means of STD control?

A

Condoms (not abstinence)

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4
Q

What are some non-typical STD infections?

A

Enteric diseases in MSM:

  • Shigella (flexneri)
  • Cryptosporidia
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5
Q

Causes of venereal chancres?

A
  • Syphilitic chancre;treponema pallidum
  • Chancroid; haemophilus ducreyi
  • Herpes
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6
Q

Causes of nonvenereal chancres?

A
  • Fixed drug eruption
  • Trauma (clean or purulent/2ndary infxn)
  • Unknown (Behcet’s dz)
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7
Q

Causes of warts/bumps?

A
  • Human papillomavirus (venereal)
  • Molluscum contagiosum
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8
Q

Causes of condyloma lata?

A
  • Extension of syphilitic infxn if 1’ untreated
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9
Q

Characteristics of syphilitic chancre?

A
  • Clearly demarcated with raised margin and clean base
  • Single or multiple
  • Genital lesions are painless
  • Most are genital (shaft of penis, labia, cervix), but possible in mouth, anus or rectum
  • Enlarged regional lymph nodes
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10
Q

Early diagnosis of syphilis?

A
  • Scraping of chancre (for 1’ infxn) and Darkfield exam
  • Early on, RPR may still be negative
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11
Q

When are women typically diagnosed with syphilis?

A

When it’s a 2’ infxn (not 1’), since the chancre is painless

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12
Q

Characteristics of chancroid lesion of Haemophilus ducreyi?

A
  • Jagged margin and purulent base
  • Painful
  • Single or multiple
  • Genital only
  • Greatly enlarged regional lymph nodes; painful (typically diagnosed syndromically)
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13
Q

Characteristics of herpes lesions?

A
  • Multiple vesicles that ulcerate because of friction from underwear
  • Painful
  • 1st episode has systemic Sx plus enlarged regional lymph nodes (less in subsequent bouts)
  • Highly associated with relapse; recurring disease (less severe). Possibly have lifelong shedding of virus even if no lesions
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14
Q

What is the most common cause of herpes? Percent?

A
  • Herpes simplex type 2
  • Causes > 80%
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15
Q

Characteristics of fixed drug eruption?

A

(Nonvenereal chancres)

  • Single
  • Round, clearly demarcated, clean base
  • May be pruritic
  • Allergy to sulfas, tetracycline, or macrolides (while taking, 3-4th day); unknown reason
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16
Q

What is the most common cause of HPV warts?

Associated with CA?

Vaccine coverage?

Epidemiology?

A
  • Usually types 6 and 11
  • (recall 16 and 18 are associated w/ CA of cervix or anus)
  • All 4 are covered by vaccine
  • Common infection among sexually active young adults (65% of inner city adolescent women in 1 study)
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17
Q

Treatment for HPV warts?

A

Topical; stimulate inflammatory response

- Podphyllin

- Imiquimod

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18
Q

Cause of Molluscum contagiosum?

A

Pox virus

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19
Q

Treatment for Molluscum contagiosum?

A
  • Self-limited
  • Liquid nitrogen
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20
Q

Characteristics of condyloma lata?

A
  • Plaque-like eruptions
  • Vulva, perineam, or anus
  • Occurs especially in MSM
  • Highly contagious
  • May be seen in moist areas as part of 2’ syphilis (but rare recently)
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21
Q

Using RPR to diagnose syphilis:

  • % positive in diff stages?
  • Titer level indicates __?
A
  • 75-80% + with 1’

100% + with 2’

  • Height corresponds to activity; rises steadily, peaking in 2’ and somewhat subsides when latent; recurs in 3’ (but highest in 2’)

1’: (-) or (+) up to 1:32

2’: 1:64 - 1:256

latent: 1:2 - 1:8

3’: 1:4 - 1:32

treated: (-) following quick treatment (1’ or 2’ infxn)

serofast: <1:4

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22
Q

What is serofast?

A
  • When RPR remains + at very low titer (<1:4)
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23
Q

What is a biological false positive in regards to RPR?

A
  • Bad terminology
  • RPR may be positive at low titer in aging or under certain immunologic/infectious diseases
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24
Q

Using MHA-TP to diagnose syphilis:

  • What does it stand for?
  • % positive in diff stages?
  • Titer level indicates __?
A
  • Micro Hemagglutinating Ab to T. pallidum
  • 90% + with 1’

100% with 2’

  • Current or prior infxn (once positive, it remains so for life); can be used to EXCLUDE but not DIAGNOSE syphilis
  • Highly sensitive and highly specific
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25
Q

2’ syphilis can cause what non-venereal presentation (1)?

  • Characteristics?
  • Diagnosed in this stage for which patients?
A

Generalized rash

  • Widespread maculopapular rash
  • Unusual b/c it involves palms and soles!
  • Many forms, but only rarely vesicular except on palms and soles (may be vesicular or pustular)
  • Diagnosed in this stage in women and MSM men in whome painless, hidden primary lesion goes unrecognized
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26
Q

Other presentations of 2’ syphilis (many)?

A
  • Generalized Sx (uncommon unless AIDS)
  • Lymphadenopathy (regional is common but generalized is not)
  • Hepatitis (subclinical; lab abnl; common)
  • Arthritis (rare)
  • Osteitis (modern era; only seen on bone scan)
  • CNS invasion (regularly occurs by asymptomatic; sets stage for neurosyphilis)
  • Uveitis
  • Nephrotic syndrome (deposition of circulating immune complexes)
  • Mucous patches
  • Eyebrow loss; patchy alopecia
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27
Q

Nuances of syphilis in HIV pts?

A
  • Surprisingly little difference early on (1’, 2’, 1st yr of latency)
  • Much slower response to drugs
  • Many more remain serofast after treatment
  • Early neurosyphilis (meningeal or meningovascular)
  • Syphilitic lesions increase likelihood of spread of HIV
28
Q

Fate of pts with 2’ syphilis?

A

Everyone eventually has spontaneous remission (4-8 wks) into latency (absence of any clinical manifestations

29
Q

Fate of pts with untreated latent syphilis?

A
  • Recurrence of 2’ lesions in 25% within 1-2 yrs (early latency time frame)
  • Does not recur in late latency (>2 years)
30
Q

Time frame of neurosyphilis in those with HIV?

A
  • May precede AIDS
  • Many with reactive RPR (>1:32) and no Sx have CNS involvement as proven by +VRDL and cells in CSF
31
Q

Pathology of neurosyphilis in those with HIV?

A
  • Cranial nerve abnormalities: II (retinitis), VII, VIII, others
  • Meningitis: subclinical, mild or frank +/- CN abnormalities
32
Q

What does RPR test?

A

Antibody to cardiolipin

33
Q

Fate of those with untreated syphilis?

A

“Rule of thirds”

  • 1/3 return to (-) serologic tests and never have evidence of dz
  • 1/3 maintain active serologic tests but never develop evidence of dz (late latent)
  • 1/3 develop 3’ syphilis

[40% neurosyphilis, 40% gummas of soft tissues/organs, 20% CVD (aortitis), perforated palate)

34
Q

What does MHA-TP test?

A

Antibody to outer membrane proteins of T. pallidum

35
Q

Using ELISA to diagnose syphilis?

A
  • Good for screening but not diagnosing
  • Gives many false positives
  • Proposed 2-step screening: ELISA first, then RPR
36
Q

How to diagnose venereal ulcers due to Haemophilus ducryei?

A
  • Culture
  • PCR
  • Syndromic, especially in developing countries
37
Q

How to diagnose venereal ulcers due to Herpes?

A
  • Rapid nucleic acid identification
  • Culture (distinguishes HSV1 and 2; prognostic value)
38
Q

Therapy for genital chancre (overview)

A
  • Immediate Darkfield
  • RPR (some delay okay)
39
Q

Treatment if Darkfield + for T. pallidum?

A

Benzathine penicillin G (prolonged to treat slow replication of organism)

40
Q

Treatment if Darkfield - but unknown RPR?

A

Treat for chancroid pending RPR with:

  • Azithromycin (1 oral dose) or
  • Ceftriaxone (1 IM dose) or
  • Ciprofloxacin (3 days) or
  • Erythromycin (4x per 7 days)

(these have a low threshold for treating syphilis anyway pending RPR that may be -)

41
Q

Treatment for initial bout of genital herpes?

A
  • Acyclovir
  • Famciclovir
  • Valacyclovir (7-10 days)
42
Q

Treatment for recurrent bout of genital herpes?

A

Lower dose and 5 day treatment only

43
Q

Usual understanding of neurosyphilis (non-HIV): - Time frame? - Affects what tissue? - Manifestations?

A
  • Appears 4-40 yrs after onset of latency, so older subjects (common pre-penicillin and still today)
  • Affects ectodermal structures like neuronal tissue
  • Broad range manifestations: tabes dorsalis, paresis, dementia, grand dementia of insane, CVA, death
44
Q

Causes of urethritis or cervicitis?

A
  • Gonorrhea (Neisseria gonorrhoeae)
  • Chlamydia trachomatis
  • Mycoplasma genitalium
  • Trichomonas vaginalis??

Gonococcal and non-gonococcal tend to coexist! (esp chlamydia and gonorrhoea)

45
Q

Characteristics of Gonorrhea?

A
  • Exuberant purulent discharge with pain (although may be minimal and non-symptomatic infxn occurs)
  • Gonococcus may cause proctitis or pharyngitis (pharynx is colonized by gonococci in 5% of MSM)
46
Q

Characteristics of non-gonococcal urethritis?

A
  • Pain less severe
  • Exudate scanty, not purulent
  • MCC of urethritis in certain populations
47
Q

Special agar for Neisseria (gonorrhoeae)?

A

Thayer Martin agar:

  • Chocolate agar
  • Vancomycin (vs. Gm +)
  • Nystatin (vs. candida)
  • Gentamycin (vs. Gm- rods)
48
Q

Gonococcal vs. Nongonococcal urethritis?

A

Gonococcal: inner city, painful, copious/purulent discharge, many WBC and organisms, responds to cell wall ABx and maybe non cell wall

Non-Gonococcal: universities, irritating, scanty discharge, few WBC/organisms, no response to cell wall Abx but responds to non cell wall

49
Q

Complications of gonococcal urethritis in men? women?

A

Men:

  • Local: epididymitis
  • Disseminated: arthritis, skin lesions

Women:

  • Local: PID, infertility
  • Disseminated: arthritis, skin lesions
50
Q

Complications of NON-gonococcal urethritis in men? women?

A

Men:

  • Epididymitis only and rare

Women:

  • PID (other bacteria may contribute)
  • Infertility (major worry)
51
Q

Chlamydia stats for adult population?

A

3-5% in 15-19 yo

52
Q

Bacterial resistance of M. genitalium?

A

> 40% resistant to azithromycin

53
Q

Diagnosis of urethritis and cervicitis (4)?

A

Gm stain of pus

  • >95% true + for men
  • Other bact in women may confuse
  • Gm stain of pharynx/rectum uninterpretable

Culture

  • Chocolate agar using Abx to supress bacteria /fung (Thayer-Martin) + CO2 supplement
  • Could just use chocoloate if TM not available

Nuclei acid amplification (PCR) or rapid immunoassays for:

  • N. gonorrhoeae
  • Mycoplasma
  • Chlamydia

Urine specimen:

  • Good in men but cervical swab unreliable to diagnose gonorrhoea
54
Q

Treatment for gonorrhea?

A

High level, short duration (1 dose) of 3rd gen cephalosporins

  • Cefixime (oral)- now resistance
  • Ceftriaxone (IM)

NO quinolones (resistance)

55
Q

Treatment for non-gonococcal urethritis?

A

Azithromycin

Try to treat in clinic since at risk population not likely to return

  • Used (but no approved) for gonorrhea, esp if cephalosporin allergy; test cure 1 wk later; some resistance
  • Higher cure rate than doxycycline for Mycoplasma genitalium
56
Q

Causes of pelvic inflammatory disease?

A

Vary with age and SES (just like gono/non-gono urethritis):

  • Gonococci (inner cities)
  • Chlamydiae (universities)
  • Mixed infxns with Gm - or anaerobic flora +/- chlamydia or mycoplasma
57
Q

Pelvic Inflammatory Disease involves what process?

A

Spread of infxn from vagina and cervix to uterus fallopian tubes, and/or peritoneum

58
Q

Symptoms of PID?

A
  • Lower abdominal pain (unrelated to meals/bowel mvts)
  • Dyspareunia (pain on intercourse)
  • +/- vaginal discharge

On exam: Minimal CDC criteria:

  • Lower abdominal tenderness
  • Tenderness w/ cervical mvt
  • Adnexal tenderness

Additional criteria:

  • Fever
  • Cervical exudate
59
Q

Lab results with PID?

A
  • Elevated WBC count
  • Pus at cervix (or culdoscopy)
  • Microbiologic confirmation of N. gonorrhoeae or Chlamydia
60
Q

Treatment for PID?

  • Hospitalize?
  • Inpatient?
  • Outpatient?
A

Must decide whether to hospitalize (often done to initiate therapy):

  • Seriously ill
  • Unable to take oral meds
  • Uncertain diagnosis
  • Abscess present
  • Pregnancy
  • Unreliable pt

Inpatient:

  • Cefoxitin or Cefotetan AND
  • Doxycycline

OR

  • Clindamycin AND
  • Gentamicin AND
  • Dyoxycycline

Outpatient (14 d):

  • Ceftriaxone or Cefoxitin AND
  • Doxycycline

All of these +/- metronidazole for 14 days

61
Q

Complications of PID?

A
  • Infertility (chlamydia infxn may be asymptomatic!)
  • Ectopic pregnancy
62
Q

What causes buboes?

A
  • Syphilis
  • Chancroid
  • Lymphogranuloma venereum (LGV) from C. trachomatis
  • Cat scratch fever if lymphadenopathy without genital lesion
63
Q

Characteristic of enlarged inguinal LNs in syphilis?

A
  • Modest size
  • Minimally tender
64
Q

Characteristic of enlarged inguinal LNs in chancroid?

A
  • Huge
  • Exquisitely tender
  • Overlying skin is very thin; LN may rupture through skin
65
Q

Characteristic of enlarged inguinal LNs in LGV?

A
  • Very large
  • Not so tender
  • Chronic
  • LNs become “matted” and involved overlying skin, causing thickening
  • Caused by L. serovars of Chlamydia trachomatis (diff from those causing urethritis)
66
Q

What else will be seen if suspect that syphilis or chancroid are causing inguinal LN enlargement?

A

Penile or scrotal lesion (always!)

Term 5: Infectious Disease (18 decks)

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