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Bologna 80-100 > 82 - Sexually Transmittable infxns incl CME > Flashcards

82 - Sexually Transmittable infxns incl CME Flashcards

1
Q

Outside of T. pallidum subspp. pallidum, what are 3 more endemic spirochetes and the disease they cause?

A

T.carateum - pinta (karate monks on beans) T. pallidum subsp. endemicum - endemic syphilis T. pallidum subsp. pertenue - yaws (yoyos are persistent)

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2
Q

is Treponema gram + or -

A

spirochete, not clasified as gram + or -

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3
Q

what popln’s are at risk of syphilis ?

A

M>>>F transgender females MSM (esp previous syphilis, online dating, metamphetamine use) AA and Hispanic

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4
Q

syphilis: transmission?

A

sexual: condyloma lata, chancre or mucous patch touching skin of recipient vertical transmission blood borne

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5
Q

% of transmission of syphilis post sex?

A

33%

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6
Q

stages of syphilis - CME

A

primary secondary early non-primary non-secondary late syphilis

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7
Q

which stage do neurosyphilis, otic and ocular syphilis belong to?

A

any stage

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8
Q

stages of syphilis - Bologna?

A

primary secondary early latent < 1 yr late latent > 1 yr tertiary

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9
Q

what do each of the stages represent in terms of immunology and systems affected?

A

1’ - Th1 response, macrophages destructing treponemes, localized 2’ - hematogenous and lymphatc spread + immune complexes 3’ - ++++ cellular immune reactivity

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10
Q

timing of primary syphilis? name of manifestation?

A

chancre @inoculation 21 days post exposure

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11
Q

clinical of chancre?

A

painless indurated ulcer with raised border dory flop (foreskin flips over at once when retraced) regional LAD can be anywhere (fingers, nipples, any mucosal site) = primary inoculation site heals w/scar in 3+ weeks

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12
Q

syphilid - defn’?

A

any manifestation of syphilis outside of primary

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13
Q

give 7 cutan. forms of secondary syphilis?

A

AAA FFLiPPP’N syphilis Alopecia - moth eaten Annular - scaly, favours oral commisures, scalp, palms and soles Acral pebbles Frambesiform - raspberry like Follicular papules - folliculitis-like Lichenoid Leonine facies Leukoderma - “venereal necklace”, trunk lues maligna Pustular - miliary, acneiform, varioliform, echthymiform, impetiginoid Psorisiform Nodular Condyloma Lata Exanthem corymbiform - central plaque with ring of papules clavi syphillitici

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14
Q

what is the manifestation of neurosyphilis?

A

general paresis, tabes dorsalis, optic atrophy

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15
Q

what is included in tables dorsalis?

A

decreased DTR in legs, pupil irregularities = Argyll Robertson (nearby reflex ok but not light), vibratory loss, ataxia, loss of pain and position sensation

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16
Q

how many patients progress to 2’? 3’?

A

2- pretty much all 3 - 1/3

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17
Q

timing of 2’ syphilis?

A

3 weeks post primary (3-12 weeks)

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18
Q

symptoms of 2’ syphilis?

A

sore throat arthralgias LNA fevers rash malaise

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19
Q

classic presentation of 2’ syphilis?

A

scaly exanthem on trunk and extremities, clasically scaly macules patches w/ “colarette of scale”

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20
Q

what is condyloma lata?

A

moist papules in the areas of apposition (under breasts, axilla, anogenital, medial thighs), +++ contagious

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21
Q

most contagious lesions in syphilis?

A

condyloma lata mucous patches chancre

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22
Q

classic mucosal manifestation of 2’ syphilis? - give 3

A

arcuate mucous patches, forming “snail track ulcers” or white leukoplakia-like plaques “split papules” mucous patches at oral commisures” also painless tongue nodules, bullous-erosive lesions like PV, non-specific shallow ulcers

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23
Q

classic alopecia in syphilis?

A

“moth eaten” >>>> AA like or diffuse

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24
Q

nail changes in syphilis? - give 5

A

brittleness, onycholysis,onychomadesis, beau lines, paronychia, tranverse grooves, splitting, pitting

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25
Q

what is lues maligna? risks?

A

ulcers with heaped up border or necrotic plaques (anywhere) w/ systemic symptoms like fevers and LNA risks: HIV with low CD4, malnutrition, alcohol abuse, MSM, DM, previous syphilis,

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26
Q

how do you treat lues maligna?

A

self-resolves in 4-12 weeks if untreated, or treat as rest

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27
Q

what is early non-primary non-secondary syphilis per CME?

A

infections diagnosed only based on serology with no s&s, acquired w/i 1 year

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28
Q

2 cutaneous types of 3 syphilis per CME?

A

gummatous noduloulcerative

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29
Q

timing of 3’ syphilis?

A

years to decades

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30
Q

common organs in 3’ syphilis per CME?

A

cardiac - aortitis +- coronary vessel dz bone - osteitis other tissues

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31
Q

risk factors for neurosyphilis? (any stage per CME)

A

male, young, MSM, HIV may be symptomatic or asymptomatic

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32
Q

should you tap spine of any patient with syphilis?

A

only if symptomatic on history and neural exam (always do neural) - including otic and ocular if + refer for optho assessment

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33
Q

would you treat syphilis in HIV differently?

A

no, but higher rate of CNS syphilis and treatment resistance

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34
Q

3’ syphilis manifestations per Bologna?

A

50% - gumma (MC) - locally destructive lesions of skin, bones, liver and other organs 25% - cardiovascular 25% - neurosyphilis

35
Q

7 manifestations of congenital syphilis?

A

easiest: frontal bossing, rhagades, mulberry mollars, hutchinson teeth, mulberry mollars, 8th nerve deafness, saddle nose head down frontal bossing of Parrot keratitis +- corneal ulcers * (reason for erythromycin drops in all newborns) saddle nose high arched palate +- perf mulberry mollars notched incisor teeth* ++ caries due to defective enamel hearing loss * rhagades - radial periorificial scars winged scapula thickening of medial clavicle - Higoumenakis’ sign Clutton’s joings - painless synovitis and effusion of the knees Saber shins - tibial bowing * Hutchinson triad

36
Q

4 classifications of neurosyphilis (Bologna)?

A

Asymptomatic Meningeal Parenchymatous Gummatous

37
Q

What 2 tests (1 of 2) are required by CDC for definitive dx of primary syphilis? secondary syphilis?

A

PCR or darkfield microscopy (for either)

38
Q

What are components of syphilis exam (JAAD)?

A

ROS - general, CNS, GI, MSK, psych exam: cranial nerve motor - strenghts nuchal rigidity DTR

39
Q

2 direct detection methods for Treponemes?

A

PCR Darkfield

40
Q

4 non-treponemal tests?

A

US(s)R does not TRUST USA’s tests of VDRL and RPR USR - unheated serum reagin TRUST - toluidine red unheated serum test VDRL - venereal disease research laboratory RPR - rapid plasma reagin

41
Q

How do treponemal tests work ? advantages?

A

MotherF)()*)(*TTreponema IgM and IgG Ab specific to T. pallidum proteins - better in early infections, detectable 2-4 weeks post exposure lifelong positive

42
Q

5 treponemal tests?

A

MotherF&&&& TTreponema TPHA - T.pall Hemaaglutinnation essay MHA-TP - microhemagluttination Assay for Ab to TP TP-PA - TP passive particle Agglutination assay FTA - ABs - fluorescent treponemal antibody absorption assay EIA - enzyme immunoassay IgG - ELISA IgM - EIA Clia - chemiluminescence immunoassay My Ha TP TPpa TpHa catches my Farts-A Clearly MHA - TP TPPA TP - HA FTA CLIA

43
Q

How do non-treponemal tests work?

A

NON-TREPONEMAL – Ab to “reagin” = measure tissue damage by detecting antibodies to cardiolipin, lecithin, cholesterol (N components of human cells - > ?T. pallidum binds to and converts these to antigens or T. pallidum damages host cells = >leak in these ); titre: most dilute serum that still yields a reactive test; ex.1:16 means test is reactive after 4 dilutions (1x2x2x2x2) if ++ reactive in spite of therapy, called serofast reactions, most common in HIV false positive – see table false negative – early or late infection, and with prozone phenomenon (Ab so high, the test cannot form normal Ag-Ab lattice, so cannot visualize positive test : ie so thick no space to react => reactive after serial dilutions); prozone phenomenon a/w pregnancy, HIV, neurosyphilis and +++ dz burden

44
Q

H&E of syphilis

A

Classic: psoriasiform hyperplasia sponge vacuolar changes elongation of retes parakeratosis lymphocyte exocytosis necrotic keratinos plasma cells present can look like MF or lymphoma b/c of lymphocyte exocytosis (aka epidermophism) lues maligna: endarteritis obliterans of dermal vessels with ischemic necrosis; spirochetes absent or sparse on stain gumma: +++ caseating necrosis H&E: spirochetes with silver or immunohistochemical stain 2 clues: endothelial cell swelling and proliferation dermal infiltration by lymphocytes and plasma cells silver stains, like Warthin-Starry - > low specificity => immunohisto preferred (more sensitive (71-100%)

45
Q

Reasons why treponemal or non-treponemal tests false positive ?

A

memorize for both: advanced age autoimmune dz like SLE IVDU Pregnancy immunizations Infections: EBV, leprosy, TB, pinta, yaws, etc

46
Q

How do you dx syphilis? reportable or not?

A
  • all patients need both non-treponemal and treponemal test; - if non-treponemal test already performed, JAAD still recommends repeat nontreponemal test on the day of treatment to enable evaluation of serologic response to tx - report to public health - establish stage of dx - assess for presence of neurosyphilis, ocular syphilis or otic syphilis o refer for CSF if pt either has:  signs or symptoms of neurosyphilis, otic syphilis or ocular syphilis  suspected treatment failure  tertiary syphilis o if ocular sx refer to optho - give benzathine penicillin G – penicillin formation with long half life - benzathine penicillin G is only therapy recommended for both pregnant people and fetus – pregnant patients must be desensitized and treated with penicillin even if allergic
47
Q

whats Jarish - Herxheimer rxn?

A
  • beware of Jarish-Herxheimer reaction o w/i 1 day of tx o fever, headache, myalgia, possible worsening rash o ?spirochette destruction causing release of lipoproteins, immune complex formation, cytokine cascade o resolves spontaneously, typically within 24 hrs o tx with antipyretics and hydration o can induce early labour
48
Q

how far back do you need to notify partners?

A
  • ensure sexual health needs met o screen for other STDs and HIV o sexual vaccines o preexposure prophylaxis: CDC recommends HIV testing for all pts with syphilis who are not known to have HIV and syphilis dx within 6 months is criterion for initializing HIV preexposure prophylaxis o partner notify:  primary: 3 months + duration of symptoms  secondary: 6 months + duration of symptms  early non-primary non-secondary : 1 year  abstain from sex for 1+ week until symptoms fully resolve o report
49
Q

how do you monitor response to tx in syphilis?

A
  • follow up to ensure response o serologic response: 4x or greater decline in non-treponemal titres
50
Q

definition of treatment failure in syphilis?

A

o treatment failure: 1 year for HIV negative pts w/ primary or secondary  2 yrs for HIV negative pts with early nonprimary nonsecondary syphilis  2 years for HIV infected pts with primary or secondary

51
Q

when should you screen for syphilis?

A
  • screening recommendations (TABLE) o pregnant: all pregnant women at first prenatal visit, rescreen in 3rd trimester and delivery if high risk o MSM: annually if sexually active, and every 3-6 months if increased risk o HIV: if sexually active, screen at first HIV evaluation and annually
52
Q

how soon should you follow-up on your syphilis patient?

A

CDC: 6 and 12 months for uncomplicated, 3, 6, 9, 12 and 24 if HIV+ 3˚: q6 months for 3 years

53
Q

Tx for 1’, 2’ or early non-primary non-secondary in non-pregnant non-penicillin allergic?

A

benzathine penicillin G 2.4 M IMx 1

54
Q

Tx for 1’, 2’ or early non-primary non-secondary in pregnant non-penicillin allergic?

A

benzathine penicillin G 2.4 M U IM x 1

55
Q

Tx for 1’, 2’ or early non-primary non-secondary in non-pregnant penicillin allergic?

A

doxycycline 100 mg BID x 14 days tetracycline 500 mg QID x 14 d ceftriaxone azitromycin

56
Q

Tx for 1’, 2’ or early non-primary non-secondary in pregnant penicillin allergic?

A

desensitize and treat with 2.4 M U IM x 1

57
Q

Tx of unknown duration or late syphilis non-pregnant non-penicillin allergic?

A

benzathine penicillin G 2.4 IM x OW x 3 weeks

58
Q

Tx of unknown duration or late syphilis pregnant non-penicillin allergic?

A

benzathine penicillin G 2.4 IM x OW x 3 weeks

59
Q

Tx of unknown duration or late syphilis non-pregnant penicillin allergic?

A

doxycycline 100 mg BID x 28 days tetracycline 500 mg QID x 28 days ceftriaxone (no azithromycin here) x time from 1’

60
Q

Tx of unknown duration or late syphilis pregnant non-penicillin allergic?

A

desensitize and treat with 2.4 M U IM OW x 3 weeks

61
Q

Tx for neurosyphilis, ocular syphilis or otic syphilis, pregnant or non-pregnant

A

aqueous penicillin G 24 MU (10x previous) divided into doses Q4 hrs x 14 days can do procaine penicillin 2.4 MU IM OD + probenecid 500 mg PO Q6 hrs x 14 d

62
Q

Tx for neurosyphilis, ocular syphilis or otic syphilis, pregnant or non-pregnant pen allergic

A

sensitize and treat with aqueous penicillin G 24 MU (10x previous) divided into doses Q4 hrs x 14 days can do procaine penicillin 2.4 MU IM OD + probenecid 500 mg PO Q6 hrs x 14 d

63
Q

Organism that causes Gonorrhea? Gram +/-? appearance?

A

Neisseria gonorrhea

gram - diplococci

needs iron to grow

64
Q

incubation of Neisseria gonorrhea?

A

2-5 days

65
Q

Classic clinical findings in W/M (Gonorrhea)?

men: ≤10% asymptomatic, gonococcal urethritis w/ dysuria and ++ pus; in ¼ sx only w/urethral manipulation “stripping”; resolves w/o tx in 6 months

women: 50% asymptomatic; © cervical canal; ­ d/c (++ yellow), dysuria, intermenstrual bleeding, menorrhagia, Bartolins swelling

A

men: ≤10% asymptomatic, gonococcal urethritis w/ dysuria and ++ pus; in ¼ sx only w/urethral manipulation “stripping”; resolves w/o tx in 6 months

women: 50% asymptomatic; © cervical canal; ­ d/c (++ yellow), dysuria, intermenstrual bleeding, menorrhagia, Bartolins swelling

66
Q

4 systemic manifestations of Gonorrhea?

A
  1. pharyngeal (post oral, usually asymptomatic)
  2. rectal (+- proctitis, rectal d/c, pruritis, tenesmus)
  3. gonococcal ophthalmia (incl ophthalmia neonatorum aka purulent conjunctivitis, can progress to severe keratitis and blindness -> reason for erythromycin drops)
  4. arthritis-dermatosis syndrome (gonococcemia) – 1%

risk factors: menstruation (a/w menses), C5-C9 deficiendy

fever + joint pain + paucilesional eruption of hemorrhagic pustules

gonococcal tenosynovitis © knees, elbows, wrists, ankles, +- overlying erythema

cutaneous: scattered pustules, necrotic due to embolic septic vasculitis, distal extremities, contain gonococci

67
Q

Clinical manifestation of arthritis-dermatosis syndrome?

A

arthritis-dermatosis syndrome (gonococcemia) – 1%

risk factors: menstruation (a/w menses), C5-C9 deficiendy

fever + joint pain + paucilesional eruption of hemorrhagic pustules

gonococcal tenosynovitis © knees, elbows, wrists, ankles, +- overlying erythema

cutaneous: scattered pustules, necrotic due to embolic septic vasculitis, distal extremities, contain gonococ

68
Q

Gonorrhea - list 5 complications?

A

complications: ascending gonorrhea: M = epididymitis, prostatitis, vesiculitis

F= acute salpingitis or PID (10-20%) -> infertility, chronic pelvic pain, ectopic

extragenital:

69
Q

Gonorrhea tx?

A

Ceftriaxone 250mg IM x 1 AND azithromycin 1 g PO x 1

(also tx Chlamydia)

if disseminated: IV ceftriaxone 1 g Q12 hrs x 7 days + 1 g azithromycin PO x 1

neonatal/opthalmia neonatorum: ceftriaxone 50 mg/kg IV x 1 dose

70
Q

Gonorrhea - histo?

A

gram or methylene blue stain of smear = gram -ve diplococci within neutrophils

71
Q

Chancroid - bacteria?

A

Haemophilus ducreyi

72
Q

Chancroid - clinical?

A

incubation 3-10 d => papule w/erythema -> pustule -> painful ulcer w/ soft undermined edges (may have few due to apposition)

“septic sore”: pus trapped within skin of penile shaft w/o obvious ulcer

coinfection w/ HSV or syphilis classic

painful inguinal lymphadenitis (buboes), unilateral >> bilateral, may ulcerate/rupture

gram- anaerobic

sexual contact w/ infected F w/ genital ulcers (infxs x 45d)

73
Q

Chancroid - histo findings?

A

3 zones of inflammation:

1 – necrotic debris, fibrin, neuts

2- granulation tissue

3- deepest – lymphocytes and plasmas; + gram neg stain rare

“school of fish” or “railroad track” pattern of gram - bacilli

74
Q

Chancroid - tx?

A

Ceftriaxone 250mg IM × 1

Azithromycin 1 g PO × 1

Cipro 500 mg bid × 3 days (c/I in pregnancy)

heals w/i 14 days

75
Q

Bacteria for lymphogranuloma venereum? incubation? sites?

A

Chlamydia trachomatis

(L1–3 serotypes)

©lymph tissue of genitals/rectum

incubation 3-12 d

76
Q

Lymphogranuloma venereum: clinical stages and organs affected in each?

A

Stage I: initial infection of genital mucosa: herpetiform lesion at site of exposure -> rapid healing; a/w lymphangitis +- cervicitis/urethrtitis/proctocolitis (all rare)

Stage II: Inguinal syndrome: unilateral inguinal LNA (bubo) w/overlying erythema à firm -> enlarges and ++ painful; skin develops bluish discoloration-> ruptures with suppuration thru ++ sinus tract w/ bubos and +- PIDà heals

Stage III (M-yrs): ano-genito-rectal syndrome: proctocolitis + intenstinal/perirectal lymph hyperplasia -> local abscesses, anal fistulas, rectofabinal fistulas, rectal strictures and stenosis

Other manifestations (in table)

  • urethra-genito-perineal syndrome
  • erythema nodosum
  • peno-scrotal elephantiasis

submaxillary or cervixal lymphadenopathy associated with oropharyngeal lesions

77
Q

Lymphogranuloma venereum : H&E/culture?

A

Giemsa stain: Gamma-Favre bodies = organisms within histiocytes

neuts, histiocytes, plasma, multinucleated giant cells

> stellate abscesses characteristic in LNs

dx via PCR >> tissue culture (need L1-3 serotypes to get LGV)

r/o chancroid, cat scratch, lymphoma, mycobacterial infections Crohn, symphilis, HIV

78
Q

Lymphogranuloma venereum Tx? (N, preggo, HIV)

A

For 3 weeks:

doxycycline 100 mg bid

erythromycin base 500mg qid (pregnancy)

examine/treat partners if w/I 30 days

HIV pts = > longer course

79
Q

Organism in granuloma inguinale?

A

Klebsiella granulomatosis

80
Q

Clinical presentation of Granuloma Inguinale?

A

painless SubQ papule or nodule à +++ vascular, beefy, bleed easily -> ulcerates -> foul exudate

men: prepuce aka foreskin, glans, frenulum, coronal sulcus
women: vulva

rare lymphadenopathy; does not heal without treatment

extragenital possible – any organ, © bones

incubation 1 day-1 year, ave 3 weeks

ddx: 2’ syphilis esp. condylomata lata, carcinoma, amebiasis, TB, dimorphic fungal, pyoderma Vegetans, Crohn disease, PG

81
Q

Histo of Granuloma Inguinale?

A

ulceration w/ +++ granulation tissue

pseudoepitheliomatous hyperplasia

++ histiocytes, plasmas, few lymphs in dermis, +- neut abscesses

Donovan bodies = parasitized histiocyte; stain bipolar

DDx = His GiRL Penelope

Histoplasmosis (histoplasma capsulatum)

Granuloma Inguinale

Rhinoscleroma (Klebsiella rhinoscleromatis)

Leishmaniasis

Pencillosis

82
Q

Tx in Granuloma Inguinale?

A

azithromycin 1 g weekly or 500 mg OD x 3 weeks and until all lesions healed

examine sexual partner w/i 60 days of onset or if symptomatic

relapses can occur

83
Q
A

Bologna 80-100 (3 decks)

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