Chlamydia; BV; Trichomoniasis; Thrush Flashcards
Chlamydia is caused by which bacterium? [1]
Describe the basic pathophysiology
Chlamydia trachomatis serovars D-K:
Infects columnar epithelial cells such as those found at the squamous-columnar junction within the cervix
Here it initiates a local inflammatory response.
Describe the clinical presentation of Chlamydia in men and women
Asymptomatic in around 70% of women and 50% of men
women:
- cervicitis: mucopurulent discharge; bleeding; pelvic tenderness
- dysuria
- post-coital bleeding
- intermenstrual bleeding
- lower abdominal pain
men:
- urethral discharge
- dysuria
PID is a major complication of chlamydia. Up to 16% of patients with untreated infections are at risk. The risk of tubal infertility is 1-20% following PID.
Describe the features of PID:
Signs [3]
Symptoms [4]
Long [3] and short [2] term complications
Systemic upset:
fever
malaise
anorexia
Symptoms:
- low abdominal pain
- abnormal vaginal bleeding
- vaginal discharge or cervical discharge
Signs
- marked abdominal pain
- cervical excitation
- mucopurulent discharge
Long-term complications:
- infertility
- ectopic pregnancy
- chronic pelvic pain
Short-term complications:
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis syndrome
NB: see PID notes
Describe how you investigate for chlamydia in men [1] and women [1]
Women:
- NAAT vulvovaginal swab
Men:
- urine test (first catch)
Tx for:
- uncomplicated urogenital chlamydia? [2]
- rectal infections [1]
A seven day course of doxycycline
OR
Aziothromycin due to potentially poor compliance with a 7 day course of doxycycline
Which patient populations do you offer a repeat Chlaymdia test in and why? [1]
Patients < 25 years old who are diagnosed with chlamydia should be offered a repeat chlamydia test in 3-6 months.
This is because there is a higher risk of reinfection (2-6x higher), which also increases the risk of PID and infertility.
Describe some complications of Chlamydia infection
PID:
- can result in tubo-ovarian abscesses and peritonitis
Epididymitis
Fertility issues:
- due to tubal damage from PID in women
- secondary to epididymitis in men
LGV
FItz-Hugh-Curtis syndrome:
- inflammation of the liver capsule and RUQ pain
Ocular complications:
- conjunctivitis that can progress to corneal scarring and blindness if not treated promptly.
Reactive arthritis
- urethritis, conjunctivitis, and arthritis
Lymphogranuloma venereum (LGV) is caused by which specific organisms? [1]
Chlamydia trachomatis serovars L1, L2 and L3.
Describe what is meant by LGV
A condition affecting the lymphoid tissue around the site of infection with chlamydia
Describe the clinical stages of LGV infection [3]
Typically infection comprises of three stages:
* stage 1: small painless pustule which later forms an ulcer
* stage 2: painful inguinal lymphadenopathy
* stage 3: proctocolitis - leading to anal pain; tenesmus and discharge
Tx for LGV? [1]
Doxycycline 100mg twice daily for 21 days is the first-line
treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.
Describe what is meant by bacteria vaginosis [1]
Describe the basic pathophysiology [1]
Overgrowth of predominantly anaerobic microorganisms in the vaginal flora and loss of the normal lactobacilli, which leads to a vaginal odour and increased discharge.
A consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
NB: The condition is a not a sexually transmitted infection (STI) but it occurs more commonly in sexually-active women.
Above what pH increases the risk of BV?[1]
> 4.5
- creates an alkaline environment that favours colonisation by anaerobic organisms, such as Garnerella vaginalis and loss of the usually dominant lactobacilli.
Describe the clinical features of BV [4]
- vaginal discharge: ‘fishy’, offensive - thin, off white / grey colour. may adhere closely to vaginal mucosa
- Irritation of vulva (uncommon)
- Dysuria (rare)
- Dyspareunia (rare)
- asymptomatic in 50%
NB: Normal speculum: apart from discharge, the rest of the examination is usually normal. Any lesion or cervicitis warrants further investigation
Describe the diagnostic criteria that needs to be met for BV dx
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:
* thin, white homogenous discharge
* clue cells on microscopy: stippled vaginal epithelial cells
* vaginal pH > 4.5
* positive whiff test (addition of potassium hydroxide results in fishy odour)
How do you differentiate between BV & trichomonas
Trichomonas:
- Frothy, yellow / green discharge
- Vulvovaginitis
- Strawberry cervix
- Wet mount: motile trophozoites
BV:
- Microscopy: clue cells
- thin, white discharge
NB: both have pH > 4.5; treat with metronidazole
How do you treat BV in:
- asymptomatic women [1]
- symptomatic [1]
- pregnant [2]
asymptomatic women:
- treatment not required (unless undergoing pregnancy termination)
symptomatic:
- oral metronidazole for 5-7 days
- a single oral dose of metronidazole 2g may be used if adherence may be an issue
pregnant
- oral metronidazole is used throughout pregnancy if symptomatic
- If asymptomatic: may be considered for treatment, but should discuss with obstetrician.
What are these cells called? [1]
BV: vaginal epithelial cells studded with adherent coccobacilli
Clear cell - indicates BV
What complication are people who suffer from BV at an increased risk of? [1]
BV is associated with an increased risk of post-surgical infections (e.g. post-C-Section).
[] is a sexually transmitted infection caused by Haemophilus ducreyi.
Chancroid
Describe the clinical presntation of chancroid [4]
Painful papules:
- early lesion that deteriorates into pustule then ulcer. May be one or more lesions
Multiple, deep ulcers
Lymphadenopathy:
- usually inguinal region
Buboe:
- infected, painful lymphadenitis that ulcerates and becomes suppurative. Can cause chronic draining sinuses.
NB: note it is rarely seen in the UK
Describe how you investigate for chancroid [2]
Chancroid is usually a clinical diagnosis. There are no laboratory tests currently available for the immediate diagnosis of chancroid.
The main investigative techniques are:
Culture and sensitivity
PCR (most sensitive)
Microscopy
Serology
Which tests should you perform if you suspect chancroid to rule out DDx? [4]
Herpes culture
Syphilis serology
HIV test
LGV
State three management options for chancroid [3]
A single IM dose (250 mg) of ceftriaxone
or
a single IM dose (1gram) of azithromycin
or an oral (500 mg) of erythromycin four times a day for seven days.
Which factors predispose patients to vaginal candidiasis? [5]
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV, iatrogenic
- Local irritatants
- Sexual activity
- Oestrogen exposure (incidence rises post menarche, but decreases post-menopause)
Describe the clinical presentation of vaginal thrush
Vaginal itching
Vaginal soreness
Vaginal discharge: characteristically thick and white (‘cheese-like’). Non-malodorous
Superficial dyspareunia
Dysuria
Dx of thrush? [1]
The diagnosis of candidiasis is usually made on the history alone and further investigations are not required.
pH in vaginal thrush compared to BV and trichomoniasis? [1]
vaginal thrush: pH < 4.5
BV & trichomoniasis: > 4.5
Treatment for uncomplicated thrush? [2]
Local tx:
- clotrimazole 500mg PV stat
Oral:
* itraconazole 200mg PO bd for 1 day or
* fluconazole 150mg PO stat
Treatment for recurrent thrush? [2]
> 4 episodes a year
induction:
- oral fluconazole every 3 days for 3 doses
maintenance:
- oral fluconazole weekly for 6 months
Treatment for thrush in pregnant patients? [2]
avoid oral anti-fungal treatments
- use intravaginal anti-fungal cream or pessary (e.g. clotrimazole 10% cream as single dose or clotrimazole pessary for 2 nights), OR
Clinical presentation of trichomoniasis?
- Frothy green-yellow discharge
- Vulval itching
- Dysuria
- Urethral irritation
- Urethral discharge
- Vulval inflammation
- Cervical inflammation (often described as ‘strawberry cervix’)
- pH > 4.5
Investigations for trichomoniasis?
Swabs taken from lateral walls of vagina: pH > 4.5
and high vaginal swab: staining, microscopy and culture.
microscopy of a wet mount shows motile trophozoites
NAAT testing - gold standard
Tx for trichomoniasis? [1]
Oral metronidazole 400–500 mg twice a day for 5–7 days
A 15-year-old presents with a mouth ulceration and fever. On examination he has severe gingivostomatitis is a stereotypical history for infection by:
HSV - primary infection
Gardnerella vaginalis
A 30-year-old woman complains of thin, white, ‘fishy’ smelling discharge. Clue cells are seen on microscopy is a stereotypical history of:
BV
Trichomoniasis
Syphilis
LGV
Candiasis
A 30-year-old woman complains of thin, white, ‘fishy’ smelling discharge. Clue cells are seen on microscopy is a stereotypical history of:
BV
Trichomoniasis
Syphilis
LGV
Candiasis
Reactive arthritis is most common after an infection of…? [1]
Chlamydia trachomatis
Explain why when prescribing treatment for BV, the advice you should give? [1]
Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment.
Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
TOM TIP: Remember that [] cells on microscopy mean bacterial vaginosis. This is a common association tested in MCQ exams.
TOM TIP: Remember that clue cells on microscopy mean bacterial vaginosis. This is a common association tested in MCQ exams.
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
