Chlamydia; BV; Trichomoniasis; Thrush Flashcards

1
Q

Chlamydia is caused by which bacterium? [1]

Describe the basic pathophysiology

A

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.

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2
Q

Describe the clinical presentation of Chlamydia in men and women

A

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

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3
Q

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

A

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

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4
Q

Describe how you investigate for chlamydia in men [1] and women [1]

A

Women:
- NAAT vulvovaginal swab

Men:
- urine test (first catch)

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5
Q

Tx for:

  • uncomplicated urogenital chlamydia? [2]
  • rectal infections [1]
A

A seven day course of doxycycline
OR
Aziothromycin due to potentially poor compliance with a 7 day course of doxycycline

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6
Q

Which patient populations do you offer a repeat Chlaymdia test in and why? [1]

A

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.

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7
Q

Describe some complications of Chlamydia infection

A

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

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8
Q

Lymphogranuloma venereum (LGV) is caused by which specific organisms? [1]

A

Chlamydia trachomatis serovars L1, L2 and L3.

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9
Q

Describe what is meant by LGV

A

A condition affecting the lymphoid tissue around the site of infection with chlamydia

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10
Q

Describe the clinical stages of LGV infection [3]

A

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

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11
Q

Tx for LGV? [1]

A

Doxycycline 100mg twice daily for 21 days is the first-line

treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.

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12
Q

Describe what is meant by bacteria vaginosis [1]

Describe the basic pathophysiology [1]

A

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.

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13
Q

Above what pH increases the risk of BV?[1]

A

> 4.5
- creates an alkaline environment that favours colonisation by anaerobic organisms, such as Garnerella vaginalis and loss of the usually dominant lactobacilli.

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14
Q

Describe the clinical features of BV [4]

A
  • 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

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15
Q

Describe the diagnostic criteria that needs to be met for BV dx

A

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)

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16
Q

How do you differentiate between BV & trichomonas

A

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

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17
Q

How do you treat BV in:

  • asymptomatic women [1]
  • symptomatic [1]
  • pregnant [2]
A

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.

18
Q

What are these cells called? [1]

BV: vaginal epithelial cells studded with adherent coccobacilli

A

Clear cell - indicates BV

19
Q

What complication are people who suffer from BV at an increased risk of? [1]

A

BV is associated with an increased risk of post-surgical infections (e.g. post-C-Section).

20
Q

[] is a sexually transmitted infection caused by Haemophilus ducreyi.

21
Q

Describe the clinical presntation of chancroid [4]

A

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

22
Q

Describe how you investigate for chancroid [2]

A

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

23
Q

Which tests should you perform if you suspect chancroid to rule out DDx? [4]

A

Herpes culture
Syphilis serology
HIV test
LGV

24
Q

State three management options for chancroid [3]

A

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.

25
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)
26
Describe the clinical presentation of vaginal thrush
**Vaginal itching** **Vaginal soreness** **Vaginal discharge**: characteristically thick and white (‘**cheese-like**’). Non-malodorous **Superficial dyspareunia** **Dysuria**
27
Dx of thrush? [1]
The diagnosis of candidiasis is usually made on the **history alone** and further **investigations are not required.**
28
pH in vaginal thrush compared to BV and trichomoniasis? [1]
vaginal thrush: pH < 4.5 BV & trichomoniasis: > 4.5
29
Treatment for uncomplicated thrush? [2]
**Local tx:** - **clotrimazole** 500mg PV stat **Oral**: * **itraconazole** 200mg PO bd for 1 day or * **fluconazole** 150mg PO stat
30
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
31
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
32
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**
33
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
34
Tx for trichomoniasis? [1]
**Oral metronidazole** 400–500 mg twice a day for 5–7 days
35
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
36
**Gardnerella vaginalis**
37
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
38
Reactive arthritis is most common after an infection of...? [1]
**Chlamydia trachomatis**
39
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.
40
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.***