Genital Lesions Flashcards
Which types of herpesvirus cause genital herpes infections?
HSV-1 and HSV-2
Classically this was HSV-2 only as HSV-1 is associated with the mouth, although due to the increase in practise of oral sex there is now much more overlap
How might a patient with genital herpes present?
Multiple, painful vesicles/ulcers on genitalia
Short history
May be flu-like illness and systemic symptoms if initial episode
Dysuria
Vaginal discharge
What is the treatment for herpes?
Oral antivirals i.e. aciclovir
True / False: A woman with a pre-existing genital herpes infection cannot give birth vaginally
False - If the infection is pre-existing, the mother will make IgG antibodies which are passed via the placenta to the baby and so risk of infection is minimal
What is the causative agent of lymphogranuloma venereum ?
Chlamydia tracomatis
What is the treatment for LGV?
Doxycycline or erythromycin
Typically, how long after infection does primary LGV appear?
3-30 days
What is the incubation period for chancroid?
3-10 days
What is the causative agent of chancroid?
Haemophilus ducreyi
What are the characteristic clinical features of chancroid?
Single or multiple ano-genital ulcers which are painful, have a purulent base and may bleed on contact
Inguinal lymphadenopathy, usually unilateral
Which virus causes genital warts?
Human papilloma virus (HPV)
Which subtypes of HPV typically cause genital warts?
HPV-6 and HPV-11
What is the mode of transmission of genital warts?
Direct skin to skin contact
True / False - Genital warts can be entirely prevented by using a condom during sexual intercourse
False - Genital warts are spread by direct skin to skin contact and condoms to not fully cover the genital area so transmission is still possible. Similarly, genital warts can be spread in the absence of penetrative sex.
Which subtypes of HPV typically cause cervical cancer?
HPV 16 and 18
What effect does syphilis infection have on the rate of transmission of HIV?
Syphilis increase HIV transmission. A person with syphilis and HIV is 4-5x more likely to mass on HIV to a partner than if they didn’t have syphilis.
List the types of syphilis serology available for testing
Treponemal tests: EIA and TPPA
Non-treponemal tests: RPR (Rapid plasma regain)
Which serological tests will stay positive forever once a patient has been infected with syphilis, even if the infection is treated?
The treponema tests: EIA and TPPA
Which test is used as a screening test in syphilis?
EIA
What is the organism involved in a syphilis infection?
Treponema pallidum
True / False: Condoms are entirely effective at reducing syphilis infection
False - They are only partially effective as syphilis can be transmitted via mucosal surfaces which condoms don’t fully cover
How does primary syphilis present?
Ulcers (painless) at the site of exposure e.g. mouth, anus, vagina
Local lymphadenopathy
How soon after exposure to syphilis do primary syphilis ulcers present?
About 2-3 weeks
True / False: Ulcers typical of genital herpes do not usually cause pain
False - Lesions in HSV are painFUL, while ulcers seen in syphilis are usually painless
Describe the features of secondary syphilis
Systemic features: Rash - Usually a maculopapular rash affecting palms / soles, not usually itchy Fever Generalised lymphadenopathy Vasculitis affects 5%
What happens if secondary syphilis is left untreated?
Usually gets better by itself even if untreated - the patient is then in the latent phase
What are the stages of syphilis?
Primary
Secondary
Latent
Tertiary
What is latent syphilis?
About 1 year after initial infection, when the patient is no longer infective, but is still infected. There is serological proof of the disease but with no symptoms.
What are the 3 manifestations of tertiary syphilis?
Neurosyphilis
Cardiovascular syphilis
Gummata syphilis
What tests might they do to test for syphilis in a GUM clinic?
Direct tests:
- PCR
- Dark ground microscopy
What is the diagnosis if there is a positive syphilis PCR, but negative for syphilis serology?
Primary syphilis
PCR has high sensitivity and specificity for early syphilis and the serology may not have turned positive yet
What might dark ground microscopy show in syphilis?
Spirochaetes
Match the types of test with the names of the test for syphilis:
Types of test - Screening, confirmation, monitoring
Names of test - RPR, EIA, TPPA
Screening test = EIA
Confirmation test = TPPA
Monitoring test = RPR
True / False: The EIA and TPPA tests look for levels of antibodies to treponema
True
True / False: The RPR syphilis test looks for levels of antibodies to treponema
False - The RPR test looks for the concentration of the disease and DOES NOT look for antibodies
How would you interpret a positive EIA and TPPA but a negative RPR test?
Previously treated syphilis
Or early primary syphilis which has not had time for titres to increase yet e.g if exposure in last couple of weeks
How long does it take for an RPR test to become positive?
About 28 days
In a person with previously treated syphilis, how might you know that they have been reinfected with syphilis?
A rise in RPR titre of at least 4x
What is the treatment for syphilis in penicillin allergy?
Doxycycline
What is the treatment for syphilis?
Penicillin (by IM injection)
What is the treatment for syphilis in a pregnant woman who is allergic to penicillin?
Penicillin desensitisation is done to allow her to receive the drug, as doxycycline (the usual alternative) is contraindicated in pregnancy
What is the Garish-Herxheimer reaction?
Sometimes seen following the first dose of treatment for syphilis - Fever, rash, tachycardia. Thought to be due to release of endotoxins following the death of bacteria
True / False: EIA negative, TPPA negative, RPR negative in an asymptomatic patient suggests they have never been infected with syphilis
True - If they had symptoms it may be that it was early primary syphilis and the serology hadn’t become positive yet, but in the absence of symptoms this is a reassuring test result
True / False: RPR 1 in 128, EIA negative, TPPA negative is consistent with tertiary syphilis
False - The EIA and TPPA results would have to be positive in this case as they stay positive lifelong. It is not unusual to get false positive results for the RPR titre (e.g. in pregnancy, infection, autoimmune / connective tissue disorders) and so there must be another reason for it’s rise
True / False: A change in syphilis RPR titre from 1 in 16 to 1 in 128 means a decrease in the concentration of the infection
FALSE - This indicates an increase in concentration of the titres. The increase of >4x suggests active infection
Out of syphilis and herpes, which is more likely to result in a single ulcerated lesion, and which is more likely to result in multiple ulcerated lesions?
Syphilis = Single lesion Herpesvirus = Multiple lesions
Which are the 3 forms of alpha herpesvirus? Where does the latent form of alpha herpesvirus exist?
Alpha herpesviruses: HHV1 = HSV1 HHV2 = HSV2 HHV3 = Varicella Zoster Virus The latent form of these viruses exists in sensorineural cells
Which are the 3 forms of beta herpesvirus? Where does the latent form of beta herpesvirus exist?
Beta herpesviruses:
HHV5 = CMV
HHV6 and 7 = Common, mild childhood infections
The latent form of these viruses exists in monocytes (and T cells if HHV 7)
Which are the 2 forms of gamma herpesvirus? Where does the latent form of gamma herpesvirus exist?
Gamma herpesviruses:
HHV4 = EBV
HHV8 = Malignancies e.g. Kaposi’s sarcoma
The latent form of these viruses exists in B cells
Which ganglion does varicella zoster virus establish latency?
Dorsal root ganglion
True / False: Herpesvirus always causes symptoms at the first acquisition
False - Only a minority of patients will develop symptoms on first acquisition. The first time symptoms manifest is usually as a result of a reactivation (e.g. in times of stress etc.)
How do you diagnose herpesvirus?
Viral PCR or antigen detection from fluid filled genital lesion
When might you do herpesvirus serology testing?
If a pregnant woman becomes infected and it’s suspected to be her first infection. You need to know whether she has the antibodies to the infection as if she doesn’t this might change the birth plan.
Does the partner of an individual infected with genital herpesvirus need to be tested?
No - The partner does not need testing or treating unless they are symptomatic
What are the 3 stages of lymphogranuloma vererum infection?
Primary i.e. transient genital ulceration: Ulcers appear at site of infection (usually a single, painless lesion)
Secondary i.e. inguinal or anorectal syndrome: 2-6 wks after primary, inguinal / femoral lymphadenopathy (painful)
Tertiary i.e. genitor-anorectal syndrome: Years after primary infection if untreated, lymphatic obstruction and genital lymphoedema
What is the causative agent of donovanosis?
Klebsiella granulomatis
Which virus causes molluscum contagiosum?
Poxvirus
What is asymptomatic shedding?
Relevant with the herpes virus infection - Patients can still pass on the virus to contacts even if they are asymptomatic at the time, especially if there is broken skin. All patients with HSV infection should be advised to use risk reduction measures e.g. condoms.
What is the treatment for genital herpes?
1st episode: - Oral antivirals i.e. acyclovir for 5 days can reduce the time course of the episode - Salt bathing - Topical anaesthetics Recurrence: - May be mild so treatment not required - Short course of antivirals
Where does the rash classically affect in secondary syphilis
Torso
Palms of hands
Soles of feet
What is the treatment for neurosyphilis?
Procaine penicillin and probenecid for 17 days, or high dose doxycycline 200mg BD
What is the treatment for cardiovascular syphilis or gummata syphilis?
3 doses of IM benzathine (weekly) or doxycycline 100mg BD for 28 days
What are the features of gummata syphilis?
Necrotic skin
Bone / visceral fibrous tumour-like lumps
What are the features of cardiovascular syphilis?
Heart failure
Angina
Aortic aneurysm
