Genital Tract Infections Flashcards
Neisseria gonorrheae
Gram negative coccus, facultative intracellular, oxidase and catalase positive, glucose utilization
Humans
Sexual transmission; neonatal (conjunctivitis)
Sex partners of infected; neonates
No capsule, Pili-undergo Ag variation, LOS, Various integral proteins: Por A, Por B, Opa, Rmp
Oxidase and Catalase pos;
Glucose utilization; IgA protease
URETHRITIS/CERVICITIS /SALPINGITIS/PID, +/- ARTHRITIS (immune complex deposition); Conjunctivitis
Thick mucopurulent penile discharge, purulent skin lesion; Cervix can reveal eroded ostium, inflammation
Can get bacteraemia and LOS-Ab immune complex deposition/ inflammatory response; conjunctivitis (neonatal or older)
History; Clinical presentation; Gram stain of urethral exudates- THICK, creamy or green pus like discharge; NYC/Thayer Martin media
Abx against resistant strains: cefixime (oral and one dose- preferred), Ceftriaxone (IM), Ciprofloxacin (now have resistant strains), also an Abx effective against Chlamydia trachomatis (poss co-infection); Sex partners should be referred and treated
No effective vaccine; condoms help but are not 100% effective
Chlamydia trachomatis (D-K)
VERY TINY bacteria, Obligate intracellular – for replication; 2 phenotypic forms (EB and RB)
Humans
Sexual contact, autoinoculation, neonatal
Sexually active
Energy parasite – cannot make own ATP
NONGONOCOCCAL URETHRITIS IN MALES; URETHRAL SYNDROME AND CERVICITIS IN FEMALES/PID/ Conjunctivitis
Thin mucopurulent penile discharge; Cervicitis, thin mucopurulent exudate and tissue becomes friable
Infection in Infants: inclusion conjunctivitis, interstitial pneumonitis (staccato cough, shortness of breath, difficult feeding)
Microscopy – intracellular inclusion bodies; culture requires McCoy or HeLa cells because it is an obligate intracellular pathogen; DFA, PCR, New serological test improved
Doxycycline, Azithromycin (one dose); eye drops for infants
Education, safe sex
Ureaplasma/Mycoplasma spp
Cell wall less, small colony producing mycoplasma; 14 serotypes; urease positive
UG tract of 2/3 of all adults; Rarely found before puberty
Primarily by sexual contact; vertically from mom to child
Unknown
Urease pos (for ID doesn’t appear to be part of pathology at present)
URETHRITIS
U. urealyticum – cause of approx half the cases of Nongonococcal and Nonchlamydial urethritis in males; M. genitalium – urethritis in males; M. hominis – complications of pregnancy
Culture on A8 agar; seen in normal individuals a lot so culturing is of little value unless you rule out all other possible causes of NGU Adding manganous sulfate reacts w/ urease => golden brown pigment
Doxycycline
Personal hygiene and reduce sexual exposure
Trichomonas vaginalis
Trichomonas vaginalis
Protozoan flagellate; no cyst form; fermentative metabolism
Humans – cases and asymptomatic carriers; Women – vagina and Skene’s gland of urethra
Men – urethra
Direct contact; sexual intercourse
Multiplies when vaginal conditions becomes more basic => overgrowth = disease
VAGINITIS (NGC URETHRITIS / CERVICITIS) – Greenish-yellow frothy discharge, vulvar itching and burning, dysuria, odor, Petechial hemorrhages on cervix (strawberry cervix); squamous epithelial cells destroyed
Clinical presentation; microscopic demonstration of motile trichomonads on wet mount of discharge; vaginal pH >4.5; Immunofluorescent staining (70-90% sensitivity)
Metronidazole (95% cure rate); Must treat sexual partners; Reinfections occur
Personal hygiene
Candida albicans
Normal body flora in skin and mucous membranes
Disease due to overgrowth
Diabetics, immunocompromised conditions, antibiotic use
VULVOVAGINITIS / VULVOVAGINAL CANDIDIASIS
“Cottage Cheese” discharge; Linear ulcer of the perineal skin; Adherent white patches (cottage cheese like) with surrounding erythema on the cervical mucosa; excoriations of the skin of the labia majora due to scratching
Microscopy and culture
Azoles; no need to treat partners
Judicious use of antibiotics, avoid invasive hospital procedures
Herpes Simplex Virus (Urethritis/Cervicitis)
Ds linear DNA enveloped
Man
Direct/indirect contact w/ active lesions
Sexually active
URETHRITIS and CERVICITIS may be w/out external lesions (rare)
Culture or PCR (rarely used Tzanck smear)
Acyclovir relieve symptoms, shorten outbreak
Avoid direct contact w/ active
lesion or during prodrome
Gardnerella vaginalis
Gram variable pleomorphic rod; an aerobe whose growth is promoted by CO2
Normal flora in UG tract
Disease due to overgrowth; synergistic with other normal flora
BACTERIAL VAGINOSIS
Perivaginal irritation milder than with trichomoniasis or candidiasis; Milky discharge w/ “fishy” odor (the “amine) test; wet mount reveals Clue cells
Homogenous discharge, pH >4.5, Positive Amine test, presence of Clue cells, Nugent score: Lactobacilli/Gardnerella/Mobiluncus
Metronidiazole and/or Clindamycin; no need to treat partners
Personal hygiene, judicious use of antibiotics
Haemophilus ducreyi
Gram negative rod; LOS cell wall; can grow on BAP but is a Canophile (req high CO2)
Humans
Sexual transmission
Sexually active, more prevalent in 3rd world countries; see several hundred in the US each year
CHANCROID – begins as papulespustulesulcer
Painful, ragged ulcers on genitals- soft chancres (less indurated than hard chancres due to syphilis); painful inguinal adenopathy develops in 50% of patients and may rupture
Serology to rule out syphilis; gram staining may reveal chains of coccobacilli in pattern referred to as “school of fish”- not useful exam; culture difficult and only 80% sensitive; PCR and antigen detection methods of choice- 90% sensitive
Cephalosporins
Education, Safe sex
Chlamydia trachomatis (L1-L3)
VERY TINY bacteria, Obligate intracellular – for replication; 2 phenotypic forms (EB and RB)
Humans
Sexual contact, autoinoculation, neonatal
Sexually active
Energy parasite – cannot make own ATP
LYMPHOGRANULOMA VENEREUM
Primary stage begins with a painless ulceration; spreads through regional lymphatics to inguinal nodes (usually unilateral); anal sex may result in perirectal and pelvic lymph node involvement; late stage may result in elephantiasis of genitalia
Buboes-Groove sign – inguinal lymph nodes swollen, inguinal ligament stretched across them forms groove
Microscopy of Inclusion Bodies; Culture requires cell culture because it is an obligate intracellular pathogen; DFA, PCR, New serological test improved
Doxycycline, azithromycin
Education, safe sex
Klebsiella granulomatis
Gram negative rod; intracellular; Bipolar staining; encapsulated
Humans
Sexual activity
Virtually never seen in North America; rare in tropical or subtropical countries in the setting of poverty and poor hygiene (Caribbean, South America, parts of India, SE Asia)
GRANULOMA VENEREUM/ DONOVANOSIS
Usually a ragged ulcer and may have inguinal adenopathy; Clinically needs to be differentiated from chancroid, LGV, syphilis
“velvety, beefy red” appearance
Microscopy looking for Donovan bodies- oval rod shaped organism that appear inside infected cells
Erythromycin, streptomycin, or tetracycline (must take the full course to minimize the possibility of relapse)
Education, avoiding contact
Treponema pallidum
Spirochete (endoflagella/ axial filaments); few external antigens – “stealth” microbe
Humans
Sexual contact w/ someone w/ primary or secondary lesion; less commonly: shared needle use, blood transfusion, transplacental transmission from mother during first 3 years of her infection; Can penetrate intact skin
Sexually active; neonates of infected mothers
SYPHILIS
- Primary Syphilis: one or more syphilitic chancres at site of invasion- painless hard ulcer w/raised border, no exudate, reg’l lymphadenopathy; Dissemination of spirochetes via lymph and blood; Spontaneous healing of ulcer w/in 2 months; Highly Infectious Stage
- Secondary Syphilis: Flu like symptoms; nonpruritic/ maculopapular rash on trunk, then spreads out to palms, soles, genitalia, and mucous membranes- can form pustules; resolves within weeks to months; latent stage (+/- relapses); Highly Infectious Stage; Syphilis-Condulomata Lata lesions are smooth, moist, flat
- Tertiary Syphilis: diffuse chronic inflammation w/ tissue destruction; Gummas (destructive granulomatous lesions) found on any tissue; spirochete primarily in CSF (so not infections unless lesions on outside)
- Cardiovascular syphilis: 10-30 yrs after infection; Aortitis (most common, esp ascending) – main complications are aneurism, aortic valve insufficiency, coronary ostium stenosis; CXR may show linear calcifications of aorta and dilation
- Neurosyphilis: see next page
- Congenital: latent infections, stillbirth, defects (multi-organ, death may occur), infectious at birth; snuffles (thick nasal discharge), discrete macular lesions on soles, generalized eruption on an otherwise healthy appearing child
Darkfield microscopy, DFA, Silver stained tissue; Culture: not able in lab; Serology: most common but cross rxns; Nontreponemal tests: Nonspecific vdrl, used to SCREEN; Treponemal (Specific) fta-abs, mha-tp, used to CONFIRM; PCR
Depends on stage; Benzathine penicillin (IM injection); Crystalline Penicillin for neuro; tetracycline or doxycycline for those allergic to pen; Jarisch-Herxheimer Rxn due to release of its components is possible- cytokine storm
Safe sex, contact notification and treatment
Herpes Simplex Virus (Genetal Herpes)
ds Linear DNA, enveloped, replicates in nucleus, lifelong inf, two viruses: HSV-1 and 2 –> mostly HSV2
Humans; mucosa, ganlia
Direct/ Indirect contact with skin and mucosa, STD, Transplacental and Neonatal infection
Neonates, kids; Sexually Active; Health care workers; those with weakened immune systems
GENITAL HERPES– primary infections often asymptomatic; many due to oral-genital contact and to HSV-1 rather than 2; mult small-grouped vesicles that progress to ulcerative lesions in 2-4 days; many primary infections associated with constitutional symptoms and regional lymphadenopathy; sacral ganglia = site of latency; may have many or few relapses that may be symptomatic or not.
Gingivostomatitis- usually the primary oral infection but also in the immunocompromised; fever and malaise followed by vesicular lesions in infected area (primarily perioral); site of latency = trigeminal ganglion.
Herpetic whitlow- lesions on fingers; site of latency= brachial ganglia.
Herpetic gladitorium- wrestlers
Herpetic keratoconjunctivitis
Tzanck smear, culture (expensive), PCR
Antivirals relieve symptoms, shorten outbreak period, don’t prevent latency; Acyclovir
Avoid direct contact with active lesion or during prodrome, c-section if active- partuition
Human Papilloma Virus
ds Circular DNA, naked, replicates in nucleus; more than 100 serotypes
Infection stimulates cell growth
Viral products E6 and E7 of oncogenic strains promote cell growth (epithelial tumors) by the following mechanisms: E6 binds p53 for degradation; E7 binds p105RB protein
Humans; co-infections occur; clinical disease rare
Direct contact (microabrasions for entry) Anyone can be infected but clinical disease is rare. Genital HPV: unprotected sex with an infected partner, unvaccinated.
GENITAL WARTS: Predominate at sites of friction; mostly soft, not scaly (not verrucal- heavily keratinized); may have some itching, irritation or burning at the site; Women- within vagina, on the cervix, and around the anus or within the rectum; Men- on the tip of the penis, on the scrotum, or around the anus; can develop in the mouth of a person who has had oral sexual contact with an infected person.
Warts- most frequently HPV 6 and 11, most develop within 3-4 months after exposure (ranges from 6 weeks to 2 years)
Cervical cancer- most frequently HPV 16 and 18
In a Biopsy, looking for Koilocytes-shrunken nucleus w/in a large cytoplasmic vacuole and +/- inclusion body
Clinical presentation; Pap smear; cytology: immunofluorescence, in situ hybridization, PCR, Koliocytic cells
Cutaneous treatment may be self-limiting, others may use cryotherapy, surgical excision, or chemical removal
Minimize exposure, condom use; Guardasil – subunit vaccine licensed for females ages 11/12 to age 26, now approved for use in males 9-26; Cevarix- subunit vaccine- HPV 16 and 18
