GENITAL ULCER DISEASE Flashcards by Alex Kinsky

What is the 3 most common STI causes of genital ulceration?

Genital herpes

Primary syphilis

Lymphogranuloma venereum

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What are the viruses responsible for genital herpes?

Herpes simplex type 1 (HSV-1)

Herpes simplex type 2 (HSV-2)

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What is the most common type of transmission of HSV-1 in the UK?

Orogenital route in sexual contact

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What is the incubation period of herpes simplex viruses?

5-14 days

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What proportion of people will develop signs or symptoms of HSV infection during the initial acquisition?

Less than half

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Where do the HSV viruses initial reside and travel to in the body?

Enters into the distal axonal processes of the sensory neuron and travels to the sensory (dorsal root) ganglion where it remains dormant.

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How does a herpes virus reactivate after a latent stage?

Travels back down axons to basal skin layers. Some of these episodes will result in symptoms, others will be asymptomatic. In this way patients may not know they are infected and may therefore pass on virus unaware.

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What is the prevalence of HSV-2 infection in the UK?

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Which type of HSV infection recurs more frequently?

Type 2

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What groups have higher rates of HSV infection?

Sex workers

MSM

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How often does HSV-2 typically recur in the first year?

10% may experience more than 10 episodes per year

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How often does HSV-1 typically recur?

Once every 18 months

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What is the definition of the first episode of genital herpes?

This is the first time a person has clinical features of genital herpes

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What are the clinical features of genital herpes?

Lesions start as vesicles

Then become superficial very painful ulcers

Ulcers may coalesce to form larger superficial lesions

These form the characteristic serpiginous edges

Local tender lymphadenopathy

Muscle aches in lower limbs

Systemic features (reported in 10%) - headache, malaise and photophobia

Fissures

Erythema

Dysuria

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How long does a typical first episode of genital herpes last for?

3 weeks

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What are the local complications of HSV infection?

Superinfection of lesions with streptococci and/or staphylococci

Adhesion formation

Vaginal candida infection exacerbation symptoms

External dysuria can lead to urinary retention

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What are the distant complications of HSV infection?

Myalgia

Dissemination (rare outside of neonates and pregnancy)

Autoinoculation to distant sites

Erythema multiforme

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What are the neurological complications of HSV infection?

Headaches

Encephalitis

Radiculitis

Transverse myelitis

Autonomic neuropathy

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What are the prodromal symptoms of a recurrent episode of HSV?

Itch

Tingling

These can be false prodromes where no lesions then occur

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What are the triggers of a recurrent episode of HSV?

Often nothing

UV irradiation

Localised trauma

What is the distribution of a recurrent episode of HSV?

Dermatomal

What factors increase the chance of experiencing a recurrent episode of HSV?

HSV type 2

No previous infection with other HSV type

Male

First year following infection

Symptomatic acquisition episode

Prolonged acquisition episode

Damaged immune system

How do we diagnose HSV?

PCR - most accurate

Culture

Antigen detection directly from genital lesions

Why is viral typing useful as part of diagnosis?

Gives some prognostic value

How do we treat the first episode of genital herpes?

Aciclovir 400 mg TDS or 200 mg 5 times a day (5-10 days) OR Valaciclovir 500 mg BD (5-10 days) OR Famciclovir 250 mg TDS (5-10 days)

How do we treat episodic genital herpes?

Aciclovir 800 mg TDS for 2 days or 200 mg 5 times a day for 5 days OR Valaciclovir 500 mg BD for 3-5 days OR Famciclovir 1 g BD for 1 day or 125 mg BD for 5 days Should be taken during the prodrome or in the first 24 to 48 hours as a lesion is developing.

What treatment do we use for suppressive therapy?

Aciclovir 400 mg BD OR Valaciclovir 500 mg - 1 g OD

What is the threat of HSV in pregnancy?

Acquisition of HSV infection in the third trimester of pregnancy is associated with an unacceptable high risk of HSV transmission to the neonate with vaginal delivery. Delivery should therefore be CS.

What is lymphogranuloma venereum (LGV)?

STI also known as tropical or climatic bulbo, and lymphogranuloma inguinale. It is caused by a type of Chlamydia trachomatis (serovar L). These organisms invade and destroy lymphatic tissue.

Where is lymphogranuloma venereum (LGV) particularly prevalent?

Tropical countries

Is classic LGV usually acquired heterosexually or homosexually across the world? In the UK?

World: Heterosexually UK: homesexually

What are the names of the different stages of LGV infection?

Primary - transient genital ulceration Secondary - inguinal or anorectal syndrome Tertiary - genito-anorectal syndrome

How long after infection does the primary stage of LGV occur?

3-30 days after infection

What are the features of the primary stage of LGV?

Transient solitary papule or ulcer at the site of inoculation Sometimes painful Heals rapidly without scarring

How long after infection does the secondary stage of LGV occur?

2-6 weeks

What are the features of the secondary stage of LGV?

Inguinal syndrome: Unilateral inguinal and/or femoral lymphadenopathy Formation of buboes (enlarged tender glands in the groin - they can rupture) Groove sign

What is the 'groove sign' in classic LGV?

Groove like depression causing by femoral and inguinal lymph node enlargement above and below inguinal ligament.

Is inguinal and femoral lymphadenopathy more associated with LGV in men or women?

Men - primary involvement in women is usually in the vagina, cervix, posterior urethra or rectum which drain into deeper lymph nodes

What are the features of the third stage of LGV infection?

Chronic untreated infection which causes fibrosis which leads to lymphatic obstruction and hence genital lymphoedema (elephantiasis).

What are the complications associated with tertiary LGV infection?

Rectal strictures Proctitis Colitis Perianal abscess Perineal fistulae Rectovaginal fistulae Urethral fistulae

How do we diagnose LGV infection?

PCR from samples taken from lesions

How do we manage LGV infection?

Doxycycline 100 mg BD for 3 weeks OR Erythromycin 500 mg QDS for 3 weeks Buboes may require repeated aspiration

What is the organism that causes chancroid?

Haemophilus ducreyi

What is the incubation period of haemophilus ducreyi causing chancroid?

3-10 days

What are the features of chancroid?

Single or multiple anogenital ulcers Soft ulcers Sore Purulent base with contact bleeding Painful lymphadenopathy

What are the complications of chancroid?

Phagedenic ulceration - tissue destruction Inguinal abscess formation (bubo) Chronic suppurative sinuses

How do we diagnose chancroid?

Microscopy/culture PCR - not widely available

How do we treat chancroid?

Azithromycin 1 g stat OR Ceftriaxone 250 mg IM stat OR Ciprofloxacin 500 mg BD for 3 days OR Erythromycin 500 mg QDS for 7 days Buboes may require repeated aspiration