GENITAL ULCER DISEASE Flashcards
What is the 3 most common STI causes of genital ulceration?
Genital herpes
Primary syphilis
Lymphogranuloma venereum
What are the viruses responsible for genital herpes?
Herpes simplex type 1 (HSV-1)
Herpes simplex type 2 (HSV-2)
What is the most common type of transmission of HSV-1 in the UK?
Orogenital route in sexual contact
What is the incubation period of herpes simplex viruses?
5-14 days
What proportion of people will develop signs or symptoms of HSV infection during the initial acquisition?
Less than half
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.
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.
What is the prevalence of HSV-2 infection in the UK?
9%
Which type of HSV infection recurs more frequently?
Type 2
What groups have higher rates of HSV infection?
Sex workers
MSM
How often does HSV-2 typically recur in the first year?
4
10% may experience more than 10 episodes per year
How often does HSV-1 typically recur?
Once every 18 months
What is the definition of the first episode of genital herpes?
This is the first time a person has clinical features of genital herpes
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
How long does a typical first episode of genital herpes last for?
3 weeks
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
What are the distant complications of HSV infection?
Myalgia
Dissemination (rare outside of neonates and pregnancy)
Autoinoculation to distant sites
Erythema multiforme
What are the neurological complications of HSV infection?
Headaches
Encephalitis
Radiculitis
Transverse myelitis
Autonomic neuropathy
What are the prodromal symptoms of a recurrent episode of HSV?
Itch
Tingling
These can be false prodromes where no lesions then occur
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
