Genital ulcers Flashcards
Which is the commonest type of HSV?
HSV 1
How many people get symptoms at the time of catching HSV?
1/3
What is the incubation os HSV2?
2 days to 2 weeks
How many recurrences can you expect with HSV1 and HSV2?
Median recurrence for
HSV2 is 0.34/month ( 4/year)
HSV1 - 1/ year
What is different about HSV in PLWHIV
More likely to shed hsv2
especially if low cd4 or also have hsv1
What is the benefit of HSV DNA detection by PCR?
It increases detection by 11-71% compared with culture
What is the gold standard for HSV detection?
Western blot but this is not commercially available
Who should HSV serology be offered to?
Recurrent genital disease ?cause
Counselling of patients with symptoms (to identify if old.new and to aid in counselling- including pregnancy women
Investigating asymptomatic partners of patients with HSV e.g. woman planning a pregnancy, couples concerned about transmission in disconcordant couples
When should oral antivirals be offered for HSV?
Within 5 days of sores, or if new sores or systemic symptoms
Is acyclovir safe?
Safety data for over 20years has shown acyclovir to be safe with no need for monitoring
If renal disease–> small dose adjustment
When to stop HSV suppression?
Stop at 1 year and review
1 recurrence often occurs on stopping- reassure
If 2 recurrences - can discuss further suppression
In which strain of HSV is shedding more common?
HSV2
Causes and treatment of resistant HSV?
More common in HIV
Usually due to thymidine kinase deficiency
Can be treated with foscarnet or cidofavir
What is in indicator of HSV on cervical cytology?
Multinucleate giant cells- 60% sensitivity
What is the underlying pathology in early syphilis?
Vasculitis predominantly affecting plasma cells
When are steroids indicated for management of syphilis?
Alongside STS treatment in neuro/eye/CVS to prevent the JH reaction worsening the inflammation and causing
- blindness
- severe neurological impairment
- -aortic damage
What follow-up serology is required for STS after treatment
3months
6 months
12 months
Then 6 monthly until serofast
What is the aetiology of chancroid?
Small gram negative coccobaccillus
Occurs in chains
Culture needs blood rich medium - atmosphere of 5-10% co2 (but PCR is most sensitive test to diagnose >95%)
Most are beta lactic producers
What is management of chancroid?
1g azithromycin stat alternatives ciprofloxacin 500mg bd 3/7 (will not mask sts as doesn't kill treponemes) Im ceftriaxone 250mg Oral erythromycin 500mg Qds 7/7
Which treatment is recommended for chancroid in HIV pos?
Ciprofloxaxin and erythromycin
Do contacts of chancroid need treatment?
Yes PN - 10 days. Should be examined and offered epidemiological treatment
what to counsel patients about when giving benzylpenicillin for syphilis?
unlicensed but widely used
may develop JH reaction
usually within 4 hours
lasts about 24h
what are symptoms of JH reaction?
muscle aches chills fever low blood pressure clinical lesions may get worse before better
what advice should you give for JH reaction?
best rest
simple analgesia
in which situations might you offer steroids in syphilis?
cardiovascular
neurosyphilis
What advice on management should be given to patients presenting with genital HSV?
Drink plenty of fluid to keep urine dilute
Saline washes
Use water jug to rinse
Analgesia
Hospital if urinary retention/meningitis/constitutional symptoms
What advice should be given about abstinence with HSV?
No sex until 7 days after lesions healed
What should be included in HSV counselling?
Natural hx Antiviral drugs- symptom control Transmission/autoinoculation with first episode Asymptomatic shedding Condoms
What advice to give to patient with HSV and pregnant partner?
Condoms should be used in pregnancy Especially 3rd trimester No sex if lesions No sex in last 6 weeks pregnant (if she is seronegative) Patient info leaflet HSV association helpline
What would you recommend if initial episode HSV in 3rd trimester?
Standard HSV treatment
Daily suppression acyclovir 400mg ads
Recommend C Section
How is HSV with HIV coinfection managed differently?
Increased dose of aciclovir
Rx dose- aciclovir 400mg 5 x day 7-10 days
Episodic/suppression 400mg TDS 5-10 days
What to do if primary HSV lesions at onset of labour?
Inform neonatologist
Recommend C section
Consider IV intrapartum aciclovir 5mg/kg tds
Treat neonate with aciclovir 20mg/kg tds
What is risk of HSV transmission to baby in recurrent hsv at time of vaginal delivery?
0-3%
What is risk of HSV transmission to baby in primary hsv at time of vaginal delivery?
41%
How is management of primary HSV in pregnancy in women with HIV different?
Its not- treat as if HIV neg
What is treatment of recurrent HSV in pregnancy in HIV pos mother?
Risk of HIV transmission is increased (3 fold) if HSV2 genital lesions present
Offer suppression from 32/40 to decrease HIV transmission risk
How common is aciclovir resistance in HSV?
Uncommon in immunocompetent Found in 5-7% of those with HIV May respond to IV if partially resistant Alternatives include- foscarnet 1% and cidofovir 1%
Management of neonate in C section primary HSV in 3rd trimestre
Low risk
Swab neonate
Hand hygiene education
How to manage neonate if spontaneous NVD and primary HSV within 6 weeks of delivery?
High risk Liaise with neonatal team Swab- skin, eyes, rectum, oropharynx IV acyclovir 20mg/kg tds until HSV ruled out If baby unwell- LP
Which treponema causes Yaws?
Treponema pertenue
Where is Yaws found and what are features?
Africa, South America, SE Asia, pacific Spread by flies SCARS on legs Crab gait Lesion on soles of feet Nasal/palatal collapse
Where is Pinta found and what are features?
Semi arid areas
Central/S America
Patchy altered skin pigmentation
Which treponema causes Pinta?
Treponema carateum
Which treponema causes Endemic syphilis? (betel/dichuchwa)
Treponema endemicum
What are features of endemic syphilis?
Nasal and palatal collapse
Transmitted by shared eating utensils
Do you get CV/neuro involvement with endemic treponemes?
No
Management of endemic treponematoses
Single dose 1.2g IM benzathine benzypenicillin
Curative
Scars may remain
(azithromycin is equally effective)
What is the infection rate following single exposure to chancroid?
male to women - 60%
How is chancroid transmitted?
Sexually including oral sex
Also autoinnoculation- especially locally by fingers
What is the incubation for chancroid?
3-7 days
What are symptoms of chancroid?
Tender red papule--> pustule-->ulcer Multiple ulcers common Kissing lesions Irregular margins Bleed on touch Non indurated May coalesce to giant ulcers Lymphadenitis--> bubo
Treatment of chancroid?
1g azithromycin STAT
alternative is ceftriaxone 250mg IM stat
If HIV positive
ciprofloxacin 500mg po bd 3/7
Erythomycin 500mg po qds 7/7
PN for chancroid?
10 days within onset of symptoms
What is the sensitivity of dark ground microscopy for STS?
79-97% sensitive
What is the specificity of dark ground microscopy for STS?
77-100% specific
What is the sensitivity PCR for diagnosis of STS?
88-91% sensitive
What is the specificity PCR for diagnosis of STS?
99% specific
How long does it take for STS serology to become positive?
9-90 days
Average 21 days
15% may have negative serology in primary STS
What response in RPR do you want to show treatment response in STS?
3/12 4 fold drop (2 dilution)
6/12 8 fold drop (3 dilution)
What may be different about STS serology in HIV?
Increased risk of prozone effect
Biological false positivity
Delayed seropositivity
What can be seen in CSF in neurosyphilis?
CSH HOA (CSF albumin x 103/serum albumin) >70
CSF WCC raised and CSF protein raised
What is a biological false positive in STS?
Positive VDRL/RPR on 2 occasions
NEGATIVE SPECIFIC TEST
No evidence of infection
Causes of biological false positive in STS
Acute
Infection (eg EBV, atypical pneumonia, malaria)
Vaccination
Pregnancy
Chronic Physiological Infection (leprosy, HIV) Autoimmune (SLE) Debilitation IV drug use
Aetiology of donavonosis?
Klebsiella granulomatosis
Human parasite
Gram negative
What is the incubation of donavonosis?
? 1-360 days
Probably ~50 days
Is there associated Lymphadenopathy with donavonosis?
No (unless 2 bacterial infection)
Spread is haematogenous to bone, liver and spleen
Is PN required for donavonosis? (granuloma inguinale)
YES
In the absence of any reliable screening test and the long incubation period, all sexual contacts of cases in the last six months should be checked for possible lesions by clinical examination.
What is the treatment of donavonosis?
All treatments for 3 weeks or until lesions healed
Azithromycin 1g orally or 500mg daily
Alternative regimens weekly
- Co-trimoxazole 160/800 mg bd orally
- Doxycycline 100 mg bd orally
- Erythromycin 500 mg four times daily orally. (PREGNANCY)
- Gentamicin 1 mg/kg every 8 h parenterally can also be used as an adjunct if lesions are slow to respond
Treatment of endemic syphilis?
1.2 g IM benzathine penicillin (600mg if <10 yo)
Is JH reaction more common in 1 or 2 syphilis?
SECONDARY
A/w start of antibiotics
75% with Secondary STS
50% with Primary STS
When is special care required with JH reaction
Involvement of coronary ostea, larynx, optic neuritis, uveitis, nerve deafness, pregnancy
Give prednisolone 3060 ng TDS 3 days. Start 24 h prior.
Which steroids should be given in interstitial keratitis (non ulcerating inflammation of cornea) to prevent JHR?
0.1% betamethasone eye drops starting prior to abx.
When to refer to fetal medicine in syphilis in pregnancy?
If diagnosed after 26/40
Evaluation of fetal involvement (hepatomegaly, splenomegaly, scalp oedema, polyhydramnios)
What might be the consequences of JH reaction in pregnancy?
Uterine contractions
Fetal distress
Preterm labour
When should treatment for congenital syphilis be considered?
If mother is untreated
Suspected CS and mum treated <4 weeks before delivery
Mum and non penicillin regime
Serological evidence of CS
How does aortitis in syphilis present?
Aortic aneurism- proximal ascending, fusiform, saccular (Without dissection)
Chest pain
Signs of compression of adjacent structures eg hoarseness/dysphagia
Can lead to AR- 30% of those with CV syphilis
Insidious
Early diastolic murmur
On forced expiration with patient leaning forward
Coronary ostia stenosis- leading to angina and heart failure
What conduction defect can you get in CV syphilis?
Stokes adams syndrome (gummatous involvement)
Heart block- leading to sudden fainting/LOC
What is the penicillin level required to be maintained throughout treatment for syphilis?
0.018 mg/l
Syphilis serology EIA - TPPA - low + RPR 1:2 IgM +
Primary (before IgG positive)
Syphilis serology EIA + TPPA - high + RPR 1:128 IgM +
Secondary syphilis
Syphilis serology EIA + TPPA - low + RPR 1:2 IgM -
Late latent syphilis
Syphilis serology EIA + TPPA - weak + RPR neat IgM -
Treated syphilis
Syphilis serology EIA + TPPA - high + RPR 1:64 IgM +
Early latent
Describe which infections associated with ulcers are painful?
Chancroid painful. (Associated LN/abscess)
HSV painful usually crops
Behcet’s- painful- usually linked with oral ulcers, may be eye signs/skin lesions
Which infections associated with ulcers and painless?
Granuloma inguinale- painless
LGV painless
Syphilis Painless
what best supports a diagnosis of neurosyphilis?
CSF TPPA >1:320
High sensitivity
What RPR after treatment is predictive of neurosyphilis?
RPR >1:32
What RPR is supportive of ACTIVE syphilis
> 1:16
CSF results supporting neurosyphilis if HIV neg
WCC >5
protein >0.45 g/l
RPR/VDRL positive
TPPA >1:320
Treatment of Neurosyphilis- including neurological/ophthalmic involvement in early syphilis
Procaine penicillin 1.8 MU–2.4 MU IM OD plus probenecid 500mg PO QDS for 14 days:
Benzylpenicillin 1.8–2.4g IV every 4h for 14 days (10.8–14.4g)
Alternative regimens
Doxycycline 200mg (NOTE 200) PO BD for 28 days
Amoxycillin 2g PO TDS plus probenecid 500mg PO QDS for 28 days
Ceftriaxone 2g IM or IV for 10–14 days
40–60mg prednisolone OD for three days starting 24h before the antibiotics.
Causes of chronic STS biological false positive?
Usually in older age >30 yo
Chronic infections e.g. leprosy
Autoimmune conditions e.g SLE
Injecting drug use
Causes of acute STS biological false positive?
Usually in younger age <30
Any acute febrile illness e.g. EBV, HIV, hepatitis
Vaccination
Pregnancy
How common are biological false positives in syphilis?
<1% of general population
How is syphilis transmitted in pregnancy?
Usually via placenta in the third trimester.
the treponemes circulate within the bloodstream.
(very rarely transmitted via a chancre on the cervix or condylomata lata/snail track ulcers at the time of birth)
Treatment of recurrent HSV- suppressive
Aciclovir 400mg bd (or 200mg qds)
Valaciclovir 400mg od
Famiciclovir 250mg bd
Treatment of recurrent HSV- episodic
5 day course
Aciclovir 200mg 5 x day or 400mg tds
Valaciclovir 500mg bd
Famciclovir 125mg bd
What are short course HSV treatment?
BASHH says short course is more convenient/cost effective for episodic and should be considered 1st line
Aciclovir 800mg tds 2 days
Famciclovir 1g bd 1 day
Valaciclovir 500mg bd 3 days
When is treponemal PCR useful?
To assess oral or other lesions where contamination with other treponemes is likely (so dark ground unhelpful)
Sensitivity/specificity of treponemal PCR from primary chancre?
Sensitivity 78%
Specificity 96.6%
Complications of chancroid?
phagedenic chancroid
Tissue destruction
Bubo/abscess 25%
Phimosis
Congenital syphilis serology
IGM positive and RPR >4 x mum (confirmed on repeat testing)- diagnostic
If IgM negative
RPR <4 x mum, no signs–> repeat IgM 3 monthly until negative
RPR/VDRL usually negative in baby by 6-12 months
Histology of primary syphilis
Primary chancre- acanthotic epidermis which erodes with time to become ulcerated.
Under the ulcer -dense lymphocytic response
Numerous plasma cells
and endothelial swelling
Histology of secondary syphilis?
The epidermis-a psoriasiform hyperplasia with superficial neutrophils.
There is also a lichenoid tissue reaction, epidermal apoptosis and exocytosis of neutrophils
The dermis shows a superficial and deep chronic infiltrate which may resemble the changes of primary syphilis.
There are numerous plasma cells in about 1/3 of cases and often endothelial swelling
What is secondary LGV?
Inguinal and less commonly, femoral lymphadenopathy is usually found.
The characteristic groove sign is seen when both inguinal and femoral lymph glands are enlarged. Systemic symptoms of fever and lassitude are described.
Buboes may develop which if untreated may rupture with protracted healing.
Lymph nodes may form small areas of necrosis, which attract neutrophils and form stellate abscesses. Further inflammation may cause loculated abscesses, fistulas and sinus tracts.
What is tertiary/anorectal LGV?
Healing of the secondary stage by fibrosis results in lymphatic vessel obstruction and elephantiasis, chronic oedema, compromised blood supply and further ulceration.
Subsequently, rectal stricture, fistula formation and adhesions may occur.
The clinical and histological picture of LGV proctocolitis may mimic inflammatory bowel disease.
Complications of donavonosis?
Complications include:
Stenosis of urethra, vagina and anus Genital elephantiasis Neoplastic changes Depression Lesions progress more rapidly in pregnancy.
Non genital sites of donavonosis
Genital in 90%
Inguinal in 10%
Extragenital: lip, gums, palate in 6%
Haematogenous spread to liver, bone is rare
Diagnosis of donavonosis- microscopy appearances?
Staining is done using a rapid Giemsa method and the whole process can be completed in a few minutes.
Donovan bodies are seen under direct microscopy as ovoid bodies with a capsular halo, sometimes with bipolar intrabacterial inclusions. They are usually found in large mononuclear cells.
Histology- Donovan bodies may be seen in association with chronic inflammation and infiltration of plasma cells using Giemsa or silver stains.
Which ulcerative conditions cause buboes?
Buboes occur in chancroid and LGV.
Which ulcerative disease has malignant potential?
donavonosis
Incubation of donavonosis?
50 days
Rarer presentation of primary syphilis?
Follman’s balanitis
Isolated raised EIA in syphilis (igG)
Can be pregnancy
If really not sure - can do immunoblot (but treat while awaiting results)
Histology of gummatous syphilis?
granuloma
What would you see on CXR if syphilis aortitis?
Egg shell calcification
How to manage recurrent HSV at onset of labour?
Vaginal delivery should be offered
Caesarean section delivery can be considered
The risk to the mother and future pregnancies should be set against the small risk of neonatal transmission of HSV
The final choice of mode of delivery should be made by the mother
Invasive procedures may be used if required
They may increase the risk of neonatal HSV infection but, as background risk is small, this increase is unlikely to be clinically significant
There is no evidence to guide the management of women with spontaneous rupture of membranes at term
Expediting delivery may minimise duration of potential exposure of the foetus to HSV
Management of primary HSV in last trimester of pregnancy?
Management will be based on clinical assessment as there will not be time for confirmatory laboratory testing:
History to ascertain if primary or recurrent episode
Viral swab from the lesion(s) - it may influence management of the neonate
The neonatologist should be informed
Recommend caesarean to all women presenting with primary episode genital herpes lesions at the time of delivery, or within 6 weeks expected delivery date
Benefits of caesarean may reduce if the membranes have been ruptured > 4 hours - however, there may be some benefit even after this time interval
Consider intrapartum IV aciclovir for the mother (5 mg/kg 8 hourly) and the neonate (20 mg/kg 8 hourly) if opting for vaginal delivery
Although vaginal delivery should be avoided if possible, in women who deliver vaginally in the presence of primary genital herpes lesions, avoid invasive procedures
Management of pregnant women with first episode genital herpes in first or second trimester (until 27 +6 weeks)?
Refer women with suspected genital herpes for assessment by a GUM physician
Confirm diagnosis with HSV PCR
Complete STI screen
Do not delay treatment whilst awaiting results - manage the woman in line with her clinical condition, using aciclovir in standard doses (usually PO, IV if disseminated)
Inform the obstetrician - if midwifery led care refer for review with an obstetrician
Paracetamol and topical lidocaine 2% gel offer symptomatic relief
Providing delivery is not within the next 6 weeks, the pregnancy should be managed expectantly and vaginal delivery anticipated
Daily suppressive aciclovir 400 mg TDS from 36 weeks reduces HSV lesions and asymptomatic shedding at term and hence the need for delivery by caesarean
Aciclovir is not licensed for use in pregnancy but is considered safe and well tolerated. Valaciclovir and famciclovir are not recommended as first line as there is less experience with their use. See full guideline for further details.
Third trimester acquisition (from 28 weeks) management HSV in pregnancy?
No additional monitoring of the pregnancy is required
Do not delay treatment - manage the woman in line with her clinical condition using standard doses of aciclovir (usually PO, IV if disseminated)
Continue daily suppressive aciclovir 400 mg TDS until delivery
Recommend caesarean, particularly if episode is within 6 weeks of expected delivery
Type-specific HSV antibody (IgG) testing is advisable to distinguish between primary and recurrent genital HSV infections
The presence of antibodies of the same type as the HSV isolated from genital swabs would confirm this episode to be a recurrence rather than a primary infection and elective caesarean would not be indicated
Plan mode of delivery with assumption that all first episode lesions are primary genital herpes (this can be modified if test results later confirm a recurrence)
Recommend discussion of serology results with a virologist or GUM physician
Management of HIV-positive women with HSV infection- recurrent HSV
There is some evidence that HIV-positive women with genital HSV ulceration in pregnancy are more likely to transmit HIV infection independent of other factors
If history of genital herpes offer daily suppressive aciclovir 400 mg TDS from 32 weeks to reduce the risk of transmission of HIV, especially if vaginal delivery is planned
Management of babies born by caesarean in mothers with primary HSV infection in the third trimester?
These babies are at low risk of HSV infection. Conservative management is recommended:
Liaise with the neonatal team
Swabs from the neonate are not indicated
No active treatment is required for the baby
Normal postnatal care with neonatal examination at 24 hours of age, after which the baby can be discharged from the hospital if well and feeding established
Educate parents regarding hand hygiene and due care to reduce risk of postnatal infection
Advise parents to seek medical help if they have concerns regarding their baby
In particular, advise to look for skin, eye and mucous membrane lesions, lethargy, irritability or poor feeding
Management of babies born by spontaneous vaginal delivery in mothers with a primary HSV infection within the previous 6 weeks?
These babies are at high risk of HSV infection. Liaise with the neonatal team.
If the baby is well:
Send swabs of the skin, conjunctiva, oropharynx and rectum for HSV PCR
A lumbar puncture is not necessary
Start IV aciclovir (20 mg/kg 8 hourly) until active infection is ruled out
Strict infection control procedures for both mother and baby
Breastfeeding is recommended unless the mother has herpetic lesions around the nipples
Advise parents to report any early signs of infection such as poor feeding, lethargy, fever or any suspicious lesions
If the baby is unwell or presents with skin lesions:
Send swabs of skin, lesions, conjunctiva, oropharynx and rectum for HSV PCR
A lumbar puncture should be performed even if CNS features are not present
Start IV aciclovir (20 mg/kg 8 hourly) until active infection is ruled out
Management of babies born to mothers with recurrent HSV infection in pregnancy with or without active lesions at delivery
The infection risk is low. Advise conservative management of the neonate.
Liaise with the neonatal team
Surface swabs from the neonate are not indicated
No active treatment is advised for the baby
Normal postnatal care with a neonatal examination at 24 hours of age, after which the baby can be discharged from the hospital if well and feeding established
Educate parents regarding hand hygiene and due care to reduce risk of postnatal infection
Advise parents to seek medical help if they have concerns regarding their baby
In particular, advise to look for skin, eye and mucous membrane lesions, lethargy, irritability or poor feeding
