Genitourinary Medicine Flashcards
1
Q
What is Fitz-Hugh-Curtis syndrome and how does it present?
A
PID complication where the liver capsule becomes inflamed leading to development of adhesions between the liver and the surrounding peritoneum. This causes right upper quadrant pain radiating to the shoulder alongside other symptoms of PID (vaginal discharge, fever)
2
Q
Managing a woman who tests positive for the first time for HR HPV after her smear test.
A
Positive cytology - refer for colposcopy
Negative cytology (no dyskaryosis of cells in the transformation zone) - repeat smear and test for HR-HPV after 12 months, if negative return to routine screen if positive without positive cytology repeat at 24 months, if positive again refer for colposcopy (increased risk of dyskaryosis)
3
Q
HIV progression
A
Classification based on CD4 count
Incubation period - asymptomatic This stage can last varying from a few months to several years.
Early Acute phase CD4+ around 500 - week to months: flu like symptoms - raised lymph nodes, rashes,
An HIV infected person will begin manifesting symptoms like rashes, weakening of the muscles, sore throat, fever, mouth sores, and swelling of the lymph nodes. The infected person may also have an unexplained weight loss of less than 10% of total body weight.
CD4 count 200-500: ongoing skin issues, lymhadenopathy, opportunistic infections
Once this stage starts, the immune system will begin to produce antibodies that will battle the virus. The patient will experience weight loss more than 10% of total weight, unexplained diarrhea, pulmonary tuberculosis, and severe systemic bacterial infections such as pneumonia, meningitis, bone and joint infections, and bacteremia.
Advanced CD4<200 - AIDS - serious infections/skin mallignancies occur occur (Pneumocystis jirovecii pneumonia, Kaposi’s sarcoma),
4
Q
How is HIV tested for?
A
1.EIA (4th gen combo assay):
Detects anti-HIV ab and detects P24 antigen, window period of 45 days (time taken for positive results following exposure)
- Confirmatory tests in lab positive - immunoblot, looks for other antigens
SECOND SAMPLE TO CONFIRM PATIENT ID
- RNA detection by PCR for ‘‘viral load’’ - MONITOR RESPONSE TO TREATMENT, <50 copies undetectable
5
Q
There is a long list of AIDS-defining illnesses associated with end-stage HIV infection where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear, what are some examples?
A
Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis
6
Q
What tests are part of the HIV follow up?
A
CD4 count - indication of how advanced disease is
HIV viral load - aim undetectable (<50 copies)
HIV resistance testing (?which rx can we use)
How is the patient/baseline monitoring - FBC, U&E, LFT, bone profile, physical assement, fundoscopy, urine dip)
Screen for relevant infection - STIs, BBIs, TB in high risk groups, OI is advanced/symptoms
7
Q
What tests are part of the HIV follow up?
A
CD4 count - indication of how advanced disease is
HIV viral load - aim undetectable (<50 copies)
HIV resistance testing (?which rx can we use)
How is the patient/baseline monitoring - FBC, U&E, LFT, bone profile, physical assement, fundoscopy, urine dip)
Screen for relevant infection - STIs, BBIs, TB in high-risk groups, OI is advanced/symptoms
8
Q
HIV anti-viral therapy
A
Tripple anti-retroviral therapy: 3 drugs - x2 NRTI plus 3rd agent
Long acting injectables
Some newer 2 drug regimes emerging
9
Q
How often are stable HIV patients monitored for viral load and routine bloods?
A
6 monthly
10
Q
Key questions to ask an HIV pt about medications?
A
Which regime?
How long taking it?
Any missed pills?
Previous treatments/failure/resistance
Other medications incuding OTC/vitamins (may react)
11
Q
How to prevent HIV transmission?
A
Condom use
Screening and regular testing (3/12 if high risk)
Treatment as prevention - U=U
PEP
PrEP
12
Q
When can HIV post exposure prophylaxis be given following a high-risk exposure, what is given?
A
WIthin 72 hours
Truvada + Raltegravir for 28 days, available via A+E or sexual health services
Reccomended following receptive anal sex with known HIV partner or ?HIV partner
13
Q
What is PrEP?
A
HIV pre-exposure prophylaxis
High risk patients eligble under NHS from sexual health centres, Truvada either given daily or ‘event based’
Reduces risk of acqusation of HIV
14
Q
HIV vs AIDs?
A
HIV – Human Immunodeficiency Virus
AIDS – Acquired Immunodeficiency Syndrome
AIDS is usually referred to in the UK as Late-Stage HIV
15
Q
What kind of virus is HIV and how does it cause pathology?
A
RNA retrovirus
The virus enters and destroys the CD4 T helper cells.
An initial seroconversion flu-like illness occurs within a few weeks of infection. The infection is then asymptomatic until it progresses and the patient becomes immunocompromised and develops AIDS-defining illnesses and opportunistic infections potentially years later.
16
Q
How is HIV transmitted?
A
Unprotected anal, vaginal or oral sexual activity.
Mother to child at any stage of pregnancy, birth or breastfeeding. This is referred to as vertical transmission.
Mucous membrane, blood or open wound exposure to infected blood or bodily fluids such as through sharing needles, needle-stick injuries or blood splashed in an eye.
17
Q
What is a normal CD4 count?
A
500-1200 cells/mm3 is the normal range
18
Q
Under what CD4 count is considered end stage HIV / AIDS and puts the patient at high risk of opportunistic infections?
A
200 cells/mm3
19
Q
How to BHIVA recommend HIV is treated?
A
a starting regime of 2 NRTIs (e.g. tenofovir and emtricitabine) plus a third agent
20
Q
Highly Active Anti-Retrovirus Therapy (HAART) Medication Classes used to treat HIV?
A
Nucleoside Reverse Transcriptase Inhibitors (NRTIs) x2
+ 1 of
Protease Inhibitors (PIs)
Integrase Inhibitors (IIs)
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Entry Inhibitors (EIs).CCR5 inhibitors
21
Q
What drug can be given to patients prophylactically with a CD4 count below 200/mm3?
A
Prophylactic co-trimoxazole (Septrin) is given to patients with CD4 < 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).
22
Q
What risk factors should be monitored in patients with HIV due to their risk of developing complications with a particular body system?
A
Patients with HIV have close monitoring of cardiovascular risk factors and blood lipids and appropriate treatment (such as statins) to reduce their risk of developing cardiovascular disease.
23
Q
How to prevent HIV transmission?
A
Condom use
Screening and regular testing (3/12 if high risk)
Treatment as prevention - U=U
PEP
PrEP
Where the affected partner has an undetectable viral load unprotected sex and pregnancy may be considered. It is also possible to conceive safely through techniques like sperm washing and IVF.
Caesarean section should be used unless the mother has an undetectable viral load. Vaginal birth may be considered where the viral load is undetectable. Newborns to HIV positive mothers should receive ART for 4 weeks after birth to reduce the risk of vertical transmission.
Breastfeeding is only considered where the viral load is undetectable however there may still be a risk of contracting HIV through breastfeeding.
24
Q
Concerns re HIV and pregnancy/birth?
A
Where the affected partner has an undetectable viral load unprotected sex and pregnancy may be considered.
It is also possible to conceive safely through techniques like sperm washing and IVF.
Caesarean section should be used unless the mother has an undetectable viral load.
Vaginal birth may be considered where the viral load is undetectable.
Newborns to HIV positive mothers should receive ART for 4 weeks after birth to reduce the risk of vertical transmission.
Breastfeeding is only considered where the viral load is undetectable however there may still be a risk of contracting HIV through breastfeeding.
25
How to manage a patient presenting after a high risk HIV exposure?
Offer PEP for 28 days if appropriate
HIV tests should be done initially but also a minimum of 3 months after exposure to confirm a negative status.
Individuals should abstain from unprotected activity for a minimum of 3 months until confirmed negative.
26
Why should women with HIV have yearly cervical smears?
HIV predisposes to developing cervical human papillomavirus (HPV) infection and cervical cancer so female patients need close monitoring to ensure early detection of these complications.
27
What should patients with Hepatitis B be advised?
Inform GP/dentist
Do not donate blood/organs/sement
Do not share needles
Cover wounds
Clean blood spills throughly
Barrier protection for SI
28
What blood born virus has the highest risk of transmission following a needle stick injury?
Hep B (1/3)
vs. 1/30 Hep C, 1/300 HIV
29
Immediate actions following a needlestick injury to prevent blood born infection transmission?
Wash and encourage to bleed
Inform senior
RIsk assessment with OH - may neeed HIV PEP, may need HBV booster +/- HBIG - within 48 HOURS
30
Window period for admission of HBIG following Hep B exposure?
48 hours
31
What should be done following Hep B exposure?
Hep B Booster if required
If inadequate immunity and exposure to person who is HBsAg positive, consider HBIG
32
What dermatological conditions may occur when HIV starts to show symptoms?
According to WHO research, a range of dermatological conditions usually appears during this stage such as herpes zoster flares, papular pruritic eruptions, seborrheic dermatitis, and fungal nail infections.
33
What is HIV seroconversion?
HIV seroconversion is symptomatic in 60-80% of patients and typically presents as a glandular fever type illness. Increased symptomatic severity is associated with poorer long term prognosis. It typically occurs 3-12 weeks after infection
Features:
sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash
mouth ulcers
rarely meningoencephalitis
34
What is the likely to be?
HSV
Labial ulcerations on both sides (more likely primary episode)
Likely to be raised tender lymph nodes in groin
35
What is the likely to be?
HSV on cervix
36
What is the likely to be?
HSV anal
37
HSV flare course?
Red sore areas appear
Blisters form
Blisters breakdown and form open ulcers
Ulcers scab over and heal on their own
5-10 days
38
Suspected herpes investigations?
Herpes simplex PCR swab of blister/wet lesion (dried lesions unlikely to pick up virus)
Additionally, full STU screen:
syphilis serology, HIV ab test, chlamydia and gonorrhea testing
39
How long after exposure can syphilis serology be tested for?
12 weeks
40
How to manage an HSV flare/initial presentation?
Rest, analgesia, saline washing (saltwater bathing), Vaseline
Antiviral - must be systemic (Acyclovir 400mg TDS 5 days)
Offer 5% lidocaine oitnment
Initial presentation usually most severe episode, do not wait for test results to treat
Avoid sexual contact while symptomatic, advise to disclose to partners
41
Potential complications of HSV?
Urinary retention (may need suprapubic catheter)
Adhesions (advise saline wash)
Meningism
Emotional distress
Recurrences
42
What should patients with HSV be counselled?
Recurrence rate 1/3 per month HSV2, >1/10 HSV1
Asymptomatic shedding can occur
Around half of patients seroconvert virus without symptoms
Condoms reduce but do not eliminate transmission
Primary episode in 3rd trimester or pregnancy is a high risk to the newborn if born vaginally (if known HSV flare, Ab passed through placenta protected by passive immunity for 6 months)
43
What is this likely to be?
Shingles, (HZV) - dermatomal lesions, not corssing lesions
44
Are herpes ulcers painful or painless?
Painful
45
Are syphilis ulcers painful or painless?
Painless
46
Common differentials for genital ulcers?
Syphilis
HSV
Lymphogranuloma venereum
Aphthous ulceration
Trauma
Mpox
Varicella, CMV, staph/strep, LGV, chancroid, donovanosis, Fungal
Bechets disease
Crohn’s disease
Malignancy (non healing)
FDE, topical reaction, IVDU, foscarnet
47
HIV pathophysiology
HIV RNA retroviruses attatch to CD4 surface receptor/fuse with cell membrane
Uncoatin: viral contents empty
HIV enzyme reverse transcriptase copies viral genetic material to DNA
Blueprint for replication or viral RNA and repeat process
Dormant infected cells reactivated against any new infection - further replicate virus
48
Diagnosis of syphillis?
From lesions: Dark field microscopy, Treponema pallidum PCR
In blood (12 week window period( EIA), TPPA, RPR, VDRL
Full STI screen including HIV
49
What organism causes syphilis? (seen here on dark ground microscopy)
Treponema pallidum
This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is 21 days on average.
50
Secondary syphillis potential manifestations
Rash, pink to brown macules. involves palms/soles in 50% of cases, may also be on back, arms
Alopecia
Condylomata Lata (healed up warts lie lesions)
Anterior or posterior uveitis
Symptomatic early neurosyphilis,with cranial nerve deficits and/or aseptic meningitis presentation
Tinea mimicker (Genito-inguinal rash)
Acute hepatitis neohrotic syndrome (Less common)
51
Potential indicator conditions for HIV that may prompt testing?
STI
Mallignant lymphoma
Anal cancer/dysplasisa
Cervical dysplasia
Herpes zoster
Hep B or C
Unexplained lymphadenopathy
Mononucelosis like illness
Unexplained leukocytopenia/thrombyctopenia lasting over 4 weeks
52
What type of virus is Hep C?
RNA flavivirus virus
53
How is Hep C transmitted?
Blood and bodily fluids
Parenteral
Vertical - 5% risk, breastfeeding and mode of delivery do not influence
Sexual - low risk - higher if coinfection with HIV or MSM
54
Hepatitis C: clinical features?
Most asymptomatic or mild
Acute icteric hepatitis
Chronic hepatitis picture
a transient rise in serum aminotransferases / jaundice
fatigue
arthralgia
55
What is the window period for Hep C (how long after exposure detectable)
6 months
56
What is the incubation period for Hep C
6-9 weeks
57
Complications of hepatitis C?
Progression to chronic infection (3/4)
Cirrhosis (30% within 14-30 years if not treated)
Hepatocellular carcinoma
58
Complications of chronic hepatitis C?
rheumatological problems: arthralgia, arthritis
eye problems: Sjogren's syndrome
cirrhosis (5-20% of those with chronic disease)
hepatocellular cancer
cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)
porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse
membranoproliferative glomerulonephritis
59
Hepatitis C testing
Anti HCV (total) used for intial screening - marks current of past infection, becomes positive 4-10 weeks after exposure
HCV RNA is the investigation of choice to diagnose acute infection to differentiate between current and past infection (if present infection current and pt infectious)
Hep C genotype used to guide treatment
60
Hep C antibodies
Patients will eventually develop anti-HCV antibodies it
Patients who spontaneously clear the virus will continue to have anti-HCV antibodies - need HCV RNA to differentiate
Ab provide incomplete protection - reinfection possible
61
HEP C TREATMENT
treatment depends on the viral genotype - this should be tested prior to treatment
95% clearance rate with treatment,
the aim of treatment is sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy
currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used
62
Complications of Hep C treatment?
ribavirin - side-effects: haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic
interferon alpha (no longer recommended) - side-effects: flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia
63
Who is high risk for Hep C?
At risk groups include intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs).
64
Hep C prevention
No vaccine or immunoglobin, no PEP
No intervention reduces vertical tranmission
Eary identification and risk moddifcation best way to prevent
65
What should you advise a patient who has been diagnosed with Hep C?
Curable - high clearence with treatment
Vaccinate against Hep B and check for other hepatitis infections
Discussion of routes of tranmission and risk reduction
Detailed explanation of condition and long term implications
When acute - notifiable disease
Screening for STIS
Do not donate blood, semen or organs
66
How to manage hep C?
Evaluate if pt stable
Assess liver function and inflammation - ALT, clotting, platelets,albumin
Reff to hepatology
Direct acting antivirals
67
Barriers to sexual history taking
Embarrassment
Misunderstanding language - medical jargon, slang, language barrier
Fear of judgement of stigmatization
Lack of privacy
Time pressure
Difficulty understanding the patients concerns and expectations
68
Potential GUM patient concerns
Judgment
Examination
Infection
Need for a cure
Who will find out
Feeling abnormal
69
GUM clinic PC - pts with female anatomy
Vaginal discharge
Genital lumps/ulcers
IMB PCB
Deep and superficial dyspareunia
Dysuria and urinary frequency
Abdominal pain
STI contact/sexual assults/TOP.sexual dysfunction
Rectal symptoms
Asymptomatic screens
70
GUM clinic PC - pts with male anatomy
Uretheral discharge
Dysuria and urinary frequency
Genital lumps/ulcers
Testicular pain-swelling
Rectal symtpoms
Sexual dysfunction and assults
Asymptomatic screens
71
Sexual history taking at GUM clinic
Past history of STI
Last episode of sex
Anatomy of partner(s)
Sexual contact - regular or infrequent, casual or relationship
Duration of sexual relationship
Sex ?cnodoms
Type: particularly MSM- insertive/receptive, active/passive, top/bottom, oral, vaginal, anal
Partner symptoms/STI history
Partner details for contact tracing
72
Blood borne virus risk factors
Hep B, Hep C, HIV
IVDU/partnr IVDU
MSM
Partners with known infection
Partners from another country with high prevalance
People with multiple partners
73
BBI high prevalence areas?
HIV - Africa
Hep B - West africa
Hep C - middle east and china
74
Male genitalia examination
INspect and palpated inguinal region
Inspect pubic area scrotum
Inspect penis (fully retract soreskin)
Palpate scrotal contents
MSM:
- Perianal
- Anal-rectal examinations with protoscope
-If symptomatic
75
Symptomatic male investigations - GUM
Urethral smear - GC/NSU, GC cuktyre
First pass urine - GC/CT dual Naats test
Bloods HIV/syphillis +/- Hep B/C
MSM- consider rectal and pharngeal swabs and cultures
Other swabs - MC&S/Candida/Herpes
Other tests - urine dip
76
Female genitalia examination (GUM)
Lithotomy position (allows for good visualisation)
Inspect and palpate inguninal region
Inspect and palpate inguinal region
Inspect pubic area, labia majra, minora and periana alreas
Speculum examination
Bimanual examination (if indicated) - abdominal pain of deep dsypareunia
If necessary: oral cavity, skin, eyes, joints
Consider anorectal examination in left lateral position
77
GUM - symptomatic female tests
HIGH VAGINAL LOOP SWAB for microscopy and pH testing - TV, BV, candida
Vulvovagina swab ''dual NAAT'' - chlamydia and gonorrhoea, may need throat and rectal
Bloods - HIV/Syph +/- Hep B/C
History and examination dependent - cgonorrhoea cultures- endocervical, HSV PCR, urinalysis, pregnancy test (pt request, ?PID)
78
GUM - asymptomatic male tests
First pass urine - NAAT of chlamydia and gonorrhea
Bloods: HIV
MSM: Hep C/B, consider throat swab
79
GUM - testing symptomatic females
Self taken vulvo-vaginal NAAT (CT G)
Serology - STS, HIV
Urinalysis/ pregnancy test as app
80
How can partners at risk (of STI) be identified?
Look-back periods (6 m chlamydiya and gonhorrea, HIV last test (note pregnant women in UK would have been tested), syphilis last test)
Refer to sexual history
Condom use-safer sex advice
Memory prompts may help recall
Document details to track progress
81
PN in primary care
Advise pts with an STI that partner/s will need testing/treating
Offer choices of partner notification e.g. pt to inform their contacts
Consider local refferal pathways for management of pt with STI to include PN arrangements
82
A symptomatic male with gonorrhea should contact partners from how long ago?
2 weeks prior to onset of urerthral discharge
(6 m if asymptomatic)
83
A symptomatic male with gonorrhea should contact partners from how long ago?
2 weeks prior to onset of urethral discharge
(6 m if asymptomatic)
84
Securing co-operation with STI partner notification
Voluntary
Non-judgemental and supportive approach
Emphasize pt choice/control
Confidentiality
Patient risk of re-infection
Partner at risk from untreated infection
Risk of transmission to others
85
STI PN methods
Patient referral
Provider referral
86
What are contact slips/cards (context GUM)?
Can provide anonymity and confidentiality for the patient index
Enable sexual contacts to seek medical advice or treatment
Inform the contact's clinic of individual pt diagnosis, and date of diagnosis
Enable cross-referencing and evaluation of partner notification
87
What details should you ask about when a patient presents complaining of vaginal discharge?
Colour
Odor
Consistency
Bloodstaining
Other symptoms: itch, soreness, intermenstrual/post-coital bleeding, dyspareunia, genital rash lesions
Sexual hx
88
Investigating vaginal discharge?
Examination - speculum (retained FB), vaginal pH
High vaginal swab - wet mount, culture, gram stain: Canida and trichomonas vaginalis
Vulvovaginal swab: NAAT for N. gonorrhea and C. trachomatis
Endocervical swab: gonorrhea culture
HSV PCR from cervix if suspected, culture for other organisms if relevant (ie. pregnancy)
89
What can a high-end vaginal swab test for?
candida albicans
trichomonas vaginalis
90
What can a vuvlovaginal swab test for?
N. gonorrhea and C.trachomatis
91
What can an endocervical swab test for?
Usually used to culture n. gonorrhea
92
Candidiasis risk factors?
Immunosupression (HIV steroids, chemotherapy)
High oestrogen levels (pregnancy, luteal phase, COCPs)
DM
Recent antibiotics
Mucosal breakdown (sexual contact, dermatitis)
Reccurent candidiasis? associated with atopy
50% associated with additional dematoses
93
pH in candida infection?
Normal (<4.5)
94
Diagnosis of candidiasis?
Microbiological confirmation not required
Confirmatory tests if unsure may include:
Vaginal wall +/- vaginal swab - gram stained slide +/- culture in transport media
95
Most common organisms causing candidiasis?
Candida albicans (90%)
Candida glabrata (5%)
96
Causes of urethral discharge in males?
Chlamydia trachomatis
Neisseria gonorrhoeae
Non-specific uveitis
97
N. Gonorrhoea on gram stain
Gram negative intracellular diplococci
98
Most sensitive test for gonorrhea?
NAAT at genital site (urethral, vuvovaginal swab)
99
Treatment of Neisseria gonorrhoeae if antimicrobial sensitivity known?
Ciprofloxacin 500mg stat dose
100
Treatment of Neisseria gonorrhoeae if antimicrobial sensitivity unknown?
Ceftriaxone 1g IM (in 2ml 1% lidocaine) stat dose
101
NG alternative management?
Azithromycin PO or gentamycin IM
102
4 ws of sexual history
when
where
with whom
what with
103
What kind of virus is hepatitis B
double-stranded DNA hepadnavirus
104
What kind of virus is hepatitis b
double-stranded DNA hepadnavirus
105
How is hepatitis b transmitted
exposure to infected blood or body fluids, including vertical transmission from mother to child
106
Incubation period of hepatitis B
6-20 weeks
107
Acute hepatitis B infection
Asymptomatic in 10-50% adults
Prodrome/icteric phase but more prolonged than hep A (icteric phase- jaundice, anorexia, nausea, and fatigue (1-3 weeks)
Preceded by prodrome phase- flu like symptoms and RUQ
pain lasting 3-10 days)
108
What does the surface antigen show in Hepatitis B serology?
If the patient has hepatitis B
109
What does the core antigen show in Hepatitis B serology?
If the patient has been exposed to hepatitis B
110
What does the surface antibody show in Hepatitis B serology?
If the patient is immune to hepatitis B
111
Management of hepatitis B
Acute infection is notifiable
Acute infection is usually self-limiting
Refer persistent infection to hepatologist
Screen for other STI's/BBI and hepatitis variants (inc.delta)
Vaccinate against Hep A if not already immune
• Treatment depends on a number of factors including;
Age, LFTs, viral load, co-infections, biopsy findings
Treatment options inc;
Pegylated interferon alpha 2a
Antivirals
Entecavir
Tenofovir
112
Complications of hepatitis B
chronic hepatitis (5-10%). 'Ground-glass' hepatocytes may be seen on light microscopy
fulminant liver failure (1%)
hepatocellular carcinoma
glomerulonephritis
polyarteritis nodosa
cryoglobulinaemia
113
Anti Hbs >100
> 100 Indicates adequate response, no further testing required. Should still receive booster at 5 years
114
Anti Hbs 10-100
Suboptimal response - one additional vaccine dose should be given. If immunocompetent no further testing is required
115
Anti Hbs >10
Non-responder. Test for current or past infection. Give further vaccine course (i.e. 3 doses again) with testing following. If still fails to respond then HBIG would be required for protection if exposed to the virus
116
Hepatitis B in pregnancy
• Mother may require
antivirals if high viral
load
• Vaccinate neonate
• Consider HBIG if HR
117
Hep B contacts
Vaccination
• HBIG if recent (<7
days)
•Condoms/dental
dams until immune
- do not share toothbrushes or razors
118
OH risk assesment of Hep B exposed worker
Source patient
Risk factors
Known positives
Viral load
• Nature of exposure
Hollow vs solid needle
Size of bore
Gloves
Skin puncture / broken skin / intact skin / mucous membrane
Time to first aid measures
• Recipient - HBV vaccine status?
119
HSV 1 vs HSV 2
1: typically orofacial, 80% seropositivity in UK, 0-1 recurrences in first year, 60% pts recurrence in first year, recurrences after one year unusual
2: typically genital, aroun 7% seropositivity in UK, 4 mean recurrences in first year, 90% recurrence in first year, variable recurrence after one year
120
What are the stages of syphilis infection?
Primary
Secondary
Latent
Late
121
Primary phase of syphillis infection
10-90 days following exposure
Chancre lesion is the hallmark - usually on penis or labia, can also occur in oral mucosa and anus. Painless
Local lymphadenopathy
Disappears in 3-8 weeks without treatment
122
Latent syphilis
Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected.
Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.
123
Late syphillis
Neurosyphilis
Gumma (ulcerating granulomas on skin, bone and internal organs)
Aortic anyreusym, coronary arterirtis
124
What is this
chancre - primary syphillis
125
Management of syphillis
Benzathine Penicillin G 2.4 MU IM
Early (primary, secondary, early latent) - 1 weekly dose
Late latent, cardiovascular and gummatous syphillis - 3 weekly doses
Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections
126
Mpox course of disease
Incubation Period 5-21 days
Initialy fever, headache, muscle aches, backache, swollen LN,chills, exhaustion,joint pain
Then rash can develop 1-5 days after fever
127
Mpox transmission
Virus enters body through broken
skin/respiratory tract/ mucous membranes
› Not sexually transmitted but association with sexual contacts
128
Giant Aphthous Ulceration
"Lipschutz Ulcer"
129
Bechet syndrome
130
Fixed drug eruption
131
Erosive lichen planus
132
Donovanosis (Klebsiella granulomatis)
133
Chancroid
(Heamophilus
ducreyi)
134
Lymphogranulo
ma venereum
(Chlamydia
trachomatis L
serovar
135
What causes syphillis?
Syphilis is caused by bacteria called Treponema pallidum.
This bacteria is a spirochete, a type of spiral-shaped bacteria.
The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection.
136
Average incubation of syphilis
21 days
137
Transmission of syphilis
Oral, vaginal or anal sex involving direct contact with an infected area
Vertical transmission from mother to baby during pregnancy
Intravenous drug use
Blood transfusions and other transplants (although this is rare due to screening of blood products)
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Symptoms of neurosyphilis
Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
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Treatment of Candidal infection
Fluconazole 150mg stat
Clotrimazole 500mg pessary PV stat
Clotrimazole 1% (+/- hydrocortisone 1%) cream top BD for 2 weeks
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Recurrent candidiasis: > 4 symptomatic episodes/ year (management)
Induction followed by maintenance therapy
e.g: Fluconazole 150mg every 72 hours for 3 doses
then Fluconazole 150mg once a week for 6 months
Note low risk of hepatitis, OCP failure
Consider alternative regimens inc cetrizine 10mg OD
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Most common cause of abnormal vaginal discharge in women of child-bearing age?
Bacterial vaginosis - caused by Gardnerella Vaginalis (Gram-variable-staining facultative anaerobic bacteria)
142
BV precipitants
Precipitants:
Unprotected sexual intercourse
receptive oral sex
perfumed bath products, douching
menstruation
Not an STI but increases
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BV is not an STI but increases the risk of what?
HIV acquisition and transmission
144
How is bacterial vaginosis diagnosed?
Hay-Ison Criteria - based on a gram-stained smear of swab from posterior vaginal fornix
Amsel Criteria - 3 of any of the following
1. Characteristic discharge
2. Clue cells on wet mount -epithelial cells
3. Raised pH
4. Odour with KOH ("whiff test")
145
pH in BV
pH value of more than 4.5
146
How is BV treated
Metronidazole 400mg BD for 5 days
147
Bacterial vaginosis
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Appearance of discharge in Trichomonas Vaginalis
Frothy yellow-green
149
Trichomonas vaginalis diagnosis
Sample sites: posterior fornix
self-taken vulvo-vaginal swab
(urethra/centrifuged first void urine in men)
Wet mount:
70% sensitive compared to culture
degrades over time
Culture:
95% sensitive in women, 60-80% in men
NAATs:
98-100% sensitive
gaining popularity
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chlamydia trachomatis gram stain
gram-negative, anaerobic, intracellular obligates
coccoid or rod-shaped
Obligate intracellular bacterium - not visible
under light microscope
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Investigation of urethral discharge in men
Examination:
Gram-stained smear from urethra (having held urine) - Gram negative intracellular diplococci
Gonorrhea culture - if clinically suspicious
Urine NAAT for Gonorrhea and Chlamydia
Consider:
Microscopy of urine threads
wet smear for TV
MSU
Herpes simplex PCR
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Diagnosis of gonorrhoea
Microscopy: urethral specimens >90% sensitivity cervical specimens ≤50% sensitivity
NAAT:
>95% sensitivity at genital sites sensitive, but not specific, at non-genital sites
Gonorrhea culture: should be taken in all cases of NAAT- diagnosed gonorrhea prior to treatment
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Infective agents that may cause non specific urethritis (NSU)
Sexually transmitted Agents STIs:
• Chlamydia trachomatis (>60-70%)
• Mycoplasma genitalium
• Ureaplasma urealyticum
• Trichomonas vaginalis
• Herpes simplex
• HPV
Non-STI pathogens:
•Urinary tract pathogens (UTI)
.Adenovirus
Candida
154
Most common bacterial STI in the UK?
Chlamydia trachomatis
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Treatment of chlamydia
Doxycycline 100mg bd
OR
Extended Azithromycin
1 gm stat followed by 500mgms dailyx2 days
(3 day treatment)
Pregnancy;
Erythromycin 500 mgms four times daily for 7
days or 500 mgms BD x 2 weeks
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What is mycoplasma genitalium
Unique flask shaped slightly curved organelle
Smallest bacterium- Gram +ve
Difficult to culture in vitro
Insensitive to beta-lactams and emerging resistance to macrolides and quinolones
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mycoplasma genitalium presentation
Men with urethritis, epididymitis, proctitis first void urine
NGU 10-20%
NCNGU 10-35%
Women
vulvovaginal swab
signs/symptoms of PID
mucopurulent cervicitis (PCB)
Sexual partners of persons MG+ve (3mths)
TOC
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mycoplasma genitalium diagnosis
Specimens: first void urine, self-taken vaginal swab,
anal swab
NAATs testing
Assays available which detect mutations associated
with macrolide resistance
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Mycoplasma genitelium treatment
1st Line Doxycycline 7/7 PLUS Extended regimen:
Azithromycin 1gm stat
500mg once daily×2 days
Moxifloxacin 400mg od 10 days
PID/Epididymitis:
Moxifloxacin 14/7
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If a urethral smear shows 5 or more polymorphism per high power field with no evidence of gram negative diplodocus, what should be treated for?
Chlamydia infection with doxycycline (azithromycin if contraindicated)
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What is a Jarisch-Herxheimer reaction?
Acute febrile reaction associated with treatment of syphilis, managed with paracetamol and reassurance usually resolving within 24 hours
162
What will swabs of Gardnerella vaginalis show?
Squamous epithelial cells coated with large amounts of bacilli
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How does lymphogranuloma venereum present?
Single painless ulcer, unilateral inguinal lymphadenopathy
164
Management of lymphogranuloma venereum?
Doxycycline
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Management of gonorrhoea
The new first-line treatment is a single dose of IM ceftriaxone 1g (i.e. no longer add azithromycin).
If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given
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What is first-line for non-pregnant women with vaginal thrush
Oral fluconazole single-dose
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What is the Amstel criteria
Diagnosing BV
A thin, white, yellow, homogeneous discharge,
A vaginal fluid pH of over 4.5 when placing the discharge on litmus paper
The release of fishy odour when potassium hydroxide is added - sometimes referred to as the 'whiff test'
Clue cells visualised on wet-mount microscopy
The presence of 3 or more of these criteria is sufficient to make a diagnosis of bacterial vaginosis. The treatment of choice is a short course of oral metronidazole.
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What causes BV
caused by a loss of the lactobacilli “friendly bacteria” in the vagina
Organism: anaerobic organisms such as
gardnerella vaginalis, (most common)
Mycoplasma hominis
Prevotella species
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Risk factors for bacterial vaginosis
Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
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How does BV present
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
A speculum examination can be performed to confirm the typical discharge, complete a high vaginal swab and exclude other causes of symptoms. Examination is not always required where the symptoms are typical, and the women is low risk of sexually transmitted infections.
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Clue cells on microscopy
BV
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How is ?BV investigated
Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
A standard charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
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Management of BV
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
Metronidazole is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.
Always assess the risk of additional pelvic infections, with swabs for chlamydia and gonorrhoea where appropriate.
Provide advice and information about measures that can reduce the risk of further episodes of bacterial vaginosis, such as avoiding vaginal irrigation or cleaning with soaps that may disrupt the natural flora.
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First line antibiotic for BV
Metronidazole
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Potential complications of bacterial vaginosis?
Bacterial vaginosis can increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
It is also associated with several complications in pregnant women:
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis
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Candidiasis risk factors
Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
Poorly controlled diabetes
Immunosuppression (e.g. using corticosteroids)
Broad-spectrum antibiotics
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Presentation of vaginal candidiasis
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
More severe infection can lead to:
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation
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Investigations for ?candidiasis
Often treatment for candidiasis is started empirically, based on the presentation.
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
A charcoal swab with microscopy can confirm the diagnosis.
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BV vs candidiasis pH
bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
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Candidiasis - delivery of treatment
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
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Treatment options for initial unconolicated cases of candidiasis
A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
A single dose of clotrimazole pessary (500mg) at night
Three doses of clotrimazole pessaries (200mg) over three nights
A single dose of fluconazole (150mg)
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Recurrent candidiasis management
recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications.
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What should you warn sexually active women being treated for thrush
Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
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Chlamydia causative organism
Chlamydia trachomatis - gram-negative bacteria - intracellular organism
185
What is tested for when a patient presents to GUM clinic for STI screening
Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)
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What are charcoal swabs used for
Charcoal swabs allow for microscopy (looking at the sample under the microscope), culture (growing the organism) and sensitivities (testing which antibiotics are effective against the bacteria)
Microscopy involves gram staining and examination under a microscope. A stain is used to highlight different types of bacteria with different colours. Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS). Charcoal swabs can confirm:
Bacterial vaginosis
Candidiasis
Gonorrhoeae (specifically endocervical swab)
Trichomonas vaginalis (specifically a swab from the posterior fornix)
Other bacteria, such as group B streptococcus (GBS)
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What are Nucleic acid amplification tests (NAAT) used for
Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism.
NAAT testing is used to test specifically for chlamydia and gonorrhoea.
They are not useful for other pelvic infections (except where specifically testing for Mycoplasma genitalium).
In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample.
The order of preference is endocervical, vulvovaginal, and then urine.
In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab.
Rectal and pharyngeal NAAT swabs can also be taken to diagnose chlamydia in the rectum and throat. Consider these swabs where anal or oral sex has occurred.
Where gonorrhoea is suspected or demonstrated on a NAAT test, an endocervical charcoal swab is required for microscopy, culture and sensitivities.
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When should chlamydia be considered in women
The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
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When should chlamydia be considered in men
Consider chlamydia in men that are sexually active and present with:
Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis
It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.
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What STIs should be considered in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits?
rectal chlamydia
lymphogranuloma venereum
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How is chlamydia diagnosed
Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia. This can involve a:
Vulvovaginal swab
Endocervical swab
First-catch urine sample (in women or men)
Urethral swab in men
Rectal swab (after anal sex)
Pharyngeal swab (after oral sex)
192
First line treatment for chlamydia
First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.
193
Management of chlamydia in pregnant or breastfeeding women
Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are:
Azithromycin 1g stat then 500mg once a day for 2 days
Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days
194
In which patients is a test of cure following chlamydia treatment reccomended
A test of cure is not routinely recommended. However, a test of cure should be used for rectal cases of chlamydia, in pregnancy and where symptoms persist.
195
Considerations when treating patients for chlamydia
Advise pt to Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
Test for and treat any other sexually transmitted infections
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse in children and young people
196
Complications of chlamydia infection
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
Pregnancy-related complications include:
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
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What is lymphogranuloma venereum
Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages
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What are the stages of Lymphogranuloma Venereum
The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex.
The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected.
The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.
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Lymphogranuloma Venereum management
Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.
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What is chlamydiyal conjunctivitis
Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.
Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.
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Causative organism in gonorrhoea
Neisseria gonorrhoeae is a gram-negative diplococcus bacteria.
It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas.
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Presentation of gonorrhoea
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with:
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain
Male genital infections can present with:
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)
Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge.
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What swab(s) are used in diagnosis of gonorrhoea
Nucleic acid amplification testing (NAAT) is used to detect the RNA or DNA of gonorrhoea. Genital infection can be diagnosed with endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas.
A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.
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Management of gonorrhoea
Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known. For uncomplicated gonococcal infections:
A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
Different regimes are recommended for complicated infections, infections in other sites and pregnant women. Most regimes involve a single dose of intramuscular ceftriaxone.
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Test of cure following gonorrhoea infection treatment
72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT
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Complications of gonorrhoea infection
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis
A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.
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What is disseminated gonococcal infection and how does it oresent
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue
208
Mycoplasma genitallium presentation
Urethritis
Epididymitis
Cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility
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Investigating mycoplasma genitallium
Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves nucleic acid amplification tests (NAAT) to look specifically for the DNA or RNA if the bacteria.
The samples recommended by BASHH guidelines (2018) are:
First urine sample in the morning for men
Vaginal swabs (can be self-taken) for women
The guideline recommends checking every positive sample for macrolide resistance, and performing a “test of cure” after treatment in every positive patient.
210
Management of mycoplasma genitallium
The BASHH guidelines (2018) recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections:
Doxycycline 100mg twice daily for 7 days then;
Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).
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What is Parametritis
is inflammation of the parametrium, which is the connective tissue around the uterus
212
What causes PID
Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:
Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium
Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as:
Gardnerella vaginalis (associated with bacterial vaginosis)
Haemophilus influenzae (a bacteria often associated with respiratory infections)
Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
213
Risk factors for PID
Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
214
Presentation of PID
Women may present with symptoms of:
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
Examination findings may reveal:
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Patients may have a fever and other signs of sepsis.
215
Investigating PID
Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections:
NAAT swabs for gonorrhoea and chlamydia
NAAT swabs for Mycoplasma genitalium if available
HIV test
Syphilis test
A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.
A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.
Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.
216
Complications of PID
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
217
What is trichomonas vaginalis
Trichomonas vaginalis is a type of parasite spread through sexual intercourse.
Trichomonas is classed as a protozoan, and is a single-celled organism with flagella. Flagella are appendages stretching from the body, similar to limbs.
Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism.
The flagella are used for movement, attaching to tissues and causing damage.
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
218
What does infection with trichomoniasis vaginalis increase the risk of
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
219
Presentation of trichomoniasis
Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:
Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.
Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.
220
Diagnosis of trichomoniasis
The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).
Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.
A urethral swab or first-catch urine is used in men.
221
Management of trichomoniasis
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with metronidazole.
222
Presentation of genital herpes
Patients affected by herpes simplex may display no symptoms, or develop symptoms months or years after an initial infection when the latent virus is reactivated.
The symptoms of an initial infection with genital herpes usually appear within two weeks. The initial episode is often the most severe, and recurrent episodes are milder.
Signs and symptoms include:
Ulcers or blistering lesions affecting the genital area
Neuropathic type pain (tingling, burning or shooting)
Flu-like symptoms (e.g. fatigue and headaches)
Dysuria (painful urination)
Inguinal lymphadenopathy
Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.
223
What herpes virus is associated with cold sores
HSV1
224
Diagnosis of genital herpes
Ask about sexual contacts, including those with cold sores, to establish a possible source of transmission. They may have caught the infection from someone unaware they are infected and not experiencing any symptoms.
The diagnosis can be made clinically based on the history and examination findings.
A viral PCR swab from a lesion can confirm the diagnosis and causative organism.
225
Management of genital herpes
Where appropriate, patients should be referred to a genitourinary medicine (GUM) specialist service.
Aciclovir is used to treat genital herpes. There are various aciclovir regimes listed in the BNF, depending on the individual circumstances. Alternatives are valaciclovir and famciclovir.
Additional measures, including to manage the symptoms include:
Paracetamol
Topical lidocaine 2% gel (e.g. Instillagel)
Cleaning with warm salt water
Topical vaseline
Additional oral fluids
Wear loose clothing
Avoid intercourse with symptoms
226
Concerns re pregnancy and genital herpes
. The main issue with genital herpes during pregnancy is the risk of neonatal herpes simplex infection contracted during labour and delivery. Neonatal herpes simplex infection has high morbidity and mortality. Neonatal infection should be avoided as much as possible and treated early if identified.
227
Management of primary genital herpes contracted prior to 28 weeks pregnancy
Primary genital herpes contracted before 28 weeks gestation is treated with aciclovir during the initial infection. This is followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery. Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection). Caesarean section is recommended when symptoms are present.
228
Management of primary genital herpes contracted later than 28 weeks pregnancy
Primary genital herpes contracted after 28 weeks gestation is treated with aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection.
229
Management of recurrent genital herpes in pregnancy
Recurrent genital herpes in pregnancy, where the woman is known to have genital herpes before the pregnancy, carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery. Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery.
After an initial infection with genital herpes, the woman will develop antibodies to the virus. During pregnancy, these antibodies can cross the placenta into the fetus. This gives the fetus passive immunity to the virus, and protects the baby during labour and delivery.
230
The incubation period between the initial infection and symptoms in syphillis is what on average
21 days
231
How can syphilis be transmitted
Oral, vaginal or anal sex involving direct contact with an infected area
Vertical transmission from mother to baby during pregnancy
Intravenous drug use
Blood transfusions and other transplants (although this is rare due to screening of blood products)
232
Stages of syphilis
Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals).
Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage.
Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.
Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.
Neurosyphilis occurs if the infection involves the central nervous system, presenting with neurological symptoms.
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Over what time period does a chancre resolve
3-8 weeksq
234
Secondary syphilis features
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions
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Tertiary syphilis lesions
Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis
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Neurosyphilis features
Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of:
Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
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Diagnosis of syphilis
Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.
Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing.
Samples from sites of infection can be tested to confirm the presence of T. pallidum with:
Dark field microscopy
Polymerase chain reaction (PCR)
The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests are two non-specific but sensitive tests used to assess for active syphilis infection. These tests assess the quantity of antibodies being produced by the body to an infection with syphilis. A higher number indicates a greater chance of active disease. These tests involve introducing a sample of serum to a solution containing antigens and assessing the reaction. A more significant reaction suggests a higher quantity of antibodies. The tests are non-specific, meaning they often produce false-positive results. There is a skill to both performing and interpreting the results of these tests.
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Syphilis management
All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need:
Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections
A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.
Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. Ceftriaxone, amoxicillin and doxycycline are alternatives.
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What is Chemsex and what drugs are usually implicated
“Chemsex” is used in the United Kingdom to describe intentional sex under the influence of psychoactive drugs, mostly among men who have sex with men. It refers particularly to the use of mephedrone, γ-hydroxybutyrate (GHB), γ-butyrolactone (GBL), and crystallised methamphetamine.3
