GUM Flashcards
What is bacterial vaginosis?
vergrowth of anaerobic bacteria in vagina.
Gardnerella vaginalis, mycoplasma hominis, prevotella species.
Loss of lactobacilli ‘good bacteria’ that produces lactic acid, keeps vaginal pH <4.5 to stop other bacteria overgrowing.
RF: multiple sexual partners (not STI), XS vaginal cleaning, smoking, recent Abx, copper coil.
Protective: COCP, condom
Features of bacterial vaginosis?
Fishy smelling discharge
Amsel’s criteria:
> 3 present
> Thin, white/ grey homogenous discharge
> Clue cells on microscopy, strippled vaginal epithelial cells
> Vaginal pH >4.5
> Pos Whiff test (addition of K hydroxide > fishy odour).
Complications of BV?
Co infection: candidiasis, chlamydia gonorrhoea
Pregnancy: miscarriage, preterm delivery, PROM, chorioamnionitis, LBW, PP endometritis
> 50% relapse rate within 3 mnths
Investigation for BV?
Speculum
high vaginal swab.
Management of BV?
Asymptomatic: no Tx
Metronidazole: 5-7 days oral
Topical clindamycin or metronidazole as alternatives
What is trichomoniasis vaginalis?
Parasite spread through sexual intercourse.
Protozoan single cell + flagella
Lives in urethra + vagina.
Features of trichomoniasis vaginalis?
Asymptomatic
Nonspecific
Discharge: frothy, yellow green
Vulvovaginitis
Dysuria, itching
Dyspareunia
Balanitis: inflam of glans penis
Men: urethritis
Complications of trichomoniasis vaginalis?
BV
HIV
PID
Cervical Ca
Preterm delivery
Investigations of trichomoniasis vaginalis?
Strawberry cervix: colpitis macularis, cervicitis, tiny haem.
Vaginal pH: >4.5
Charcoal swab, microscopy: microscopy of wet mount > motile trophozoites
Endocervical swab: post fornix
Urethral swab + 1st catch urine men
Management of trichomoniasis vaginalis?
GUM referral, contact tracting.
Metronidazole: oral for 5-7 days or 1 off 2g dose.
What is candidiasis?
Candida albicans. Can colonise w/o causing Sx, progress to infection when environment right > preg, Tx with broad spec Abx
RF: ↑oest, DM, IC (CS, HIV)
Features of candidiasis?
Thick, white discharge > cottage cheese
No smell
Vulval, vaginal itching, irritation, discomfort
Complications of candidiasis?
Erythema
Fissures
Oedema
Dysuria, dyspareunia
Excoriations
Satellite lesions
Investigations of candidiasis?
Vaginal pH <4.5
Charcoal swab + microscopy
Management of candidiasis?
Oral fluconazole: 150mg (CI in pregnancy)
Single dose of 500mg clotrimazole pessary at night
Clotrimazole cream 1 or 2%, 2-3 times a day.
Canesten duo OTCH: fluconazole tablet + clotrimazole cream
Recurrent infections: >4 in 1 yr. High vaginal swab, blood glucose. Induction + maintenance regime over 6 months Induction: oral fluconazole every 3 days for 3 dose, maintenance: oral fluconazole weekly for 6 months.
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
What is chlamydia?
Gr- bacteria. Intracellular
RF: young, sexually active, multiple sexual partners.
Incubation: 7-21 days.
Features of chlamydia?
F: asymptomatic, abnormal vaginal discharge, yellow or cloudy, pelvic pain, abnormal vaginal bleeding (IMB, PCB), dyspareunia, dysuria
M: urethral discharge/ discomfort, dysuria
Anorectal: discomfort, discharge, bleeding, change in bowel habits
Lymphogranuloma venerum: MSM, painless ulcer, swelling inflam, pain of rectum + anus > change in bowel habits, tenesmus + discharge.
Complications of chlamydia?
Epididymo-orchitis
Reactive arthritis
PID
Infertility
Chronic pelvic pain
Prostatitis
Ectopics
Perihepatitis: Fitz-Hugh Curtis synd
Conjunctivitis: chronic erythema, irritation + discharge (>2wks), unilat, young adults + neonates.
Preterm, PROM, LBW, PP endometritis, neonatal infection (conjunctivitis + pneumonia)
Investigations for chlamydia?
Screening: every sexually active person <25 annually or when change sexual partners.
NAAT test: vulvovaginal, endocervical or 1st catch urine sample
Chlamydia testing should be carried out 2 wks after possible exposure
Test for cure: 3mnths after Tx.
Management of chlamydia?
Doxycycline 100mg BD 7 days. CI BF + preg.
2nd: azithromycin (1g for 1 day, 500mg OD for 2 days)
Pregnant: azithromycin, erythromycin, amoxicillin
Abstain from sex for 7 days of Tx
Men with urethral Sx: all contacts since + 4wks prior to onset.
Woman + asymptomatic men: all partners from last 6mnths or most recent sexual partner.
What is Neisseria gonorrhoea?
Gr- diplococcus
Incubation: 2-5 days
RF: multiple sexual partners, drug use, prior STI, MSM.
Features of gonorrhoea?
F: less symptomatic, odourless, purulent discharge (green/ yellow), dysuria, pelvic pain, cervical friability (cervicitis).
M: odourless purulent discharge, dysuria, testicular pain or swelling. Tenderness/ swelling of epididymis
Rectal: anal/rectal discomfort, discharge anal pruritis, tenesmus rectal bleeding
Pharyngeal: sore throat, ant cervical lymphadenopathy
Prostatitis: perineal pain, urinary Sx, prostate tenderness.
Conjunctivitis: erythema, purulent, discharge
Fever
Complications of gonorrhoea?
PID
Chronic pelvic pain
Infertility, salpingitis
Epididimo-orchitis
Urethral strictures
Disseminated untreated, bacteria spreads to skin + joints. Migratory polyarthritis + dermatitis, polymyalgia, tensosynovitis, fever + fatigue
Skin lesions
Fitz-Hugh-Curtis syndrome: inflam of liver capsule leading adhesions
Septic arthritis
Endocarditis
Meningitis
Conjunctivitis > neonates. Opthalmia neonatorum, medical emergency, sepsis, perforation of eye, blindness
reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)
Investigations for gonorrhoea?
NAAT: endocervical vulvovaginal or urethral swabs, 1st catch urine.
MC+S.
Urinalysis in men: pos leukocyte esterase
Follow up test: NAAT if asymptomatic, cultures if symptomatic. 72 hrs post Tx > culture, 7 days after Tx > RNA, NAAT. 14 days after Tx DNA + NAAT.
Management of gonorrhoea?
Uncomplicated: IM ceftriaxone 1g if sensitivities unknown, if sensitivities known + sensitive to ciprofloxacin 500mg.
If ceftriaxone refused: oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose).
Complicated: ceftriaxone + doxycycline
Disseminated: add azithromycin
Features of disseminated gonococcal infection
- tenosynovitis
- migratory polyarthritis
- dermatitis (lesions can be maculopapular or vesicular)
Summary of genital warts?
caused by the many varieties of the human papillomavirus HPV, especially types 6 & 11.
Features
- small (2 - 5 mm) fleshy protuberances which are slightly pigmented
- may bleed or itch
Management
- topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion
> multiple, non-keratinised warts are generally best treated with topical agents
> solitary, keratinised warts respond better to cryotherapy
- imiquimod is a topical cream that is generally used second line
- genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
- surgical removal
What is pneumocystis jiroveci?
Unicellular eukaryote, most common opportunistic infection in AIDs.
All pts CD4 <200/mm3
Sx:
Dyspnoea, dry cough
Fever
Very few chest signs
Complications: Pneumothorax Hepatosplenomegaly Lymphadenopathy Choroid lesions
Investigations:
CXR: bilat interstitial pul infiltrates
Exercise induced desat
Sputum often fails to show PCP, bronchoalveolar lavage often needed
Management:
All pts CD4 <200/mm3 should receive PCP prophylaxis.
Cotrimoxazole
IV pentamidine
Aerosolised pentamidine. Less effective with risk of pneumothorax
Steroids if hypoxic
Neuro complications of HIV?
Toxoplasmosis 50% of cerebral lesions in pts with HIV Headache, confusion, drowsiness CT: single/ multiple ring enhancing lesions, mass effect, thallium SPECT neg Tx: sulfadiazine, pyrimethamine
1° CNS lymphomas
30% cerebral lesions. EBV associated
CT: single or multiple homogenous (solid) enhancing lesions, SPECT post.
Tx: steroids, chemo (methotrexate), irradiation, surgery.
Tuberculosis: less common, single enhancing lesion.
Encephalitis: CMV or HIV itself. CT: oedema brain.
AIDS dementia complex: HIV itself Behav changes. Motor impairment. CT: cortical + subcortical atrophy
Cryptococcus
Most common fungal infection of CNS.
Headache, fever, malaise, N/V, seizures focal neurological deficit.
CSF: high opening pressure, india ink pos.
CT: meningeal enhancement, cerebral oedema. May cause SOL.
Progressive multifocal leukoencephalopathy
Widespread demyelination. Due to infection of oligodendrocytes by JC virus (a polyoma DNA virus)
Subacute onset, behav changes, speech, motor, visual impairment
CT: single or multiple lesions, no mass effect, don’t usually enhance.
MRI: better, high signal demyelination, white matter lesion seen
What is HIV?
AIDS: 10-15yrs
3 stages: acute infection, clinical latency, AIDS
Virus attaches to CD4 receptor on host cell (t lymphocytes, macrophages, monocyte, dendritic cells), with gp120
Features of HIV?
2-6wks after infection Sore throat, ulceration, painful swallowing Lymphadenopathy Malaise, myalgia, arthralgia D/N, WL Maculopapular rash Mouth ulcers Rarely meningoencephalitis
Diarrhoea: HIV enteritis or opportunistic cases. Cryptosporidium + other protoxoa, CMV, mycobacterium avum, intracellular, giardia.
Cryptosporidium: most common, intracellular protozoa, 7 day incubation. Mild-severe diarrhoea. Modified Ziehl-Neelsen stain of stool may reveal red cysts. Tx difficult, mainly supportive.
Mycobacterium avium intracellulare: atypical mycobacteria in CD4 <50. Features: fever, sweats, abdo pain, diarrhoea. Hepatomegaly, deranged LFTs. Blood cultures + BM exam. Tx: rifabutin, ethambutol + clarithromycin.
Complications of HIV?
Pregnancy: vaginal delivery if viral load <50 copies/ml at 36 wks. Zidovudine infusion started 4hrs before CS. Zidovudine administered orally to neonate if maternal load <50copies.ml, otherwise triple ART used, therapy for 4-6wks. Advised not to BF
Kaposi’s sarcoma: HHV-8, purple papules or plaques on skin or mucosa (GIT, RT), tumour of vascular + endothelium, skin lesions may ulcerate. Resp involvement may cause massive haemoptysis + pleural effusion. Radiotherapy + resection.
Oesophageal candidiasis: CD4<100 dysphagia, odynophagia. Tx: fluconazole, itraconazole
Investigation for HIV?
HIV antibodies: ELISA + Western blot assay
P24 antigen: viral core protein, early in blood as RNA levels↑.
Combination HIV p24 + HIV IG: if pos repeat to confirm. If asymptomatic 4wks after poss exposure repeat at 12 wks if initial neg.
Post Tx: viral RNA load, CD4+ count, CD4+:CD8 ratio.
Start ART as soon as diagnosed
Management of HIV?
Pre-exposure prophylaxis PrEP, if sig risk for HIV, daily dose, prevent infection, useful in IVDU
Post-exposure prophylaxis: PEP, HIV neg who have been exposed. Tenofovir, emtricitabine, lopinavir + ritonavir ASAP up t0 72hrs following exposure. For 4wks
2 NRTI + PI or NNRTI or INI or 3NRTI
NRTI: zidovudine, lamivudine, abacavir. Emtricitabine, didanosine, stravudine, zalcitabine, tenofovir.
NNRTI: nevirapine, efavirenz, delavirdine.
Protease inhibs: indinavir, nelfinavir, ritonavir, saquinavir.
Integrase inhibs: block action of integrase. Raltegravir, elvitegravir, dolutegravir. SE: ↑CK
Entry inhibs: enfuvirtide, maraviroc.
What is genital herpes?
HSV-2 but there is overlap
Initial infection > latent in sensory nerve ganglia (trigeminal cold sores, sacral in genital).
Features of genital herpes?
Asymptomatic
2 wks after infection
Ulcers or blistering lesions, vesicular, painful, genital ulceration.
Aphthous ulcers, small painful. Mouth
Neuropathic pain: tingling, burning, shooting.
Flu like Sx: fatigue, headache
Dysuria, urinary retention (pain + autonomic neuropathy)
Complications of herpes?
Herpes keratitis: inflam of cornea, dendritic corneal ulcer, painful red eye, photophobia, epiphora, visual acuity ↓. Immediate opthalmology referral topical acyclovir.
Herpetic whitlow: painful skin lesion on finger + thumb
Pregnancy: risk of neonatal herpes simplex during labour
Investigations for herpes?
NAAT
HSV serology
Management of herpes?
GUM referral
Acyclovir
Chlorhexidine mouth wash
Tx of Sx: paracetamol, topical lidocaine (2% gel), clean with warm salt water, topical Vaseline, oral fluids, wear loose clothing, avoid intercourse
Pregnancy
1° <28wks: acyclovir from 36 wks, if asymptomatic at delivery can do vaginal, CS preferred
1° >28wks: acyclovir immediately, elective c-section at term preferred
Recurrent: regular prophylactic acyclovir from 36 wks gestation
What is syphilis?
a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages.
The incubation period is between 9-90 days
Transmission: oral, vaginal anal sex, mother to baby, IVDU, blood transfusion, transplants.
Latent: asymptomatic, 2yrs + onwards
Features of syphilis?
Primary features
- chancre - painless ulcer at the site of sexual contact
- local non-tender lymphadenopathy
- often not seen in women (the lesion may be on the cervix)
Secondary features - occurs 6-10 weeks after primary infection
- systemic symptoms: fevers, lymphadenopathy
- rash on trunk, palms and soles
- buccal ‘snail track’ ulcers (30%)
- condylomata lata (painless, warty lesions on the genitalia )
Tertiary features gummas (granulomatous lesions of the skin and bones) ascending aortic aneurysms general paralysis of the insane tabes dorsalis Argyll-Robertson pupil
Features of congenital syphilis
blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
Complications of syphilis?
Tabes dorsalis > ataxia
Neurosyphilis: headache, altered behav, dementia, paralysis, sensory impairment, Argyll Robertson pupil (constricted pupil, accommodates when focusing on near object but doesn’t react to light), altered mood, confusion.
Pregnancy: IUGR, spont abortion, stillbirth, premature labour.
Management of syphilis?
Single deep IM benzathine benpen. Alternatives > doxycycline.
Late + neurosyphilis: ceftriaxone, amoxicillin, doxycycline.
Congen: IV aqueous benpen or IM procaine benpen
Jarisch-Herxheimer reaction: following Tx, fever, rash, ↑HR, after 1st dose of Abx, no wheeze of hypotension. Release of endotoxins following bacterial death. Typically within few hrs of Tx. No tx other than antipyretics.
Cardiolipin false pos pregnancy, SLE, APS TB, leprosy, HIV, malaria.
What is mycoplasma genitalium?
Non-gonococcal urethritis
Bacteria.
Can also be caused by chlamydia trachomatis
Features of mycoplasma genitalium?
Similar to chlamydia
Urethritis
Dysuria
Pain on ejaculation
Watery/cloudy discharge (onset of Sx between 4 days + wks after contact)
Proctitis
Bleeding between periods
Lower abdo pain
Dyspareunia
Urethral irritation or itching between voids
Orchialgia (heaviness in male genitals)
Complications of mycoplasma genitalium?
Epididymitis
Orchitis
Cervicitis
Endometriosis
PID
Reactive arthritis
Preterm delivery
Tubal infertility
Investigations for mycoplasma genitalium?
Slow growing swabs + culture not useful
NAAT: 1st urine sample for men, vaginal swabs for women.
Check every pos sample for macrolide resistance
Test for cure
Investigations for mycoplasma genitalium?
Slow growing swabs + culture not useful
NAAT: 1st urine sample for men, vaginal swabs for women.
Check every pos sample for macrolide resistance
Test for cure
Management of mycoplasma genitalium?
Doxy 100mg BD for 7 days (CI in pregnancy + BF)
Azithromycin 1g stat then 500mg OD for 2 days, pregnancy + BF.
Moxifloxacin: 499mg daily for 10 days complicated infections
Pregnant: azithromycin of amoxicillin
