GUM Flashcards
HSV 1 and 2 causing anogenital/oral infections
HSV 1 is most commonly associated with oral infection (coldsores), and is now the most common cause of anogenital infections in the UK
HSV 2 can cause oral but is mostly associated with anogenital infections, it is the most common cause of recurrent anogenital infections.
R/Fs for HSV transmission?
Multiple sexual partners
Prev STI
Unprotected sexual encounters
Multiple sexual partners
Early age of sexual first contact
MSM
Female gender
HIV infection
Primary infection presentation of HSV?
The first time the virus presents, may be asymptomatic
Febrile flu symptoms (5-7 days)
Tingling neuropathic pain in buttocks/genital area
Painful blisters and ulcers
Tender lymph nodes
Local oedema
Dysuria
Vaginal/urethral discharge
Can last up to four weeks.
Usually bilateral lesions
Presentation of recurrent HSV infection?
Usually unilateral
Last about 10 days, usually mild and may be self-limiting
Can be asymptomatic shedding (infective at this point)
Tests for HSV?
Viral culture
Swab & PCR
Serology (however take 12 weeks after primary infection)
HSV infection management?
Supportive:
- Saline bathing
- Oral analgesics
- Lidocaine gel/cream
- Pee while in a bath
Antiretroviral:
- Topicals not very good and not recommended
Primary: Acyclovir (400mg TDS) 5d
Recurrence: Acyclovir 800mg TDS 2d
Suppressive: Acyclovir 400mg BD PO
Types of HPV?
120 HPV types, 30 cause anogenital infection
16 & 18 are oncogenic (cervical cancer risk)
Non oncogenic (warts) 6 & 11
Difference in keratinised and non-keratinised genital warts?
Non-keratinised arise from areas of mucosa i.e. urethra, anus and vagina
Keratinised arise from keratinised epithelium (e.g. coronal sulcus (bit just below foreskin, labia)
Management of warts?
Should be referred to sexual health clinic always, as can more accurately test for other STIs, and may be able to contact trace.
All treat growth, not HPV infection:
Podophyllotoxin self application:
- Non-keratinised warts
- NO IN PREGNANCY
Imiquimod:
- Kertinised/non-keratinised
- NO PREGNANCY
- Expensive
- Hyper/hypopigmentation
Physical ablation (Hyfrecation, cryo and excision)
- safe in pregnancy
-
R/Fs for HPV infection
Smoking
Multiple sexual partners
Early loss of virginity
Other STIs
Anoreceptive intercourse
Manual sexual practices (fisting, fingering)
Immunosuppression
Viral STIs?
HPV HSV HIV Molluscum contagiosum EBV Hepatitis (A-E)
What cells does HIV bind to?
CD4 positive cells, this includes t-helper cells, macrophages, monocytes and neural cells.
What specific marker predicts risk of progression to AIDS in HIV+ individuals?
Viral load.
Stages of HIV infection?
Seroconversion illness
- initial presentation, 4-6 weeks after infection
- Triad of Rash, Fever and pharyngitis
- Increased inflammatory markers
Asymptomatic
- Can have lymphadenopathy
Symptomatic
- Fever, diarrhoea, weight loss, night sweats
- Opportunistic infections
AIDS:
- severe immunodeficiency
Investigations?
Detection of anti-HIV antibodies (ELISA) - diagnostic
Viral load assessment
FBC: may see anaemia, thrombocytopaenia, lymphocytopaenia, reduced CD4 cell count.
Raised ESR,
Assess for other infections and other STIs
CXR & cervical smear
Three satges of HIV infection and their CD4 count?
Early CD4 > 500
Symptomatic CD4 200-499
Complications 50-199
Some complications typically associated with a CD4 count 50-200?
Oral & oesophageal candidiasis
Cervical dysplasia (cervix)
PCP pneumonia
Kaposi sarcoma/lymphoma
Mycobacteria avium intercellulare
Histoplasmosis
What infection can seriously complicate treatment of AIDS?
Hepatitis
Late stage complications in HIV?
Cervical cancer
CMV retinitis
Disseminated mycobacterium avium intercellulare
Cerebral toxoplasmosis
Primary brain lymphoma
Multifocal leuko-encephalopathy and dementia
General management of HIV+ patients?
Make early diagnosis
ART (anti-retroviral Therapy)
Prophylaxis if CD4 < 200
Reduce transmission
prevent and treat long term complications
General categories of ART drugs in HIV?
Entry inhibitors
NRTIs (nucleoside reverse transcriptase inhibitors)
Non-NRTIs
Protease inhibitors
Integrase inhibitors
Prevention for HIV?
Behavioural:
- Condoms
- Abstinence
- Sero-sorting
Medical:
- Circumcision
- Treatment as prevention
- Prevention of mother to child transmission
- PEP/PEPSE (post exposure prophylaxis)
- PREP (pre exposure prophylaxis)
How effective is treatment as prevention?
Pretty effective about 96% has no transmission
In occupational needle stick injury what factors may make you consider PEP?
Deep injury
Visible blood on device
Injury with needle been in artery or vein
Terminal HIV related illness/ high viral load
Large volume blood transferred
Time window for PEP?
72 hours
6 point plan for STIs?
Make diagnosis
Treat infection
Exclude other infections
Screen contacts
Test of cure
Patient education
HIV Risk Factors?
MSM IVDU Large HIV infection prevalence in area where they are from Been paid/paid for sex Condomless sex Partner positive (Illicit drugs)
Causative organism for gonorrhoea?
Neisseria gonorrhoea
Complications of gonorrhoea infection?
Complications worse in women
Dissemination
PID (infertility)
Conjunctivitis
Perihepatitis
Bartholin’s abscess
Diagnosis of gonorrhoea?
Nucleic acid (urine/swab)
Culture
Microscopy (only really if urethritis)
Areas gonorrhoea and chlamydia may infect?
Rectum
Urethra
Pharyngeal
Endocervical (in women)
Genital gonorrhoea presentation?
- discharge (80% in men)
- dysuria (can be bad)
- proctitis
Women can be asymptomatic (50-70%), small number have pelvic pain.
Management of gonorrhoea?
6 point plan
Diagnose: NAAT (nucleic acid)
Treat: check local sensitivities, however: ceftriaxone 500mg IM stat plus azithromycin 1 g orally stat.
Screen for others (60% will have)
Contact tracing
TOC (>72 hours culture, 2 weeks NAAT)
Educate (condoms etc.)
Causative organism for chlamydia?
Chlamydia trachomatis
Chlamydia and Gonorrhoea gram positive or negative?
Negative
Chlamydia symptoms?
Can often be asymptomatic
Female:
- Discharge
- Dysuria
- Vague lower abdo pain
- Fever
- Deep dyspareunia
Men:
Classically urethritis with dysuria and urethral discharge or unilateral testicular pain & swelling (epididymo-orchitis)
Can also be rectal, pharyngeal and present as reactive arthritis.
Chlamydia signs?
Female:
- inflamed cervix
- discharge
- abdo tenderness
- adnexal tenderness (uterine pain)
- cervical excitation
Male:
- Epididymal tenderness.
- Mucoid or mucopurulent discharge.
- Perineal fullness due to prostatitis.
Testing for chlamydia?
NAATS tests
First catch urine for men
Vulvovaginal swab for women
Treatment for chlamydia?
1g STAT azithromycin
Doxy 100mg BD for 7 days
What is mycoplasma genitalium?
Very low grade bacterium causing similar problems to chlamydia, picked up on NAATS, hard to culture.
Causative organism of syphilis?
Treponema Pallidum
Complications of chlamydia?
Endometritis Salpingitis PID Infertility (need a few infections) Ectopic preg Fitz-curtis (abdominal pain - perihepatitis) Reactive arthritis
What is NSU?
non-gonococcal, non-chlamydial urethritis
Normally due to Mycoplasma
Risks of chlamydia in pregnancy?
Transmission to the newborn:
- eyes
- chlamydial pneumonitis
Symptoms of chlamydial pneumonitis in the newborn?
Staccato cough
Failure to thrive
Tachypnoea
Disseminated gonococcal infection presentation?
Rare
Females
Fever, rash
Arthritis, tendonitis
Genital lump Ddx?
Normal anatomy
Sebaceous cyst, or other benign cause
STIs:
- Molluscum
- Warts
- Papular or nodular phase: Syphilis, LGV, Scabies, Herpes)
Procto-colitis causative organisms? When does this occur? What does it cause?
Generally in MSM populations, through oro-anal contact
Cause bowel symptoms
Giardia, shigella, Entamoeba
What is TV (simply)?
TV is an STI caused by Trichomonas vaginalis (protozoa)
What causes syphilis?
Treponema pallidum
What is cervical inra-epithelial neoplasia (CIN)?
Premalignant squamous cell lesion
Three settings in which Molluscum contagiosum occur?
Routine physical contact
- Most common (90% in GPs)
- Children <15yrs
- Face, Neck Trunk or limbs
STI
- young adults
Immunocompromised
- Serious infection, often on face and neck
What is LGV?
Lymphogranuloma venereum:
- complication of certain (tropical) types of chlamydial infection where the infection spreads to the inguinal lymph nodes.
Features of Molluscum lesions?
- 1-30 lesions in clusters
- Occassionally itch/discomfort
- Projecting, pearly, umbilicated, round lesions with erethematous edge
Management of Molluscum?
Warn about formites and autoinoculation
Often no treatment, however can podophylotoxin, imiquimod, cryo it.
How is molluscum diagnosis made?
Clinically
Progression of herpes lesions?
- Erythema and (possibly) swelling of skin
- Vesicles and pustules
- Ulcers
- Scabbing
- Healed skin
Management of HSV in pregnancy?
1st episode in 3rd trimester:
- Oral Acyclovir 400mg TDS until delivery
- C-section
If acquired before pregnancy or in 1st/2nd trimester then can deliver vaginally, considering prophylaxis from 36weeks: acyclovir 400mg TDS
HSV complications in pregnancy?
Disease in skin/eye/mouth:
- with treatment <2% neuro-ocular morbidity
Disease in CNS causing encephalitis:
- 6% mortality, 70% neuro morbidity
Disseminated:
- Mortality 30% with treatment, neuro morbidity 17%
Stages of syphilis?
Primary:
- painless ulcer (chancre), lymphadenopathy, serology can be negative.
Secondary:
- Mucosal lesions
- Rash
- Arthralgia
- Lymphadenopathy
- Meningitis
- Iritis
- CN palsy
Latent:
- Asymptomatic, detectable on serology
Tertiary: (after 4 years)
- CVS syphilis: Aortoi aneurysm, Aortic regurg,
- Neurosyphilis
How do you diagnose syphilis?
Microscopy (in primary)
Antigen assay (EIAs) (IgM, in acute infection, not very accurate)
Non-specific VDRL/RPR
Specific: TPPA/TPHA
Specific remains positive for life
Non-specific is useful for monitoring the disease activity, if negative then not infectious and:
- Very early infection, or;
- Old infection (treated)
Tx for syphilis?
Penicillin, IM preferred
if allergic then doxy
Tropical STIs?
Chancroid - haemophilus ducreyi
- Soft ulcer unlike syphilis
LGV
- Chalydial subtypes
Donovanosis
- Bacterial disease caused by Klebsiella granulomatis
Vaginal discharge Ddx?
Infective STIs:
- TV
- HSV
- Gonorrhoea
- Chlamydia
Infective non-STI:
- BV
- vulvovaginal candiasis
From the vagina:
- Vaginitis
- malignancy
From cervix:
- Ectopy
- Polyp
- Malignancy
From endometrium:
- Malignancy
- Polyp
What is BV?
Bacterial vaginosis:
- Imbalance in normal vagina flora
- not considered to be an STI
Overgrowth of anaerobic bacteria with a pH rise
BV R/Fs?
- Smoking
- Vaginal Douching
UPSI Change of partner Receptive cunnilingus Presence of STI WSW Increased lifetime partners
Presentation of BV?
50% fishy discharge
50% asymptomatic
Not assoc. w/ soreness, itching or irritation
Complications of BV in pregnancy?
Late miscarriage
Preterm
PROM
Post partum endometriosis
Routine screening not recommended
Diagnosis of BV?
Ison Hay criteria
Gram stained microscopy:
- Loss of lactobacilli
- Mixed increased growth
Tx for BV?
Tx if:
- risk of ascending infection
- Symptomatic women
Oral metronidazole 400mg BD 5d
For recurrent BV:
- Vaginal metronidazole gel twice a week
Most common causative organism of vulvovaginal candidiasis?
Candida albicans
Symptoms in Vulvovaginal Candidiasis?
Vaginal itch Vaginal discharge Vulval soreness External dysuria Superficial dyspareunia
Diagnosis of thrush?
Microscopy
Culture
Tx for thrush?
Antifungal topical imidazole, e.g. clotrimazole 500mg pessary stat +/- cream
OR
Oral fluconazole 150mg stat
Treatment of recurrent candidiasis?
Speciated fungal culture (to identify species)
Vulval care emolients and soap substitute
medication:
- Fluconazole 150mg every 72hrs 3x (eradication)
- prophylactic fluconazole weekly for 6/52
TV common symptoms?
Females:
- Vaginal discharge
- Vaginal itch
- Dysuria
- offensive odour
Males:
- Urethral discharge
- Dysuria
10-50% asymptomatic (both sexes)
Complications of TV in pregnancy? What should you do?
Preterm
Low birth weight
Post partum sepsis
Treatment doesn’t improve complication risk, and is risky itself.
TV diagnosis?
Microscopy
Culture
NAAT
Management of TV?
6 point plan
Metronidazole 500mg bd 5d/ 2g stat
Screen and contact trace (4/52)
What is epididymo-orchitis (epididymitis)
Presentation?
Inflammation of the epididymides and/or testicular inflammation triggered by an infectious agent
Usually unilateral (but may be bilateral) - scrotal swelling, erythema and pain.
O/E: testicular discomfort, tender swollen epididymis
Cause of epididymitis?
Gonorrhoea, chlamydia
E coli, enterobacteriaceae (>35, ?structural abnormality)
M. tuberculosis (rare) - chronic epididymitis
Epididymitis Tx?
Doxy 100mg bd 14d
What is pediculosis?
Lice there are two types, genital and body (corporis & capitus)
Stages of genital lice?
The nit
The nymph
The adult
Clinical features of pediculosis?
Infests thighs, perineum, abdo, axilla also eyebrows and lashes
Symptoms:
- intense irritation & movement noticed
- blue macules, black spots, lice & nits
Pediculosis management?
6 step plan
Medication:
- Malathion 0.5%
- In pregnancy: Permethrin 1%
All body hair treated and left for 12 hours, then repeated 1 week later
Wash clothes and bed linen at 50
Full STI screen
Presentation of scabies?
Symptoms result from a hypersensitivity reaction
Pruritis (itch - worse at night)
Eczematous looking lesions
Burrows (fine grey channels)
Indurated (hard) nodules
How is scabies transmitted?
Prolonged skin-skin contact
Formite spread
Sexually transmitted
What is norweigan scabies?
Highly contagious form, found in elderly and immunocompromised, kyperkeratotic lesions.
Scabies management?
Permethrin 5%
Malathion 0.5% lotion
Apply to body from neck down and leave for 12 hours
Wash linen and clothes at 50
Treat partner and household contacts of 8 weeks
Why worry about asymptomatic STIs in MSM?
increased likelihood of HIV transmission
LGV proctolitis problems?
Proctocolitis with scarring adhesions and fistula formation
Histologically indistinguishable from IBD
Hepatitis types associated with MSM?
Hep A - outbreaks in MSM, but prevalence similar to population. Not routinely vaccinated for.
Hep B - All MSM should be vaccinated
Hep C - Current MSM outbreak, associated with traumatic sexual practices & cocaine, majority HIV+
Chemsex drugs?
MDMA, Ketamine, Mephedrone, Crystal meth and GHB/GBL.
2 situations where confidentiality can be breeched in GUM?
Beastiality
Court order
Non-STI causes of genital ulceration?
Trauma
Apthosis
Erythema multiforme
Behcets disease
STIs that cause genital ulceration?
Herpes Syphilis LGV Chancroid Donovanosis
STIs with vaccines?
Hep A/B, HPV
What other conditions can give rise to a false positive syphilis test?
Lupus/autoimmune
Acute febrile illness
Autoimmune
Clinical features of congenital syphilis?
Hutchinsons teeth
Keratitis
Deafness
Drugs in PREP?
tenofovir and emtricitabine, tablet is truvada
One pill a day
What treatment for warts is unsuitable for people with dark skin?
Cryo
What determines your choice of treatment for warts?
Site
Keratinised/non-keratinised
Number
Pregnant or not
Patient choice
Pigment of skin
