GUM Flashcards
1
Q
Typical finding on microscopy for gonorrhea?
A
Gram negative diplococci. Intracellular
2
Q
Anatomical sites infected by gonorrhea?
A
Urethra, endocervix, rectum pharynx, conjunctiva
3
Q
Signs and symptoms of gonorrhoea in males?
A
Urethral discharge (80% within 2-5/7 of infection), dysuria, asymptomatic (10%), rectal discharge/perianal pain, 90% pharyngeal are asymptomatic. Mucopurulent discharge, epididymal tenderness (rare)
4
Q
Signs and symptoms of gonorrhoea in females?
A
Asymptomatic, vaginal discharge (50%), lower abdo pain (25%), dysuria (12%), rectal and pharyngeal are generally asymptomatic. Cervical contact bleeding, occasionally IMB/menorrhagia.
5
Q
Complications of gonorrhoea?
A
PID, epididymal orchititis, SARA, haematogenous dissemination (skin lumps, arthralgia, arthritis, tenosynovitis)
6
Q
Diagnosis of gonorrhoea?
A
Microscopy 90-95% sensitive in males with urethral discharge. NAAT 96% sensitive in symptomatic and asymptomatic.
7
Q
In people who have undergone gender affirming surgery what sampling should be taken?
A
Neovaginal NAAT swab and urine, neo-penis first void.
8
Q
Coinfection rate for chlamydia with gonorrhoea positive individuals?
A
19%
9
Q
Gonorrhoea window period?
A
2 weeks.
10
Q
Treatment of gonorrhoea 1st line?
A
Patient info, full screen, culture and naat all exposed sites, ceftriaxone 1g/im/stat (ciprofloxacin 500mg stat is sensitivities known, abstain 7/7 after completing tx. ToC 2/52.
11
Q
Complications of ciprofloxacin?
A
Joint/MSK/tendonitis – avoid if previous problems or >60 yo/CKD/corticosteroid user
12
Q
Ciprofloxacin resistant gonorrhoea %
A
UK? 36% in 2017
13
Q
A male has a positive gonorrhoea NAAT, cultures show ceftriaxone sensitive, ciprofloxacin resistant, and macrolide sensitive. He had breathing difficulties after penicillin based treatment for tonsilitis in the past. What antibiotic would you offer him?
A
Gentamycin 240mg/IM and azithromycin 2g stat. Cephalosporins contraindicated in penicillin anaphylaxis
14
Q
Treatment of disseminated gonorrhoea infection?
A
IV ceftriaxone 1g for 7/7 but PO switch after 24-48hrs of symptom improvement.
15
Q
PO switch for disseminated gonorrhoea infection?
A
Cefixime 400mg BD or ciprofloxacin 500mg BD or ofloxacin 400mg BD depending on sensitivities.
16
Q
Pregnancy treatment for gonorrhoea?
A
Ceftriaxone, spectinomycin or azithromycin
17
Q
Partner notification for symptomatic males gonorrhoea?
A
All in past 2/52 or most recent partner if >2/52 since LSI
18
Q
Gonorrhoea partner notification for females or asymptomatic males?
A
3/12
19
Q
A male partner of a gonorrhoea positive male patient attends as a contact, they last had sex 17 days ago, what would you advise with respect to testing and treatment?
A
NAAT only if asymptomatic, and await results. If symptomatic test and treat. 14 days is the cut off for the LSI for treatment and testing on the same day.
20
Q
When is the test of cure done for gonorrhoea?
A
2/52 after treatment (can have culture at 72 hours), treatment failures should be reported to PHE.
21
Q
Prevalence of mycoplasma genitalium?
A
1-2% males more than females.
22
Q
Risk factors of M.gen?
A
<25, smoker, multiple partners, BAME origin.
23
Q
% NCNGU which is m.gen +ve?
A
10-35%
24
Q
% PID m.gen positive?
A
10-13%
25
Signs and symptoms of m.gen
Asymptomatic 90% men and 95% women. Otherwise discharge, dysuria, urethral irritation, urethritis, IMB/PCB, cervicitis, low abdo pain in women/PID, fertility impact, SARA, epididymal orchitis.
26
When to test of m.gen?
NGU/PID, current partner of m.gen positive patient, consider in proctitis, epididymal orchitis, cervicitis
27
% macrolide resistance in m/gen in uk?
40%
28
Window period for m.gen?
not known
29
29. Treatment for m.gen?
Patient info, test for other STI, abstain 14/7 after start of tx and until symptoms resolve. TOC 5/52 (no sooner than 3/52). If macrolide resistance not known or sensitive doxycycline 7/7 100mg BD then 1g azithromycin stat and 2 x 500mg for 2/7, if macrolide resistant moxifloxacin 400mg 10/7 or if tx failure.
30
Partner notification for m.gen?
test current partner only treat if +ve, same antibiotics as index case.
31
M.gen treatment in pregnancy?
Azithromycin 3/7 (moxi/doxy CI)
32
A patient with NGU was treated with azithromycin for 3/7 due to a doxycycline intolerance, their m.gen test has returned positive with macrolide resistance NOT found, what is the next step in their management?
ToC 5/52 post tx.
33
A patient with NGU was treated with azithromycin for 3/7 due to a doxycycline intolerance, their m.gen test has returned positive with macrolide resistance was found, what is the next step in their management?
Moxifloxacin then TOC
34
A patient with NGU was treated with doxycycline for 7/7, their m.gen test has returned positive with macrolide resistance NOT found, what is the next step in their management?
Azithromycin 3/7 then ToC 5/52 post tx.
35
A patient with NGU was treated with doxycycline for 7/7, their m.gen test has returned positive with macrolide resistance WAS found, what is the next step in their management?
Moxifloxacin then TOC 5/52
36
Abstinence period for m.gen?
14/7 after start of treatment
37
Complications of Moxifloxacin?
Achilles tendon rupture – inform patient of risk .
38
NSU causes?
Chlamydia 11-50% esp younger patient, m.gen 6-50%, uroplasma 11-26%, TV 1-20%, adenovirus 2-4%, HSV 2-3%, UTI 6%. Also EBV, candida, foreign bodies, urethral stricture.
39
Signs and symptoms of NSU?
Discharge, balanoposthitis, dysuria, irritation.
40
Complications of NSU?
SARA/ epididymal orchititis.
41
Investigation of NSU?
Only if symptoms. Microscopy >5 PMNLs/HPF over 5 fields. No microscopy discharge, 1+ leukocyte on udip, threads in urine. NAAT
42
Management of NSU?
Information, sti screen.
| Doxy 7/7 100mg/po or azithromycin 3/7 (1g stat 2 x daily 500mg) or ofloxacin 40mg OD 7/7. Abstain 14/7 after tx started.
43
Abstinence period for NSU?
14 days
44
A man was treated for NGU with doxycycline 10 days ago, his symptoms persist and GC and C4 naats are negative, how would you manage him?
Ensure abstinence/ compliance, M.gen screen, azithromycin 3/7 and metronidazole 5/7 400mg/BD. If doxy>2 weeks ago treatment with doxy then azithro and metro (reduces m.gn burden for azithromycin to work).
45
A man was treated for NGU with azithromycin 10 days ago, c4 and GC naats are negative, his symptoms persist, how would you manage him?
Ensure abstinence and compliance, moxifloxacin 400mg bd 10/7 and metronidazole
46
Look back period for NGU?
4/52.
47
Partner tx for NGU?
Doxycycline 7/7 or azithromycin 1g stat.
48
%persistent NGU
15-25%
49
Recurrent NGU within 3/12 of tx %?
10-20%
50
A man was treated for NGU with azithromycin 10 days ago, c4 and GC naats are negative, his symptoms persisted and he reattended, your colleague ensured abstinence and compliance screen him for m.gen and gave him moxifloxacin 400mg bd 10/7 and metronidazole. His symptoms persist, mgen is negative, what next?
Ensure no psychological overlay, abstinence and give 1g azithromycin, then 4/7 500mg and 5/7 metronidazole 400mg BD.
If that fails moxiflocacin 10-14/7 400mg bd, consider 3/52 erythromycin 500mg qds or clarithromycin 500mg BD 3/52.
51
Incubation periods for LGV?
3-30/7
52
Most common serovar of LGV in UK?
L2
53
Classic location of primary LGV infection?
Painless pustule/ulcer on coronal sulcus, posterior vaginal wall, perianal area or lip.
54
Left untreated what are the sequalae of LGV?
Lymphadenitis, lymphadenopathy, bubo (unilateral grove sign), chronic prostatitis, fistulae, strictures, sara, fevers, pneumonitis, deranged LFTs.
55
Diagnosis of LGV?
Clinical suspicion esp HIV+ve/MSM, culture ulcer or pus (on cycloheximide treated mccay cells), NAAT, rectal slide >10 PMNL.
56
Histology of LGV?
Lymph nodes show follicular hyperplasia and abscesses.
57
Treatment of LGV?
Doxycycline 21/7 100mg BD
58
2nd and 3rd line tx for LGV?
Tetracycline 2g/po/od 21 days or erthyromycin 21 days 500mg/QDS, or azithromycin 1g weekly for 3 weeks. (azithromycin and erythromycin are safe in pregnancy and breast feeding)
59
Partner notification for LVG?
4/52 before symptoms onset or 3/12 if asymp, treat with 21/7 doxy.
60
TV symptoms/signs in male and females?
Males usually asymptomatic, occasionally mild urethral discharge/irritation, dysuria or urinary frequency. Females discharge, frothy/yellow, itch, urethral irritation, dysuria, strawberry cervix (2%), vulvovaginitis. Asymp 10-50%.
61
What type of pathogen is TV?
A flagellated protozoon
62
Diagnosis of TV?
NAAT is gold standard 88-97% sensitive and 98% specific.
Culture 100 specific, 75-95% sensitive, Microscopy 45-60% sensitive, needs to be done quickly so the TV doesn’t die.
POC 80-94% sensitive, 95% specific.
63
Partner notification for TV?
Current and 4/52 prior.
64
Abstinence following tv treatment?
1/52 or until negative toc
65
Treatment of TV?
Metronidazole 5-7/7 40-5mmg mg PO BD or 2g stat.
66
What should patients be adviced regarding metronidazole and alcohol?
Avoid, disulfram like reaction 48hrs for metro, 72hrs for tinidazole
67
2nd line tx for TV?
Tinadzoe 2g/po/stat
68
Breast feeding and metronidazole?
Impacts on taste, discard for 12-24hrs after finishing.
69
Tinadazole and pregnancy?
No
70
Causes of TV treatment failure?
Inadequate therapy (compliance/vomiting), reinfection, resistance
71
Treatment for partners of TV infection?
Metronidazole 400-500mg/po/bd 5-7/7
72
If tx failure of first line what next in TV?
High dose metro or tinidazole 2g 5-7/7 or 800mg metro TDS 7/7
73
Persistent failure TV
2g BD tinidazole 14/7 +/- intravaginal tx.
74
Definition of recurrent thrush according to BASHH?
4 or more episodes in 12/12. 2 confirmed on culture/micro (at least 1 positive culture)
75
Non-albicans species of candida?
C. Glabrata (especially in diabetics), C. tropicalis, C. krusei, (intrinsically resistant to fluconazole), C. parapsilosis, Saccharomyces cerevisiae
76
First line treatment of acute candida?
PO fluconazole 150mg stat or 500mg PV clotrimazole PV stat
77
% women colonized with candida who are asymptomatic and do they require treatment?
10-20% no treatment needed.
78
% clearance rate of candida of vaginal imidazole and oral azoles?
80%
79
What can all vaginal medications do to condoms and diaphragms?
Weaken them, avoid SI whilst on tx.
80
% increase in candida colonisation and symptoms in pregnancy?
30-40%
81
Treatment of candida in pregnancy?
7/7 500mg PV clotrimazole
82
Why a longer course of treatment of candida in pregnancy?
Cure rate 90% for 7/7 and 50% after 4/7
83
Risk of prescribing fluconazole PO and erythromycin together?
Long QT risk
84
Fluconazole induces with enzyme pathway?
CYP450
85
Risk of what with statins and fluconazole?
myopathy and rhabdomyolysis If concurrent treatment is necessary, monitor for symptoms of myopathy and rhabdomyolysis, and monitor creatine kinase.
86
Treatment of recurrent candida?
Culture for sensitivities and speciation, examine, micro, general advice, baseline LFTs and U&E (consider TFT/FBC although evidence poor for this), udip for glucosuria, ensure no risk immune compromise. Fluconazole 150mg x 3 72hrs apart then weekly for 6/12.
87
2nd line pharmacological tx for recurrent candida?
Clotrimazole 500mg 7-14 days, then weekly.
88
First line tx of severe but not recurrent candida?
Fluconazole 150mg day 1 & 4, clotrimazole HC topically BD 7 days.
89
Second line tx of severe but not recurrent candida?
Clotrimazole 500mg day 1 and 4 and clotrimazole HC topically BD 7 days.
90
Third line tx for severe but not recurrent candida?
Miconazole PV 1200mg day 1 and 4 and clotrimazole HC topically BD 7 days.
91
Describe role of high oestrogenic states in recurrent candida?
Possible link, prepubertal and post menopausal women get less thrush. HRT is linked to more thrush, CHC may be. Worth a try on something else if acceptable to patient and suppression not helping.
92
Link to IUC and recurrent candida?
possible biofilm formation and colonisation of device reducing in poorer clearance, worth trying without if acceptable to patient and alternative contraception can be found.
93
Risk of recurrent candida?
5% of women of reproductive age with a primary episode will develop recurrent disease.
94
% reduction in recurrence from suppressive therapy for candida immediately, 3/12 and 6/12?
88%, 65 and 60% respectively
95
Additional non-azole tx which may be useful in recurrent candida?
Cetirizine
96
Which immune-deficiency condition associated with recurrent infections is associated with recurrent candida?
Mannose binding lectin deficiency
97
A woman with poorly controlled diabetes presents having been treated by your colleague for presumed candida, she had had a poor response to treatment. Microscopy reveals multiple spores but no hyphae – what is the likely causative pathogen?
Candida glabrata and requires higher dose fluconazole
98
A woman has been treated for candida with fluconazole to no avail, microscopy reveals long grains of rice appearance, which species of candida is it likely to be?
Krusei which is intrinsically resistant to fluconazole but responds to voriconazole
99
Treatment options for non-ablicans species of candida?
1st line: Nystatin pessaries daily for 2 weeks.
Alternatives include Amphotricin B pessary 50mg od for 14 days, Boric acid 600mg vaginal suppository daily for 2-3 weeks. ?teratogenic risk, Intravaginal flucytosine 1 g pessary +- amphotericin to reduce chances of resistance
100
Signs and symptoms of vulvovaginal candida?
Itch, white discharge, superficial dyspareunia, satellite lesions, dysuria, fissuring, hyperkeratosis
101
Differential diagnosis for vulvovaginal candida?
Eczema, lichen, TV, vulvodynia, aerobic vaginitis, cytolytic vaginitis
102
Bacteria associated with BV?
Gardnerella vaginalis, Prevotella sp, Mycoplasma hominis, Mobiluncus sp.
103
Normal vaginal pH?
<4.5
104
Risk factors for BV?
vaginal douching, receptive cunnilingus, black ethnicity, recent change of sex partner, smoking, presence of an STI
105
Signs and symptoms of BV?
Thin homogenous discharge, fishy smell, rare to have itch/pain. Asymptomatic in 50%
106
Complications of BV?
Increased risk of HIV acquisition, high prevalence in women with PID, post TOP endometritis
107
BV related complications in pregnancy:
late miscarriage, preterm birth, PPROM, postpartum endometritis
108
Amsel’s criteria for BV?
thin, white, homogenous discharge, clue cells on microscopy of wet mount, vaginal pH >4.5, Wiff test: 10% KOH releases a fishy odour
109
Hay-Ison criteria for BV grade 1-4?
Grade 0: No bacteria present
Grade 1: Normal flora – lactobacillus morphotypes predominate
Grade 2: Mixed flora with some lactobacilli present bur Gardnerella or Mobiluncus morphotypes also present.
Grade 3: BV. Predominantly Gardnerella and/or Mobiluncus morphotypes. Few/absent lactobacilli,
Grade 4: Gram positive cocci only
110
Pregnancy & Breastfeeding does BV need treating?
No evidence that screening asymptomatics will prevent preterm birth/misc, but treating before 20 weeks may reduce risk, so symptomatic women should be treated and women with additional risk factors for preterm birth may benefit from treatment before 20 week gestation
111
Recurrent BV treatment?
Suppressive metronidazole (0.75%) vaginal gel twice weekly for 16 weeks. May get candida (43 vs 21%). Probiotics: daily on days 1-7 and 15-21 (antibiotics & probiotics in combination may have increased cure rates), no evidence but lactic acid washes eg balance activ and reduce recurrence but not induce remission.
112
Treatment for BV?
all have 70-80% cure rates;
Metronidazole 400mg bd for 5-7 days,
Metronidazole 2g
intravaginal metronidazole gel (0.75%) od for 5 days
intravaginal clindamycin cream (2%) od for 7 days
113
Lifecycle of adult public lice?
15-25 days (hence tx day 1 and day 7 to catch them all)
114
Incubation time of public lice eggs?
5 days (can be longer)
115
Treatment for public lice?
Malathion 0.5% min 2hrs ideally over night, retreat day 7.
Permethrin 1% 10mins then wash off day 0&7.
116
Treatment for public lice in pregnancy?
Permethrin 1% 10mins then wash off day 1&7.
117
Treatment of public lice in eye lashes?
Permethrin 1% 10mins then wash off day 1&7 or yellow paraffin BD for 8-10 days (suffocates them)
118
Partner notification for public lice?
Treat current partner and 3/12 lookback.
119
How long is the life cycle of scabies?
4-6weeks
120
How long do scabies eggs take to hatch?
10-15 days
121
How long can scabies mites live off host?
24-34hrs
122
How long does it take to become symptomatic after primary scabies infection?
3-6 weeks (type 4 delayed hypersensitivity)
123
How long does it take to develop symptoms following reinfection of scabies?
1-3 days (already sensitised)
124
Symptoms and signs of scabies?
Distribution: finger webspaces, sides of fingers and under nails, flexor wrists, extensor elbows, axillary folds, nipple in women and penis/scrotum in men, umbilicus, medial thighs, buttocks, sides and back of feet.
Puritis worse at night.
Pathognomonic lesion: burrow (linear intra-epidermal tunnel) made by moving mite.
Nodular lesions, on penis ad scrotum, buttocks, groin and axillae – intensely itchy.
May persist after Tx
125
Tx for classic scabies?
Permethrin 5%, leave on 12hr, reapply 1 week (safe in pregnancy and breastfeeding)
126
Alternative tx for classic scabies not permethrin?
Malathion 0.5% leave on 24rs and reapply 1 week.
127
Treatment for Norwegian/crusted scabies?
Premethrin daily 7 days, then twice weekly until cure +/- ivermectin PO day 1,2,8,9,15
128
How long may the scabies itch last for?
Up to 2 weeks even if treated, persistent symptoms after this should consider retreatment as failure or reinfection
129
Lookback period for scabies?
1/12
130
Partner notifications for scabies?
Treat all close contacts, sexual and household.
131
What causes molluscum contagiosum?
Pox DNA virus.
132
Which subtype of the Pox DNA virus is most common in molluscum contagiosum?
M1 (M2 more common in HIV+ve)
133
Transmission of molluscum contagiosum?
kin to skin, sharing towels/bedding
134
Appearance of molluscum contagiosum?
Smooth, domed, firm 2-5mm lumps with central umbilicus, usually asymp.
135
Treatment for molluscum contagiosum?
Expectant – will spontaneously regress usually unless immunocompromised, skin care and avoid autoinoculation (shaving/waxing)
136
If HIV+ve treatment for molluscum contagiosum?
If on HAART will usually regress, but flare during initial tx whilst immune-reconstitution ongoing. Can try cryo or topical cidofovir or podophyllotoxin, skin care and avoid autoinoculation (shaving/waxing)
137
Genital warts cause (and subtype)?
90% caused by HPV subtype 6 & 11
138
Rapid growth to very large and erosion in a genital wart is likely to be what lesion?
Buschke-Lowenstein lesion (condyloma acuminata), need surgery to prevent destruction of adjacent structures.
139
Condoms can reduce transmission of genital warts by how much?
30-60%
140
Treatment of genital warts, keratinised on penile shaft?
Info, STI screen, stop smoking, expectant mx, cryo, imiquimod, podophyllotoxin, TCA, surgery/electrocautery. Cryo tends to work well in keratinised.
141
Cryo therapy protocol in genital warts?
3 cycles of cryo weekly for 4-6 weeks, if not improving try alternative tx.
142
Expectant management of genital warts – expected success rate over what time?
30% in 6/12
143
Incubation periods for genital warts?
3-8/12 (up to 18/12)
144
Podophyllotoxin regimen for genital warts?
Twice daily for 3 days, 4 day rest, 4 cycles
145
Imiquimod regimen in genital warts?
5%, OD for 3 days weekly, leave on for 6-10hrs, 16 cycles.
146
Mechanism of action of Imiquimod?
TLR7 agonist – promotes viral clearance.
147
Treatment options on pregnancy of genital warts?
Cryo or physical destruction (imiquimod and Podophyllotoxin teratogenic). Doesn’t warrant c-section.
148
Treatment options on breastfeeding of genital warts?
Cryo or physical destruction (imiquimod no advice in SPC)
149
Patients with immunocompromised are likely to need what duration of treatment for genital warts compared to immunocompetent?
Longer.
150
Intravaginal genital warts treatment options?
expectant, cryotherapy, electrosurgery and TCA. Podophyllotoxin has been used <2cm2 (not licensed)
151
Cervical genital warts treatment options?
expectant, cryotherapy, electrosurgery and TCA. Colp not required unless suspecting neoplasm.
152
Urethral meatus genital warts treatment options?
Base of lesion visible - treat with cryotherapy, electrosurgery, laser ablation, podophyllotoxin or imiquimod. Deeper lesions - surgical ablation under direct vision, which may require urology referral or use of a meatoscope.
153
Treatment options for intra-anal warts?
Expectant, cryotherapy, topical imiquimod (unlicensed indication), electrosurgery, laser ablation and TCA.
154
Genital warts in children?
<2yo can be vertical transmission, high index of suspicion for abuse.
155
Tx of HIV+ve patient with genital warts?
Same as non-HIV +ve but will likely need longer tx, HARRT will help clearance.
156
Cause and % of acyclovir resistant HSV in PLWHIV?
5-7% in HIV +ve, HSV thymidine kinase
157
What if the difference between primary episode and primary infection?
Pimrary episode is first time symptoms, might not be the primary infection. Primary infection = 1st ever infection with no pre-existing antibodies.
158
Which type of HSV is most common in UK on the genitals?
Typically how many episodes for HSV 1 and 2 are expected within a 12/12 period?
Type 1
1 for HSV 1
4 for HSV 2
159
What proportion of people will not develop symptoms at time of HSV-2 acquisition?
2/3
160
Incubation time for HSV?
2 days to 2 weeks
161
What does HSV do once symptoms subside?
Lies dormant in sensory ganglia.
162
% asymptomatic shedding?
10%
163
Condoms can reduce transmission by how much?
Up to 50%
164
Symptoms and signs of HSV?
Genital ulcers, pain, dysuria, uriary retention, fever/malaise, asymp
165
Complications of HSV?
Superadded infection, autoinoculation to fingers ect, proctitis, aseptic meningitis.
166
How is HSV diagnosed?
DNA PCR
167
What type of virus is HSV?
Double stranded DNA
168
Detection rate of HSV on DNA PCR?
11-71%
169
Management of HSV first episode?
Info, skin care, saline bath, STI screen, analgesia (oral and lidocaine 5% topical), antivirals if within 5 days of start of episode (acyclovir 400mg TDS PO 5/7)
170
Alternative antiviral to acyclovir in treatment of 1st episode of HSV?
Valaciclovir 500mg BD 5/7 or famciclovir mg TDS 5/7
171
Treatment of recurrent episode of HSV?
Skincare, saline bathe, analgesia, antiviral can reduce duration 1-2 days. Standard antiviral tx or short course (ACV 800mg TDS 2/7 or famciclovir 500mg-1g one day or valaciclovir 500mg BD 3/7
172
Partner notification and look back period for HSV?
No lookback, should encourage to tell partner but partner doesn’t need screening if asymp
173
HIV +vet x for HSV?
Same as standard if CD4 ok and not severe, but if severe ACV 400mg x 5 times daily for 7-10 days and continue until lesions epithelializing.
174
What information regarding sex with pregnant women should people with HSV be told?
Avoid SI with pregnant women esp in 3rd trimester and esp if that woman has not had HSV before.
175
Criteria for suppression therapy for HSV?
6 or more episodes in a year or significant distress.
176
Suppression treatment options in HSV?
6-12 months of tx, with plan to stop, likely to get outbreaks on stopping but should settle. ACV 400mg BD or famciclovir 250mg BD or valciclovir 500mg OD
177
Treatment of outbreak of HSV whilst on suppression?
400mg tds 5/7 ACV.
178
Risk of transmission of HSV for vaginal delivery if recurrent HSV?
0-3%
179
Recommendation for all pregnant women with known HSV regarding ACV use?
36/40 400mg TDS until delivery and plan vaginal birth, if genital HVS at delivery 24hrs observation of neonate.
180
Management of primary episode of HSV in pregnancy at 26/40?
All under 27+6 tx as normal, inform obs team, offer suppression from 36/40 and plan vaginal delivery
181
Management of HVS first episode in pregnancy at 32/40?
Information, ACV as normal and swabs, and suppression therapy until delivery, recommend c/s (41% reduction in transmission),
serology (may take a couple of weeks to come back) - Type-specific HSV antibody (IgG) testing is advisable to distinguish between primary and recurrent genital HSV infections.
The presence of antibodies of the same type as the HSV isolated from genital swabs would confirm this episode to be a recurrence rather than a primary infection and elective caesarean would not be indicated
182
Management of a woman in labour who’s never been known to have HSV lesions?
Hx to find out if recurrent or not, swab lesions, inform neonatal team, c/s where possible. Consider intrapartum IV aciclovir for the mother (5 mg/kg 8 hourly) and the neonate (20 mg/kg 8 hourly) if opting for vaginal delivery, avoid invasive procedures eg foetal blood sampling.
183
Risk of transmission of HSV to neonate if primary genital lesions at time of delivery?
41%
184
Management of babies born to mothers with recurrent HSV infection in pregnancy with or without active lesions at delivery?
Maternal IgG will be protective this infection risk low. Conservative mx. Examination at 24hrs and no tx. General hygiene.
185
Management of babies born by caesarean section in mothers with primary HSV infection in the third trimester?
infection risk low. Conservative mx. Examination at 24hrs and no tx. General hygiene.
186
Management of babies born by spontaneous vaginal delivery in mothers with a primary HSV infection within the previous 6 weeks if baby well?
Swab skin, empirical ACV, and await swabs.
187
Management of babies born by spontaneous vaginal delivery in mothers with a primary HSV infection within the previous 6 weeks if baby unwell?
Swab skin, LP, empirical ACV until active infection ruled out.
188
Management of HIV +ve mothers with recurrent HSV?
ACV from 32/40 to reduce HIV transmission
189
Management of HIV +v mothers with primary episode of HSV?
Same as non-HIV
190
Management of primary genital herpes in preterm prelabour rupture of membranes (PPROM)?
IV ACV, MDT choice to delivery.
191
Management of recurrent genital herpes in preterm prelabour rupture of membranes (PPROM)?
PO ACV TDS and management as per obs team for delivery/MDT input, limited evidence.
192
Suppression therapy dose/frequency of ACV in HVS in pregnancy?
400mg TDS ACV (volume of distribution increased in pregnancy)
193
Partners tx and look back for donovanosis?
Look back 6/12
| Assess partners for symptoms and offer treatment
194
In vertical transmission of donovanosis where is typically affected on the neonate?
The ear.
195
Cause of donovanosis?
Klebsiella granulomatis
196
Typical appearance of donovanosis?
Papule turns in to painless ulcer, beefy red, bleeds readily to touch, rolled edge, lymph nodes locally.
197
Stains used to look for donovanosis in as smear slide?
Giemsa, wright or Leishman
198
Stains used to look for donovanosis in as biopsy?
Giemsa or silver
199
Histological findings for donovanosis?
Large histocytes, pleomorphic appearance, Bipolar densities and a capsule often seen, Gram negative inclusion bodies (Donovan bodies)
200
First line tx of donovanosis?
Azithromycin 1g weekly po for 3 weeks or until lesion healed
201
Alternatives tx other than azithromycin for tx of donovanosis?
Always for 3/52 or until lesion healed,
doxy 100mg bd,
Co-trimoxazole 160/800 mg bd PO,
erythromycin 500mg QDS
202
Treatment of choice for donovanosis in pregnancy?
erythromycin 500mg QDS 3/52 or until lesion healed
203
Follow up for donovanosis?
until lesion healed
204
Lookback period for donovanosis?
All partners 6/12
205
Partner notification for donovanosis?
Assess partners for symptoms and offer treatment
206
% extra genital site infection in donovanosis?
6%
207
% donovanosis infections affecting the genitals?
genitals 90%, inguinal area in 10%
208
Cause of chancroid?
Haemophilus ducreyi
209
Incubation time of chancroid?
3-7 days
210
Lookback period for chancroid?
10days
211
Treatment of asymptomatic partners in lookback period with chancroid?
All partners examined AND treated regardless of symptoms
212
Typical sites affected by chancroid male and female?
Frenulum and prepuce, cx/vulva/ perianal in women.
213
Typically appearance of chancroid?
Ragged edge, granulomatous, grey ulcer, papule to pustule to ulcer. Can look like STS and HSV.
214
Dx of chancroid?
NAAT better than culture 95% SENSITIVE vs 75%
215
First line tx of chancroid?
Ceftriaxone 250mg IM stat or
Azithromycin 1g po stat.
216
2nd line tx of chancroid?
Ciprofloxacin 500mg BD 3/7 or Erythromycin 500mg QDS 7/7
217
Follow up for chancroid?
Until sx resolved, usually 3-7 days to see improvement. Abstain until partner tx and resolved.
218
Microscopy findings of chancroid?
Gram negative, coccobacilli, with occasional chaining.
219
Infectious period and look back period for Hep A ?
2/52 pre jaundice and 1/52 post jaundice
220
What type of virus is hep A?
RNA
221
Transmission route of Hep A?
faeco-oral
222
Incubation time for Hep A?
28 days (15-42)
223
Symptoms of Hep A and what time scale?
Day 3-10 flu like illness and RUQ pain, then 3/52 of jaundice, malaise, dark urine, pale stool, LFTs deranged.
224
% people with Hep A requiring hospital admission and % severe illness?
15% admitted, 0.4% severe.
225
Mortality rate of severe illness in hep A?
40%
226
Ix for hep A?
Hep A IgM, LFTs and clotting
227
Mx for hep a if mild/moderate?
Supportive, food workers must stay off 1/52 post resolution of jaundice. Notify PHE.
228
Mx of H A if older, HIV +ve or chronic liver disease?
More likely to get severe illness, consider human normal immunoglobulin in addition to LFTs, clotting and supportive tx.
229
Hep A vaccine schedule?
0 and 6 months
230
How long after first hep A vaccine can send be given without restarting schedule?
36 months
231
HIV+ve Hep A vaccine special considerations?
Booster when CD4> 500
232
P/N for hep A?
Household contacts, food workers.
233
What type of virus is hepatitis B?
DNA
234
Transmission rotes for hep B?
Sex, vertical, parenteral
235
When is Hep b infectious?
2/52 before jaundice until 1/52 after HBsAG negative
236
Incubation time for hep B?
40-160 days
237
% people with hep b who are asymptomatic?
10-50%
238
How many subtypes of hepatitis b are there?
8 (A-H)
239
Symptoms of Hep B?
longer version of hep a: flu like illness and RUQ pain, then jaundice, malise, dark urine, pale stool, LFTs deranged.
240
Ix for hep b?
Serology, LFTs, STI screen
241
Mx of Hep B?
supportive, refer hepatology, advice to avoid toothbrush, needle, razor sharing, blood and organ donation until 1/52 post HBsAG negative
242
Partner notification for acute hep b?
2/52 before jaundice until 1/52 after HBsAG negative
243
Partner notification for chronic hep b?
2/52 before jaundice or 3 years.
244
Post exposure tx options for Hep B?
HBIH 12-48hrs post exposure, ultrarapid vaccine, babies at birth get HBIG and vaccine at birth.
245
Standard vaccine schedule for hep B and efficacy?
0/1/6 months, 95% 20mcg engerix
246
Ultrarapid hep b schedule and efficacy?
0/1/3 weeks booster at year. 80% before booster, 95% after
247
Response check to hep b vaccine time and value meaning immunity?
4-8 weeks, anti-HBs or HBsAb >100iu.
248
If anti-HBs or HBsAb 10-100 iu/l response to hep b, what do you offer?
Booster and check response 4-8 weeks, if still low, repeat standard schedule
249
HIV +ve hep b schedule and dose/brand?
0/1/2/6 months 40mcg (double standard) engerix or 20mcg fendrix
250
HIV+ve patient with anti-HBs or HBsAb 10-100 response to hep b vaccine?
1 x booster recheck 4-8 weeks
251
HIV+ve patient with anti-HBs or HBsAb <10 response to hep B vaccine?
3 x monthly doses and check response 4-8 weeks.
252
Patient has HbSAG negative, Anti HBC negative and Anti HBs (HBsAb) negative, what do these results mean?
Never vaccinated and susceptible.
253
Patient has HbSAG negative, Anti HBc postive and Anti HBs (HBsAb) negative, what do these results mean?
Resolved infection
254
Patient has HbSAG negative, Anti HBC negative and Anti HBs (HBsAb) positive, what do these results mean?
Vaccinated
255
Patient has HbSAG positive, Anti HBC positive and Anti HBs (HBsAb) negative, what do these results mean?
Active infection
256
How long after starting hep b vaccination can missed doses be given without restarting schedule?
4 years.
257
What type of virus is hepatitis C?
RNA
258
Incubation time for Hep C
4-20 weeks
259
% patients with hep C asymptomatic?
60%
260
Which type of hepatitis is most strongly associated with risk of hepatocellular carcinoma?
Hep C
261
what serology is positive first and how soon following infection with Hep C?
HCV RNA, 2 weeks
262
How long does it take Anti-HCV to become positive following infection with hep c?
3/12 (up to 9/12)
263
What % of hep c infected become chronic carriers?
50-85%
264
HPV vaccines are offered to whom in a sexual health setting?
MSM <45 yo.
265
HPV vaccine schedule for adult MSM?
0, 1 & 4-6 months
266
Missed does of HPV vaccine?
don’t restart but give at 3/12 interval
267
What % under 25s have chlamydia?
5-10%
268
Time of lifecycle of chlamydia?
48-72hrs
269
Serovars causing anogenital chlamydia?
L1-L3
270
% concordance of infection of chlamydia between partners?
75%
271
Risks factors for chlamydia?
<25, >1 sexual partner in past year, no condom use.
272
% chlamydia that can resolve spontaneously?
50% in 12 months
273
Sites affected by chlamydia trachomatis?
Eyes, pharynx, genitals, rectum.
274
Signs and symptoms of chlamydia in females?
Vaginal discharge, PCB, IMB dysuria, dyspareunia, lower abdo pain, cx excitation, PID. Asymptomatic
275
Signs and symptoms of chlamydia in males?
Asymptomatic, urethral discharge, dysuria, recal discomfort or discharge.
276
% males and females asymptomatic of chlamydia?
75% females, 50% males
277
Complications of non-lgv chlamydia?
SARA <1%, epidydimalorchitis , PID, endometritis/salpingitis, perihepatitis (fitz hughes Curtis)
278
% infertility in females with 1 episode of chlamydia?
8%
279
% infertility in females with 2 episodes of chlamydia?
20%
280
% infertility in females with 3 episodes of chlamydia?
40%
281
What % <25s are reinfected with chlamydia?
10-30% therefore retest 3/12
282
Window period for chlamydia?
2/52
283
Investigation to look for chlamydia in males and females?
Vulvovaginal NAAT female, first void urine male. Rectal NAAT if MSM or only anal SI if female.
284
Sensitivity in NAAT for chlamydia?
96-98%
285
1st line tx of chlamydia?
Patient info, partner notification, doxycycline 100mg BD 7/7
286
Abstinence period following doxy for chlamydia?
Until tx complete
287
Abstinence period following azithromycin for chlamydia?
7/7 after first dose
288
2nd line tx for chlamydia?
Azithromycin 1g stat then 2 days of 500mg daily.
289
Tx of chlamydia in pregnancy?
Azithromycin 1g stat then 2 days of 500mg daily (erythromycin 500mg BD 10-14 days if unable to have azithromycin or amoxicillin if unable to have macrolides amox 500mg TDS 7days)
290
When is a ToC required following chlamydia treatment?
In pregnancy only 3-5 weeks after tx
291
Side effects of macrolides?
GI upset, hepatotoxic, rash, long QT risk, exacerbates myasthenia gravis.
292
Complication of ofloxacin use?
Tendon rupture
293
Side effect of doxycycline?
GI upset, sunlight sensitivity
294
Congenital chlamydia symptoms/types?
Conjunctivitis 5-12 days post delivery, pneumonia 1-3 months after delivery
295
Partner notification for chlamydia males with and without symptoms?
Symptoms 4/52, 6/12 without
296
Partner notification for chlamydia in females with and without symptoms?
6/12
297
Define epididymo-orchitis?
Clinical syndrome consisting of pain, swelling and inflammation of epididymis +/- testes
298
Causes of epididymo-orchitis?
STI, enteric, mumps, post vasectomy, TB
299
A 23 yo presents with dysuria and unilateral testicular pain and swelling, he had a new sexual partner 10 days ago. What is the most likely diagnosis and cause?
epididymo-orchitis, STI cause as <35.
300
Most likely cause of epididymo-orchitis in 40yo male?
Enteric, UTI pathogens.
301
A 19yo uni student presents with 10/7 headache, fever and a neck swelling, he’s now developed unilteral testicul pain, you exclude torsion, what is the most likely cause of this man’s epididymo-orchitis?
Mumps
302
Complications epididymo-orchitis?
Reactive hydrocoele, abscess formation and infarction of the testicle, infertility: obstructive azoospermia secondary to previous infection. mumps may lead to testicular atrophy.
303
First line treatment of epididymo-orchitis in a 28yo male?
Ceftriaxone 1g, doxycycline 100mg BD 10-14 days.
304
First line treatment of epididymo-orchitis in a 28yo male unable to have doxycycline?
Ceftriaxone and ofloxacin.
305
First line treatment of epididymo-orchitis in a 28yo male at low risk of GC?
doxycycline 100mg BD 10-14 days.
306
Lookback period for epididymo-orchitis?
Unknown. Based on the pathogen found. (used to be 6/12 screening, not treating but would consider tx partner if in long term relationship and reinfection risk.
307
First line treatment of epididymo-orchitis in a 50yo male?
Ofloxicin 200mg BD 14/7 (cover enteric/UTI causes)
308
What % males with epididymo-orchitis related testicular swelling will resolve by 3/12?
80%
309
If epididymo-orchitis related testicular swelling persists beyond 3/12 what should you do?
USS to assess, consider urology referral
310
Ix for suspected epididymo-orchitis?
Udip, MSU, STI screen, gram stain, culture urethra.
If suspecting TB: x3 early morning urine for AFB. if needed intravenous urography, renal tract USS and biopsy, CXR.
Mumps: IgM/IgG serology if risks
311
Follow up for male with epididymo-orchitis started on abx?
3/7 (can be phone) and 2/52. ToC if GC.
312
Causative organisms in PID?
CT & GC only account for 25%; Gardnerella vaginalis, anaerobes (inc prevotella, Atopobium, Leptotrichia) may also be implicated. Mgen also implicated
313
Signs and symptoms of PID?
Lower abdo pain – typical bilateral, deep dyspareunia, abnormal vaginal bleeding inc PCB/IMB/HMB, abnormal vaginal discharge; purulent, lower abdominal tenderness – bilateral, adnexal tenderness on bimanual, cervical motion tenderness, fever >38
314
Complications of PID?
Fitz-Hugh-Curtis syndrome – perihepatitis, right upper quadrant pain, Removal of IUD can be considered and may have better short term outcome BUT weigh against risk of pregnancy, infertility 8% one episode
315
Differential Dx for PID?
Ectopic, Appendicitis, Endometritis, Ovarian cyst complication, UTI, functional
316
Ix for PID?
Swabs: microscopy (low vaginal, wet slide for TV, endocervical), NAATs (C4/GC/TV +/- M Gen) and GC cultures (endo cx and urethra). Pus on cervical slide not diagnostic – poor PPV ~17% but its absence has high NPV ~95%. PT, BP/HR/temp (if systemically unwell).
317
Treatment of PID?
Info, analgesia, drink/fluids if needed, Ceftriaxone 1g IM stat + oral doxycycline 100mg bd for 14 days + metronidazole 400mg bd for 14 days
318
2nd line tx for PID of pen anaphylaxis?
ofloxacin 400mg BD and metronidazole 400mg bd for 14 days or moxifloxacin 400mg OD for 14 days
319
Tx of choice for PID due to m.gen?
Moxifloxacin 400 OD 14 days.
320
F/U of woman managed as outpatient with PID?
72hrs and 2-4 weeks.
321
Does a coil need removing in a woman being manged as an outpatient for PID?
No, 72hrs abx and r/v if still not improving remove (locus for infection).
322
A patient is treated for PID empirically, her m.gen returns positive what do you need to do for her?
If macrolide susceptible azithromycin 1g, 2 x 500mg or moxifloxacin.
323
P/N for PID?
Current partner and tracing of sexual contacts within 6/12 of symptom onset is recommended but can be amended according to sexual history.
324
Tx of partner of woman with PID?
Doxycycline 100mg BD 7/7 unless pathology known eg GC/TV. If m.gen test and treat if +ve.
325
Abstinence period in PID?
Partners should be advised to avoid intercourse until they and the index patient have completed the treatment course
326
Infertility risk with 1/2/3 episodes of PID?
infertility risk 20% with 2 episodes, 40% with 3
327
Inpatient IV abx for PID?
iv therapy should be continues until 24 hours after improvement Ceftriaxone 2g iv daily + iv doxycycline 100mg bd followed by oral doxycycline 100mg bd + oral metronidazole 400mg bd for a total of 14 days or Clindamycin 900mg tds iv + iv gentamicin 2mg/kg (loading) followed by 1.5mg/kg tds followed by oral clindamycin 450mg qds OR oral doxycycline 100mg bd + oral metronidazole bd for a total of 14 days.
328
Is PID common in pregnancy?
No it is rare
329
Average incubation period for STS and range?
21 days (9-90)
330
How long does a primary STS chancre take to resolve?
3-8 weeks
331
What % of untreated STS develop secondary STS?
25%
332
typical time from chancre to secondary STS signs developing?
4-10 weeks
333
Typical symptoms of secondary STS?
Macocutaneous rash, generalised lymphadenopathy, mucus patches, conylomata lata
334
Time frame to be considered early latent STS?
<2yrs
335
Time frame to be considered late latent STS?
>2yrs
336
Symptoms of late latent STS?
Gummatous disease (skin/bone lesions), CVD (usually affects ascending aorta – dilation and aortic regurgitation), neurological (menigovascular; infections arteritis stroke, general paresis; forgetful, personality changes, psychosis, seizures and hemiparesis, tabes dorsalis; sensory ataxia, argyll Robinson pupi, charcot joints, dorsal column loss (absent reflexes, join position sense and vibration sense))
337
Hx for sts?
Sexual, symptoms, previous test and treatment, and results, risk of jaw/pints/bejel, obs hx, examine genitals/skin/eyes/mouth, neuro exam if symptoms.
338
Ix for STS chancre?
Dark ground micro or PCR
339
Ix for STS bloods?
EIA screen, TPPA/VDRL to confirm, RPR to assess activity, IgM for sort of early disease.
340
Tx for primary, secondary or early latent sts?
1 x benzathine penicillin (2.4 megaunits) IM
341
Tx for late latent sts?
3 x benzathine penicillin (2.4 megaunits) IM day 0/7/21.
342
Follow up bloods for any STS?
0/3/6/12 months
343
What is considered a good response to tx in RPR in STS tx?
4 fold reduction
344
What reaction can take place after tx STS?
Jarisch-Herxheimer (febrile illness 4hrs after tx, can feel really ill for 24hrs)
345
If penicillin allergy what are the treatment options for sts?
Desensitisation or doxycycline
346
2nd line therapy for early latent STS tx where penicillin allergy is reported?
Doxycycline 100mg/BD for 14 days
347
2nd line theray for late latent STS tx where penicillin allergy is reported?
Doxycycline 100mg/BD for 28 days
348
If a person is treated with something other than penicillin based therapy for sts what follow up do they require?
0/3/6/12 months then annual for life
349
What should be given before treating cardiovascular sts?
Oral steroids 40-60mg prednisolone to reduce SE of tx. (same for neurosyphilis)
350
Treatment of early or secondary sts in a woman who’s 16/40 gestation?
1 x benzathine penicillin (2.4 megaunits) IM
351
Treatment of a women with early STS at 18/40?
2 x benzathine penicillin (2.4 megaunits) IM
352
Treatment of a women who is 30/40 with STS?
3 x benzathine penicillin (2.4 megaunits) IM, neonatal alert.
353
Treatment options for a penicillin allergy pregnant woman with STS?
Desensitisation therapy if time, amoxicillin, ceftriaxone azithromycin or erythromycin but tx failure more likely with macrolides.
354
If a person presents with high risk of sts but has negative serology what should be recommended?
Retest 6 and 12 weeks, ideally abstain
355
Abstinence period after STS tx?
Until 2 weeks after tx finished
356
Look back period for primary sts?
3/12
357
Look back period for secondary or early latent sts?
2 years
358
Lookback period for late latent STS?
Life long or until last neg test
359
Ix and Tx of ocular sts?
LP, serology, prednisolone 3 days starting 24hrs before tx with Procaine penicillin 1.8-2.4 MU IM OD plus probenecid 500mg qds for 14 days
360
When should sts serology be taken after a suspicious ulcer was dark ground or prc negative?
2/52
361
Adverse pregnancy outcomes for STS?
polyhydramnios, miscarriage, pre-term labour, still birth, hydrops, congenital abnormalities
362
what causes balanitis xerotica obliterans (BXO).
lichen sclerosis in men
363
treatment for balanitis xerotica obliterans (BXO).
information
skin care
steroids
annual f/u as minimum
364
what type of HPV is linked to Bowenoid papulosis?
HPV 18
365
a 60yo man presents complaining of skin changes to his penis, on examination you see a glazed orange area with red dots, it's been there for a few weeks or so and isn't particularly painful - what is the likely dx
zoon's balanitis (plasma cell)
366
what is the risk of balanitis xerotica obliterans (BXO) left untreated
loss of architecture, meatal stricture, scarring.
| Risk of malignant transformation
367
a 28 yo male presents with a sore and swollen penis and discharge. His last sexual intercourse was 6/12 ago.
O/E the glans is oedematous, and the discharge fowl smelling and hygiene standards suboptimal what is the likely dx and tx.
anaerobic balanitis
culture/sti screen
Tx with metronidazole (or co-amoxiclav)
368
a 28 yo male presents with grey white patches on the end of his penis, he also has discharge and microscopy suggests GC, he also has a knee. What is the likely overarching syndrome and what is the name for his penile skin condition
SARA (Reactive arthritis)
| Circinate balanitis
369
more common drugs to cause a fixed drug reaction
tetracyclines, salicylates, paracetomol, phenolphthalein and some hypnotics
370
management of a fixed drug reaction
hx taking to find the drug
stop the drug
can re-challenge with consent (may be worse)
rarely need biopsy
371
what is the condition where the biopsy findings are of follicular hyperkeratosis. This overlies a band of dermal hyalinisation with loss of the elastin fibres, with an underlying perivascular lymphocytic infiltrate
Lichen sclerosis and BXO
372
what is the condition where the biopsy findings are:
early cases show epidermal thickening but this
is followed by epidermal atrophy, at times with
erosions. There is epidermal oedema (often mild) and a
predominantly plasma cell infiltrate in the dermis with
haemosiderin deposition and extravasated red blood
cells
zoon's balanitis (plasma cell)
373
tx of zoon's balanitis
topical steroids, hygiene and skin care
| consider circumcising
374
a 28 yo male presents with grey white patches on the end of his penis, he also has discharge and microscopy suggests GC, he also has a knee. What would you investigate and treat this patient?
SARA and circinate balanitis
STI screen and treat as appropriate
Skin care/emollients
topical steroids
375
a 28 yo male presents with scaly red patches on his penis, the a slightly itchy. He has psoriasis on his torso and you suspect penile psoriasis, what is the treatment
emollients, steroids, consider dermatology in put ? calcitriol.
376
what are Erythroplasia of Queyrat, Bowen's disease, Bowenoid papulosis and VIN all forms of
Pre-malignant penile conditions.
377
three broad classifications of balanoposthitis
Infections (candida, TV, anaerobes, step A/B, staph aureus, STS, HSV, HPV, ect )
Dermatosis (lichen planus and sclerosis/zoons/psoriasis/circinate, fixed drug/SJS/contact allergy)
Miscellaneous (trauma, irritant, pre-malignant)
