HSV, genital ulcers, chlamydia, gonorrhea, proctitis Flashcards
HSV, and infectious genital ulcers like chanchroid or syphilis or chlamydia
How to decrease HSV transmission in discordant couples
behavior and education - education about asymptomatic viral shedding.
consistent condom use (esp male to female transmission),
abstinence with prodromal symptoms and active lesions even with condoms
Serological testing for HSV
required for pt who is not previously diagnosed or previously confirmed with HSV
Test partner for susceptibility for HSV1 and HSV2
how to prevent HSV transmission to partner (medical tx)
daily valacyclovir (best studied once daily dosing)
daily acyclovir (more affordable)
helps to reduce asymptomatic viral shedding, decreases number of outbreaks and shortens outbreak duration.
small vesicles or ulcers on a erythematous base and see mild LAD
HSV, these are painful
larger deep ulcers with gray yellow exudate well demarcated borders and soft friable base with severe LAD that may suppurate
Haemophilus ducreyi (chancroid) and this is painful
chancroid is a painful
larger deep ulcer that is well demarcated and may have severe LAD that may suppurate seen from haemophilius ducreyi
single painless ulcer with regular borders and hard base
syphilis (painless) and it’s a chancre
small shallow ulcers that are often missed can progress to be painful and fluctuant adenitis
chlamydia trachomatis serovars L1-3 these are painless
lymphogranuloma venereum is also caused by
chlamydia trachomatis these can progress to painful fluctuant adenitis (buboes)
what test should always be ordered if someone has a genital ulcer
check HIV
lymphogranuloma venereum can have
regional lymph node suppuration and matting and develop sinus tracts. This is from Chlamydia trachomatis serovars L1-3
infectious genital ulcers chart
how does a tuboovarian abscess present?
acute lower abdominal pain, fever, and chills
see purulent cervical discharge.
Why do we not retest pts for chlamydia within 3 weeks after being treated for chlamydia
because NAAT can create false positives. NAAT for chlamydia can detect living and dead organisms.
Chlamydia trachomatis presentation in women
When to screen women for chlamydia trachomatis?
initial prenatal visit
age<25
age >25 with risk factors (multiple sex partners, sex workers)
clinical features of a chlamydia trachomatis infection
asymptomatic (most commonly)
cervicitis (post coital bleeding, purulent cervical discharge)
urethritis (sterile pyuria)
PID and perihepatitis (Fitz-Hugh-Curtis syndrome)
How to diagnose chlamydia trachomatis?
Nucleic acid amplification testing( NAAT) PCR from cervical swabs
Treatment of chlamydia is
azithromycin OR doxycyline
STI testing for HIV and Neisseria gonorrhea
how to follow up for test of cure for chlamydia?
test of cure 3 weeks after tx during pregnancy
test for reinfection 3-6 months after treatment
What is first line diagnostic test for chlamydia?
Can you have a false positive ?
NAAT or nucleic acid amplication testing for chlamydia trachomatis is more sensitive and specific than culture methods and is preferred for diagnosis of chlamydial infection.
Can have false positive test within 3 weeks of initial treatment because the tests detects both living and dead organisms.
test of cure is not indicated if the chlamydia infection is treated with first line antibiotics and resistance is low.
pt develops sudden onset inability to move her left side of face- left sided facial drooping, facial asymmetry and loss of left nasolabial fold. unable to fully close left eye wrinkle forehead or nose and inflate left cheek or show her teeth. NO other neurological complaints. NO travel, illness, rashes or tick bites. what is this?
How to treat?
What also to consider in differential?
sudden onset bell’s palsy and this is a result of HSV reactivation.
Generally 70-85% recover within 3 weeks but prednisone given 3 days of symptom onset improves recovery. Some also suggest valacyclovir can help with pts who have SEVERE facial paralysis.
ALso consider HIV, lyme dx, space occupying lesions (sarcoid or tumor or cholesteatoma or Sjogren’s syndrome).
Acute cervicitis
what causes it?
What is it’s clinical presentation
What happens if you don’t treat acute cervicitis?
can cause pelvic inflammatory disease or PID with sequelae like infertility, ectopic pregnancy and chronic pelvic pain.
In pregnant women it can cuse: spontaneous abortion, preterm labor from rupture of membranes or neonatal conjunctivitis
what is the clinical presentation of pts who have acute cervicitis?
see asymptomatic, mucopurulent discharge,
post coital or intermenstrual bleeding, or friable cervix.
how to diagnose acute cervicitis?
nucleic acid amplification testing (NAAT) for chlamydia or gonorrhea but also need testing for vaginosis and trichomoniasis.
Guidelines recommend empiric treatment (not waiting for test results) for pt and sex partners with azithromycin and ceftriaxone for gonorrhea and chlamydia.
Repeat testing is recommended in 3-6 months after treatment in pts with high reoccurrence.
do we ever get cervical gram stain to diagnose chlamydia or gonorrhea?
no because it has poor sensitivity for diagnosing gonorrhea
Sexually transmitted proctitis
what causes it?
What are the symptoms?
tenesmus, purulent discharge and small volume stools with blood is
proctitis
Can be due to UC, radiation tx, and infections - like neisseria gonorrhea which is the most common cause for this in anal receptive intercourse.
how to diagnose pts who have proctitis?
purulent discharge should be cultured and sent for gram stain, Tzanck prep, and culture for HSV, PCR for chlamydia trachomatis.
Also check for RPR and HIV.
differential for vaginitis and chart
What is this?
This vulvovaginal candidiasis - this is normal vaginal flora and seen commonly. But it can have overgrowth and invasion into the vaginal cells which creates symptomatic vulvovaginal candidiasis.
see vaginal discharge, pruritis, dysuria and dyspareunia.
Exam will show vaginal discharge and clumpy white discharge.
See pseudohyphae and budding yeast on wet mount microscopy.
what does this smear show?
bacterial vaginosis- diagnosed with 3 out of 4 cirtiera are present
-see thin gray vaginal discharge
vaginal pH >4.5
amine odor after applicaiton of potassium hydroxide (whiff test)
clue cells (epithelial cells covered in bacteria) on wet mount microscopy
Treatment of bacterial vaginosis is:
oral or vaginal metronidazole
can use clindamycin
also self limiting condition
erythema and infalmmation of vulvuovaginal area and see this on smear
This is trichomonas vaginitis
Treatment is metronidazole and must treat partner
treatment of vulvovaginal candidasis
can occur after antibiotic use
see vulvaginal pruritis, thick white clumpy discharge with this on wet mount (pseudohyphae)
tx with fluconazole
what is uncomplicated vulvovaginal candidiasis?
less than 3 episodes per year of VVC
immunocompetent
mild symptoms
Treatment of uncomplicated vulvovaginal candidiasis
Treatment of complicated vulvovaginal candidiasis
Treatment for uncomplicated vulvovaginal candidiasis is single course of oral (fluconazole) or topical (miconazole or clotrimazole) antifungal agent.
Complicated infections need longer treatment other than Candida albicans
Diagnosis of HSV
1st line - get a PCR testing or NAAT (nucleic acid amplification testing) by taking a sample by rotating swab firmly on the ulcer base after a vesicle is unroofed or from a lesion that has been ulcerated in less than 24 hrs.
2nd line - can get viral culture if not able to do PCR NAAT for HSV.
direct fluorescence antibody - not as sensitive as NAAT
type specific serological tests should not be obtained to confirm diagnosis.
what is done for HIV testing?
1. this screens serum for HIV antibodies + antigen screening at the same time as initial ELISA test
Basically looking at HIV antibodies (ELISA for HIV1/HIV2) and HIV p24 antigen
rationale: pts in window period where they are infected but not producing antibodies at high enough level to be detected will be missed. The antigen/antibody combination had a low false positive rate.
confirmatory testing is: with a HIV1/2 antibody differentiation immunoassay - if intermediate, then get HIV RNA testing by PCR.
if HIV1/HIV2 antibody differentiation immunoassay is positive- confirms infection.
If negative HIV1/HIV2 antibody differentiation, get HIV RNA testing by PCR. If that is positive, then it confirms HIV infection.
Treatment of PID (pelvic inflammatory disease)
Parentarel therapy
oral/ IM therapy
parenteral therapy: cefotetan 2g IV q12h or
cefoxitin 2g IV q6h + doxycycline 100 mg IV or PO q12h or
clindamycin 900 mg IV q8h + gentamicin 2mg/kg IV followed by a 1.5 mg/kg IV q8h
PO/IM therapy:
ceftriaxone 250 mg IM single dose + doxycycline 100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid for 14 days
or
cefoxitin 2g IM single dose with probenecid 1 g PO + doxycycline 100 mg
PO bid for 14 days with or without metronidazole 500 mg PO bid for 14 days
how to screen and diagnose chlamydia?
NAAT or nucleic acid amplification testing
1st catch urine (for men and women)
endocervical (for women) and urethral (for men) swabs
also screen for Neiserria gonorrhea too.
chlamydia can also cause oropharyngeal and rectal infection and so evaluate based on sexual practice.
empiric treatment for chlamydia/gonorrhea cervicitis and urethritis
ceftriaxone 250 mg IM single dose + azithromycin 1 gram PO single dose
ceftriaxone 250 mg IM single dose + doxycycline 100 mg bid for 7 days if can’t use azithromycin.
*cefixime 400 mg PO single dose if cannot use ceftriaxone.
Treatment of epididymitis?
ceftriaxone 250 mg IM single dose + doxycycline 100 mg PO bid for 10 days if due to chlamydia/gonorrhea
ceftriaxone 250 mg single dose + levofloxacin 500 mg PO daily (or ofloxacin 300 mg PO bid for 10 days) - if infection was chlamydia/gonorrhea and enteric organisms (insertive anal sex)
Do we test for cure in chlamydia and gonorrhea?
No, not for routine pts but if pregnant pt should be tested for cure.
No, except if you treated pharyngeal gonorrhea and used an alternate antibiotic regimen then you should test for cure.
All pts with gonorrhea and chlamydia should be retested in 3 months or next appointment due high risk for reinfection.
in disseminated gonorrhea, what must be done for culture isolates?
all N. gonorrhea isolates should be tested for antimicrobial susceptibility.
all suspected disseminated gonococcal infections should have cultures performed on blood, joint fluid (if arthritis is present), purulent skin lesions (if present) and CSF (if meningitis is present)
NAAT is always preferred; swab all potential sites of exposure (genital, pharyngeal, rectal). culture has poor sensitivity.
disseminated gonococcal infection has: arthritis, dermatitis, endocarditis or meningitis)
HPV strains that cause cervical and anal cancer?
HPV 16 18 31
pt has multiple myeloma and on bortezomib. What do you do?
bortezomib - has risk for herpes zoster reactivation so needs prophylaxis with acyclovir.
man presents with scrotal swelling, pain, and dysuria. sexually active with both men and women. no prior trauma. Has fever, HR 101 and vital signs are normal.
has right hemiscrotum that is edematous, tender to palpation of the superolateral aspect. scrotal pain lessens with elevation of scrotum. No penile discharge. NAAT of chlamydia and gonorrhea are pending.
what to treat with?
Treat with ceftriaxone + levofloxacin
pt has insertive anal sex. Need to cover for both chlamydia, gonorrhea, and enteric bacteria (of rectum) so need levofloxacin and not doxycycline.
epididymitis symptoms
fever, erythema, swelling of the hemiscrotum and tendereness to palpation near epididymitis
see urinary symptoms
Prehn’s sign - alleviation of pain with elevation of testicle or scrotum - supports epididymitis.
what is the Prehn’s sign?
Prehn’s sign - alleviation of pain with elevation of testicle or scrotum - supports epididymitis.
epididymitis has a bimodal distrubtion men <35 yrs and >55 years old.
Men <35 yrs STI from chlamydia and gonorrhea
Men >55 yrs those who practice insertive anal intercourse, E coli, enterobacteriaceae and pseudomonas.
