ICL 8.4: STIs Flashcards
what are the common STDs in the US?
- syphilis
- gonorrhea
- HSV
- chalmydia
- trichomonad
- HIV
- HPV
- Hepatitis A,B,C
- public lice
what type of treatment regimens do we want for STDs?
simple, one dose curative treatment!!!
what are the 5P’s of sexual history?
partners
practices
prevention of pregnancy
protection from STDs
past history of STDs
what are the characteristics of gonorrhea?
nonmotile non spore forming gram negative intracellular diplococci
may have pili which increase virulence by allowing better attachment to mucosal surfaces
what are the mechanisms of drug resistance of gonorrhea?
- chromosomal mediated
- plasmids
- transfer of naked DNA
what is the pathology of gonorrhea infections?
primarily infects columnar or cuboidal epithelium via attachment of bacteria to epithelium
bacteria then penetrate through and between epithelial cells
neutrophil response results in purulent discharge
how common is gonorrhea?
1 million cases/year in the US
sexual itnercourse and perinatal transmission are the 2 most common routes of transmission
what is gonorrhea in men?
most commonly recovered organism in acute urethritis in men under 35
90% of men with urethras gonorrhea infection are symptomatic however the majority of rectal and pharyngeal infections are asymptomatic
what are the symptoms of gonorrhea in men?
- abrupt onset of copious discharge and dysuria
- anorectal FC can be associated with proctitis
- pharyngeal GC is usually asymptomatic; harder to eradicate than the other types
what are the symptoms of gonorrhea in women?
most are asymptomatic…..
if symptomatic, vaginal discharge and prururitis are most common complains
can sometimes have pain
what are the severe presentations of gonorrha?
- PID = abdominal pain, adnexal.cervical tenderness, fever
- Fitz-Hugh Curtis syndrome
perihepatitis associated with PID resulting in RUQ
what is disseminated gonorrhea?
usually more common in women
two classic forms:
1. tenosynovitis, dermatitis, polyarthalgia syndrome = fever, ashiness, inflamed tendons, scattered pustules
derma
- septic arthritis
how do you diagnose gonorrhea?
gram stain of urethral discharge in symptomatic men –> 99% specific and 95% sensitive when PMNs and gram negative intracellular diploccoi are seem
DNA probes, NAAT, PCR are all types of non-culture methods for diagnosis of GC which are good for urine, endocervical specimens, and urethral swabs
how do you treat gonorrhea?
500 mg ceftriaxone IM single dose + 1 g orally azithromycin for chlamidya
how do you treat gonococcal conjunctivitis?
500 mg ceftriaxone IM single dose + 1 g orally azithromycin for chlamidya
how do you treat disseminated gonorrhea?
ceftriazone 1 gram IB or IM + azithromycin
how do you treat gonorrhea in pregnant women?
250 mg IM ceftriazone plus 1 gm PO azithromycin
doxycycline is not an alternative during pregnancy
which 3 chalmydia species cause disease?
- C. psittaci (pneumonia)
- C. pneumonia (pneumonia)
- C. trachomatis
different servars: LGV, etc.
what is the pathophysiology of chlamydia?
attaches to epithelial cells and enters to the cell by pinocytosis or endocytosis
it then resides intracellular membrane bound inclusions and growth and replication begins
what is LGV?
strain of chalmydia aka lymphogranuloma venereum
endemic in africa, SE asia, india and south america
predominantly a disease of the lymphatic system so associated with lymphangitis, inflammation and fibrosis of regional lymph nodes
what are the stages of LGV?
- painless ulcer or papule on genitals
- lymphadenopathy and systemic complaints 2-6 weeks later – unilateral femoral or inguinal lymphadenopathy with red, swollen tender lymph nodes which can form big abscessed inflammatory masses
- in about 20% of untreated cases, strictures of the anogenital tract can occur
how do you diagnose LGV?
clinical symptoms usually
can use NAAT with PCR if needed
what is LGV associated with?
75% of patients with LGV also have HIV!
how do you treat LGV?
doxycycline
what is chlamydia trachomatis serovars D-K?
urogenital infection resulting in urethritis
dysuria, urethral discharge sometimes but asymptomatic infections are common
what are the complications common in untreated chlamydia trachomatis serovars D-K?
- proctitis
- urethritis/epididymitis
- endometritis, cervicitis, salpingitis
- PID, ectopic pregnancy, infertility
- reactive arthritis (Reiter’s syndrome)
how do you diagnose chlamydia trachomatis serovars D-K?
NAATs
serology, cytology are rarely used
how do you screen for chlamydia trachomatis serovars D-K?
different recommendations from different groups….
CDC recommends routine annual screening of sexually active women under 25 and older women with new partners/multiple partners/other risk factors – prescreen all women who are treated 3 months later due to high reinfections
how do you treat chlamydia trachomatis serovars D-K?
azithromycin or doxycycline
azithromycin is preferred because it’s one dose while doxy is twice a day for 7 days
what is the big problem with chlamydia trachomatis serovars D-K treatment?
abstinence from sexual intercourse is recommended for 7 days after completion of therapy in patients AND sexual partners
this obviously is a problem and reinfection is very high
how do you treat chlamydia trachomatis serovars D-K in pregnancy?
azithromycin 1 gram by mouth one time – amoxicillin or erythromycin are fine but not doxy
test of use needed 3 weeks after therapy
retesting 3 months after treatment
do we screen for chalmydia in pregnancy? why?
recommended to prevent neonatal chlamydia infections:
- ophthalmia neonatorum whiten 5-12 days of birth
- pneumonia
what are the characteristics of trichomonas vaginalis?
flagellated, motile protozoan
how do women vs men present with trichomonas vaginalis?
women: asymptomatic to yellow vaginal discharge, dysuria, vulvar itching, dyspareunia, lower abdominal pain –> most common is purulent, copious frothy discharge with foul odor
men are usually asymptomatic
how do you diagnose trichomonas vaginalis?
- wet prep – take vaginal swab and mount on microscope to look for organism but only 60% sensitive
- culture is 95% sensitive
- NAATs are most commonly sued
how do you treat trichomonas vaginalis?
metronidazole or tinidazole 2 g orally in single dose
both fine in pregnancy
follow up because reinfection is common so prescreen 3 months after treatment
how does trichomonas vaginalis effect pregnancy?
adverse outcome in pregnancy like premature ROM, preterm delivery or low birthweight
however, standard treatment doesn’t seem to help these outcomes….
what is bacterial vaginosis?
not an STD but often confused with trichomonas vaginalis
partners don’t need to be treated
mild to moderate vaginal discharge, thing gray adherent, itching with odor
how do you diagnose bacterial vaginosis?
- homogenous thin white discharge that smoothly coats vaginal walls
- clue cells (epithelial cells coated with bacteria)
- pH over 4.5
- fishy odor og vaginal discharge before or after additional of KOH aka whiff test
how do you treat bacterial vaginosis?
metronidazole 500 mg orally twice a day for 7 days
how does bacterial vaginosis effect pregnancy?
adverse outcomes like preterm labor, PROM, intramaniotic infection, endometritis
treatment may improve these but clinical trials have mixed results….treat symptomatic pregnancy women with BV either way though
how does HSV present?
60% are asymptomatic with primary infection so usually when people walk in it’s actually a reactivation
vesicular lesions that are clustered is the most common – can also form painful ulcers and can affect urethra which can be mistaken for UTI
primary disease lasts up to 3 weeks with regional lymphadenopathy, fever, malaise, anorexia, assertive meningitis –> recurrence occurs in 90% of patients with symptomatic HSV2 genital infections with itching, tingling, burning prior to an eruption but systemic complains are rare
how is HSV transmitted?
usually it’s transmitted by persons unaware that they have the infection or who are asymptomatic when transmission occurs because they are intermittently shedding the virus in the genital tract
asymptomatic viral shedding is more frequent with HSV2 than HSV1
how do you diagnose HSV?
- Tzanck smear
- cutlure
- PCR
how do you treat HSV?
acyclovir
how does hSV effect pregnancy?
can cause neonatal herpes….
it’s 30-50% for women who acquire genital HSV near term but only 1% in women with a history of genital HSVHSV in the first 1/2 of pregnancy
treat with acyclovir 400 mg 3x daily
what causes syphilis?
treponema pallidum
what is the pathology of syphilis?
spirochetes penetrate skin or mucous membranes then enter lymphatics and hematogenously idsseminate
what is the presentation of primary syphilis?
- ulcerated non-tender ulcers = chancres; with hard, smooth clean base
- contender inguinal lymphadenopathy often bilateral
serologic tests are positive only 50% of the time at this stage…
what is the presentation of secondary syphilis?
3-6 weeks after chancre
generalized rash involving the palms, soles oral mucosa and genitals but it isn’t that itchy
can also see sore throat, myalgia, constitutional complaints, patchy alopecia, generalized lymphadenopathy, condylomata lata, oral ulcers
what is the presentation of tertiary syphilis?
- meningitis
- dementia
- hearing loss
tabes dorsalis - disease of aorta with potential incompetence/aneurysm
- arthralgia
- argyll robertson pupil = = accomodates to near vision but doesn’t react to light
- gummas
when do you screen for syphilis?
screen at first prenatal visit and consider prescreen in third trimester
how does syphilis effect the fetus?
- saber shins
- saddle nose
- Hutchinson/mullbery teeth
how do you diagnose syphilis?
treponema test for antibodies against T palladium
nontreponemal tests are nonspecific so there’s lots of false positive!
VDRL and RPR are both nontreponemal tests which test for IgG antibodies
titers drop with treatment and eventually become negative
how do you treat syphilis?
penecillin
no other recommendation!! even if they’re allergic
what is a chancroid?
infection with gram negative rod H. ducreyi
presents with painful ulcer, ragged edges, painful inguinal lymphadenopathy
often associated with HIV
how do you treat a chancroid?
azithromycin, ceftriaxone, ciprofloxacin, or erythromycin base
what is donovanosis?
klebsiella granulomatis that results in painless destructive ulcers without regional lymphadenopathy
omg so horrible looking
how do you treat donovanosis?
doxycycline, azithromycin, or cipro
