Infections Flashcards
a 19-year-old sexually active woman who presents to your office with complaints of yellow vaginal discharge and intermittent postcoital vaginal bleeding for 1 week. She otherwise feels well. On examination, there is purulent discharge visible in the endocervical canal. After you collect vaginal fluid for a wet prep and cervical samples for gonorrhea and chlamydia cultures, you note bleeding at the cervical os. On bimanual examination, the patient complains of tenderness on cervical palpation but denies uterine or adnexal tenderness. Wet prep reveals vaginal pH 4; negative whiff; 20 white blood cells (WBCs) per high-power field; and no clue cells, trichomonads, or pseudohyphae.
what is the likely diagnosis
gonorrhea cervicitis
what is the diagnostic test for gonorrhea cervicitis
Nucleic acid amplification test (NAAT) of discharge or urine
what are the recommendations for treatment of gonorrhea
ceftriazone 500 mg IM as a single dose for a person weighting < 300lbs
what is the treatment of chlamydia trachomatis
oral doxycycline (100mg BID) for 7 days
a 21-year-old male complaining of pain during urination and a watery discharge from his penis. Gram stain of the discharge is negative for bacteria but shows many neutrophils. When questioned about his social history, he says that he uses condoms most of the time but occasionally has unprotected sex. The patient responds to treatment with doxycycline.
what is the diagnosis
chlamydia
a sexually active 18-year-old female with a complaint of vague pelvic pain, dysuria, frequency, and urgency. Pelvic examination is remarkable for cervicitis and the presence of cervical motion tenderness. Her urine sample is negative for nitrites, has greater than 5 to 10 WBC/HPF, and 3+ leukocyte esterase but no bacteria.
whats the diagnosis
chlamydia cervicitis
what is the most common STI
Chlaymdia
how does a woman present with chlamydia
urethritis
bartholinitis
cervicitis characterized by dysuria
abnormal vaginal discharge or post-coital bleeding
what is the gold standard diagnostic test for chlamydia
Nucleic acid amplification test (NAAT) = gold standard
a 22-year-old patient presents with a complaint of painful blisters on the vulva and vaginal introitus. She admits to a prodrome of burning, tingling, and pruritus before the appearance of lesions. Upon examination, you note vesicles on an erythematous base.
what is the diagnosis
Herpes simplex cervicitis
what is the gold standard diagnosis for herpes simplex
viral culture
can also do PCR or Tzanck prep scraping
what is the treatment options for herpes simplex
Valacyclovir (1,000mg BID for 7-10 days) > acyclovir due to TID dosing
if a patient has severe or frequent herpes outbreakes - what is the treatment of choice
valacyclovir 500mg once daily for most patients
a 38-year-old male with a history of soft, raised flesh-colored growths on his glans penis, prepuce, and penile shaft. He is sexually active with multiple partners and uses condoms infrequently. An excisional biopsy was carried out.
what is the diagnosis?
Human Papillomavirus (HPV)
what subtypes of HPV accound for >90% of genital warts
subtypes 6 and 11
what is the diagnostic test for HPV
shave or punch bipsy
Koilocytic squamous epithelial cells in clumps on PAP
what is the treament for HPV
spontaneous remission in months to a year is typical of skin warts - can do topical imiquimod or surgery
vaccination (gardasil and Gardisil9)
when is the guardasil vaccine administered
11-12 years should recieve 2 doses; may be initiated at 9 years old
Catch up for all persons 13-26 years regardless of risk factors
a 30-year-old woman complains of a painful sore on her vulva that first resembled a pimple. On examination, you find an ulcer with clearly demarcated borders, gray base, and foul-smelling discharge.
What is this sore called
Chancroid
what is the causative agent of chancroids
haemophilus ducreyi (gram negative rod that is very contagious)
what is the diagnostic test for chancroids
serologic testing for syphilis - PRP/VDRL
Gram stain, culture and biopsy
what is the treatmetn for chancroids
ceftriaxone 250mg IM and 1 dose of azithromycin 1g PO x
what is lymphogranuloma venereum (LVG)
ulcerative disease of genital area
uncommon STI
what are the stages of Lymphogranuloma venereum infection?
- primary stage: development of painless genital ulcers or papulses
- secondary stage: unilateral or bilat tender inguinal and/or femoral lymphadenopathy
- late stage: strictures, fibrosis and fistulae of anogential area
how is lymphogranuloma venereum diagnosed?
serologic testing for syphilis - RPR/VDRL
Definitive diagnosis = serology tests
HIV testing should be considered in pts with STI
what is the treatment of lymphogranuloma venereum infection?
doxycycline 100mg orally BID for 21 days
alternative regimen: erythromycin 500mg QID for 21 days
what are complications of PID
Infertility, ectopic pregnancy, tubo-ovarian abscess
what type of infection occurs when an infection ascents from the cervix or vagina to involve the endometrium and/or fallopian tubes
PID
what is the sign associated with cervical motion tenderness
chandelier sign
what are clinical findings that are suggestive of PID
abdominal tenderness
cervical motion tenderess
adnexal tenderness + one or more of the following:
- temp > 38C
- WBC count >10,000
- pelvic abscess found by manual examination/US
what are inpatient regimens of PID
IV cefotetan or IV cefoxitin + doxycyline (orally or IV)
what is the outpatient treatment of PID
- IM ceftriaxone + oral doxycyline +/- oral metronidazole
- IM cefoxitin + oral Probenecid + oral doxycyline +/- oral metronidazole
what is the cause of Syphilis
spirochete treponema pallidum
what is the presentation of primary syphilis
painless ulcer (chancre) in genital or groin region, persisting for 3-6 weeks
what is the presentation of secondary syphilis
non-pruritic maculopapular rash that includes the palms and soles or condyloma latum, lymphadenopathy, and constitutional sympotms persisting for 2-6 weeks
what is the presentation of tertiary syphilis
widespread systmic involvement and can present with major vessel changes, such as in the aorta, permanent CNS changes (neurosyphilis), or even gummas)
what is the presentation of condyloma latum
painless, flat, gray, wart-like lesions that occur on the skin in the genital region
what are gummas
painless, soft, tumor-like masses that can form in the skin, bones, liver or any other organ
how is syphilus diagnosis
RPR/VDRL and confirmed by the treponemal antibody - absorption test (FTA-ABS)
lyme disease can cause a false positive
what is the treatment of syphilis
Benzathine PCN G, 2.4 million units IM x 1 dose for primary and secondary disease
what are the symptoms of BV
vaginal discharge, with or wihtout vaginal odor and pruritis
what are the signs of BV?
Homogenous, frothy discharge, elevated vaginal pH, and a positive whiff test
what is the whiff test
detection of a fishy odor (caused by amines) when vaginal secretions are placed in 10% KOH
what is seen on the wet mount with BV?
clue cells and the absence of leukocytes, trichomonads and normal flora of rods
what are clue cells?
squamous eppithelial cells with ragged borders and stippling caused by colonization with bacteria
How is the diagnosis of BV made?
at least 3 of the following are required:
1. thin homogenous vaginal discharge
2. elevated vaginal pH (>5)
3. clue cells
4. positive whiff test
what is the treatment for BV?
Metronidazole 500mg PO BID for 7 days
what is the incidence of vulvovaginal candidiasis?
3/4 of woman suffer at least one episode in their lifetime, nearly half of these women have recurrent episodes
what are risk factors for vulvovaginal candidiasis
OCP use, recent abx therapy, corticosteroid therapy, pregnancy, poorly controled DM, tight-fitting undergraments
what is the cardinal symptom of vulvovaginal candidiasis
pruritis
how is the diagnosis of vulvovaginal candidiasis made?
pseudohyphae in vaginal secretions mixed wtih 10% KOH
vaginal pH = normal (<4.5)
what is the sensitivity of the KOH prep for vulvovaginal candidiasis?
aproximately 50-75%
what is the treatment for vulvovaginal candidiasis?
topical antifungal agents such as miconazole, clotriazole, terconazole, or a single dose of PO fluconazole
what risk factor is associated with trichomoniasis?
increased number of sexual partners
what are symptoms of trichomoniasis?
yellow vaginal discharge, dysuria, vulvar itching, dyspareunia, and occasionally lower abdominal pain
what are clinical findings of trichomoniasis
purulent frothy discharge with foul order; vaginal pH >5
what is the etiologic organism associated with trichomoniasis?
protozoan parasite trichomonas vaginalis
How is the diagnosis of trichomoniasis made?
Motile trophozoites, often accompanied by polymorphonuclear cells, are seen on wet mount
what is the treatment of trichomoniasis
metronidazole or tinidazole, 2g by mouth as a single dose therapy. all sexual partners should be treated
what presents as thich white cottage cheese discharge
candidal vaginitis
what presents with fishy, frey, scant, thin and sticky discharge
BV
what presents with green/yellow “frothy” discharge
Trichomonas
what presents on physical exam with a strawberry cervix
Trichomonas
a 32-year-old woman with an itchy vaginal discharge for the past two days. She has been healthy other than a recent sinus infection for which she took a 10-day course of amoxicillin. Her husband is her only sexual partner, and he has no symptoms. On examination, the vulva is noted to be slightly erythematous and swollen, with some evidence of excoriation. The discharge is white and clumpy.
what is the diagnosis
candida vaginitis
how is vaginal candida diagnosed
KOH branching Hyphae
pH < 4.5 (acidic)
a 24-year-old sexually active woman complains of a profuse, whitish-gray vaginal discharge with a fishy odor that becomes stronger after intercourse and during menses. She denies any irritation and states that her sexual partner has no symptoms. Microscopic evaluation of the discharge reveals granular-appearing epithelial cells.
what is the diagnosis
BV
what is the causative agent of BV
gardnerella (anaerobic bacteria)
what is the first line treatment of BV
Metronidazole (flagyl) either orally or vaginally
a 23-year-old G1P0 at 20 weeks gestation presents for a routine obstetric visit and complains of vaginal discharge for one week. She describes the discharge as watery and yellow and has had an associated burning sensation on urination. Her pregnancy has been uncomplicated. She denies having new sexual partners or a previous history of sexually transmitted diseases. On pelvic exam, there is a foul odor. You note red punctate lesions and inflammation of her cervix.
what is the diagnosis
Trichomonas vaginitis
a 59-year-old woman who is 9 years postmenopausal and complains of urinary urgency, frequency, and occasional incontinence. On pelvic examination, her vaginal mucosa appears shiny, pale pink with white patches, and bleeds slightly to the touch. Her urinalysis and urine cultures are negative.
what is the diagnosis
atrophic vaginitis
how is atrophic vaginitis diagnosed
presence of thin, clear, or bloody discharge, pH of 5-7, loss of vaginal rugae
- vaginal exam
what is the treatment of atrophic vaginitis
topical estrogen creams
conjugated estrogens vaginal cream 0.5-2g vaginally daiyl for three weeks then taper to lowest effective dose twice weekly
what infectious vaginal issues presents with a vaginal pH of >4.5
BV
what infectious vaginal issues presents with a vaginal pH of 4 to 4.5
vulvovaginal candidiasis
what infectious vaginal issues presents with a vaginal pH of 5-6
trichomonasis and atrophy
