Infections

Question 1

what are clinical phases of syphillis

Answer 1

primary: days to weeks (9-90 days)
- single, nonpainful ulcer with clear margins

secondary: weeks to months (6 weeks to 6 months)
- condyloma lata
- maculopapular rash

tertiary: many years later
- gumma
- cardiac lesions
- tabes dorsalis
- argyll-robinson pupil

latent: most diagnosed during this time
- asymptomatic
- early latent = within 1 year of infection
- late latent = after 1 year of infection
- latent of unknown duration

Question 2

how is syphilis diagnosed?

Answer 2

• if active lesion: darkfield microscopy from shedding
• non-treponemal (sensitive) then treponemal tests (specific)
• non-treponemal: RPR, VDRL, STS
• treponemal: FTA-Abs, TP-PA, TPI, EIA
• if concern for neurosyphillis: need CSF VDRL

non-treponemal Abs change over time (therefore used for treatment response). treponemal are always positive

Question 3

what causes false positive RPR?

Answer 3

• autoimmune diseaese (SLE or positive ANA)
• small pox vaccintaion
• malaria
• mycoplasma pneuomnia
• aging
• IV drug use
• lyme disease

Question 4

how do you treat syphillis?

Answer 4

• primary + secondary + early latent: Benzathine PCN 2.4 million units x 1
• unknown + late latent + tertiary (with normal CSF exam): Benzathine PCN 2.4 million units x 3 weekly
• neurosyphilis + ocular syphilis: IV crystalline aqueous PCN

Question 5

what defines treatment failure for syphillis?

Answer 5

• sx persistence or recurrence
• 4x increase in titer for > 2 weeks
• failure of at least 4-fold decrease in 6-12 months

Question 6

options if pt is PCN allergic?

Answer 6

• Doxycycline 100 mg BID x 14 days or

- Tetracycline (Erythromycin 500 mg QID x 14 days)

Question 7

What is the diagnosis for a vulvar ulcer?

Answer 7

• HSV
• Syphillis
• Chancroid
• Lymphogranuloma venereum (LGV)
• Granuloma inguinale
• Bechet’s
• Vulvar cacrinoma

Question 8

clinical characteristics of chancroid, and diagnosis?

Answer 8

• painful ulcers with suppurative lymphadenopathy
• negative HIV, and negative lesions specific testing of syphillis (darkfiled microscopy) and HSV (PCR/culture of that site)
• It is due to H. Ducreyi (testing not available)

Question 9

treatment of chancroid?

Answer 9

• Azithromycin 1 mg PO
• CTX 250 mg IM x1
• Cipro 500 mg BID x 3 days PO
• Erythromycin 500 mg TID x 7 days

OR

Question 10

clinical characteristics, diagnosis of lymphogranuloma venereum (LGV)?

Answer 10

• due to chlamdyia
• clinical characteristics = gential ulcer or proctocolitis and LAD -> treat presumptively
• can support diagnosis with chlamydia serology but this is not needed

Question 11

treatment of lymphogranuloma venerum (LGV)?

Answer 11

• doxycyline 100 mg BID x 21 days

- erythromycin 500 mg QID x 21 days

Question 12

granuloma inguinale: clinical characteristics? diagnosis?

Answer 12

• due to klebsiella granulomatis
• painless ulcer with + subcutaneous granuloma. NO LAD
• highly vascular lesion (beefy red)
• dark staining of donovan bodies on microscopy required for diagnosis

Question 13

treatment for granuloma inguinale

Answer 13

• azithromycing 1 g weekly x3 or until all lesions completely healed
• alternative bactrim, cipro, doxy

Question 14

what is jarisch-herxeimer reactoin?

Answer 14

• acute febrile illness (can include HA, myalgia)
• typically in 1st 24 hours of syphillis tx, due to toxin released by spirochete
• can cause PTL

Question 15

primary treatment for HSV?

Answer 15

• acyclovir 400 mg TID x 7 days
• valacyclovir 1000 mg BID x 7 days
• Famciclovir 250 mg TID x 7 days

secondary: all for 5 days, except famciclovir 125 mg TID x 5 days
For HIV 5-10 days (except famciclovir increase dose to 500 mg BID)

suppression: acyclovir 400 mg BID, famciclovir 250 mg BID, valacyclovir 1000 mg daily
in HIV: valacyclovir 500 mg BID, acyclovir 400-800 mg BID-TID, famciclovir 500 mg BID
in pregnancy: acyclovir 400 mg TID or valacyclovir 500 mg BID