JH IM Board Review - Infectious Disease IV Flashcards
PID - Encompasses:
- Endometritis.
- Salpingitis.
- Tubo-ovarian abscess.
- Pelvic peritonitis.
PID - MC etiology:
- N.gono.
- C.trachomatis.
==> Anaerobes, Gram(-) bacilli, streptococci, mycoplasma.
PID - CP:
HALLMARKS = FEVER + BILATERAL LOWER ABDOMINAL PAIN.
- RUQ tenderness from perihepatitis (Fitz-Hugh-Curtis syndrome) is seen in 10%.
- Pelvic exam may reveal cervical motion tenderness, adnexal tenderness, or purulent endocervical discharge.
- A palpable adnexal mass suggests a tubo-ovarian abscess.
PID - Dx - Clinical criteria for Dx:
ONE of the following:
- Uterine tenderness.
- Adnexal tenderness.
- Cervical motion tenderness.
PID - Dx - Additional criteria:
- Mucopurulent cervicitis.
- Presence of WBCs in vaginal secretions.
- Documented N.gonorrhoeae or C.trachomatis.
- Oral temperature greater than 38.3C.
- Elevated ESR or CRP.
PID - Dx - Definitive criteria include:
- Histopathologic evidence of endometritis.
- Radiologic evidence on transvaginal US.
- Laparoscopic evidence of PID.
PID - Tx - Outpatient Tx:
Ceftriaxone + Doxycycline +/- MNZ.
==> Empirical Tx is broad spectrum to cover N.gono, C.trachomatis, anaerobes, Gram(-) bacteria, and strep.
Inpatient Tx is provided when:
- Surgical emergencies cannot be excluded.
- Patient is pregnant.
- There is lack of response to or inability to take oral abx.
- Tubo-ovarian abscess is present.
Epididymitis/Prostatitis - Epididymitis is defined as …?
Inflammation of the epidydimis caused by:
- Infection.
- Trauma.
Epididymitis - Etiology:
In men <35 ==> N.gono (30%) + C.trachomatis (70%).
In men >35 ==> Gram(-) enterics (non STDs).
Prostatitis - Acute/chronic:
- Acute ==> E.coli and occasionally N.gono.
2. Chronic ==> Gram(-) bacilli (incl. E.coli) + Enterococci.
Epididymitis - CP:
UNILATERAL testicular pain and tenderness, edema, +/- hydrocele.
Epididymitis - Must r/o:
Testicular torsion - Especially when onset of pain is sudden, and pain is severe.
==> PYURIA is generally seen in epididymitis.
==> Doppler US.
Acute prostatitis - CP:
- Fever + Chills.
- Perineal pain.
- Back pain.
- Dysuria.
==> The prostate gland is tender on examination.
Chronic prostatitis - CP:
Indolent.
Epididymitis/Prostatitis - Dx:
- For epididymitis ==> Gram stain, culture, and/or NAA test of urethral exudates, intraurethral swabs, or urine.
- Dx ==> Of prostatitis is usually clinical ==> “Milking” the prostate by digital exam before voiding may induce pyuria.
Epididymitis/Prostatitis - Tx of epididymitis:
- For epididymitis most likely caused by gonococcal or chlamydial infection, Tx should cover both organisms.
- For epididymitis in patients >35 without risk of gonococcal or chlamydial infection, Tx should cover E.coli.
Tx of acute/chronic prostatitis:
- Tx of acute prostatitis ==> Ceftriaxone, quinolones, TMP-SMX for 14 days.
- Tx of chronic prostatitis ==> 4-6 weeks of a quinolone or 6-12 weeks of TMP-SMX.
Vaginitis - 3 types:
- Bacterial vaginosis.
- Trichomoniasis.
- Vulvovaginal candidiasis.
Bacterial vaginosis - Organism:
Replacement of normal Lactobacillus spp. with anaerobes.
Bacterial vaginosis - Discharge:
White, noninflammatory coating discharge..
Bacterial vaginosis - Specific diagnosis:
Clue cells seen on microscopy.
==> Vaginal pH>4.5 + whiff test (fishy odor on addition of 10% KOH).
Trichomoniasis - Organism:
T.vaginalis. (protozoan)
Trichomoniasis - Discharge:
Foul-smelling, frothy, yellow-green discharge.
Trichomoniasis - Specific Dx:
- Organism seen on microscopy of secretions (<70% sensitive).
- Culture.
- PCR now considered gold standard.
Vulvovaginal candidiasis - Discharge:
White, “cottage cheese” discharge.
Vulvovaginal candidiasis - Specific Dx:
Fungal elements seen on wet prep.
==> Vaginal pH 4-4.5.
Vaginitis - Tx - Bacterial vaginosis:
7-day MNZ 500mg twice daily.
Vaginitis - Tx - Trichomoniasis:
Single dose 2g oral MNZ.
Vaginitis - Tx - Sex partners of women with trichomoniasis should be treated …?
With 2g MNZ.
Vulvovaginal candidiasis - Tx:
Topical and oral antifungal agents may be used to treat vulvovaginal candidiasis.
Proctitis - Definition:
Inflammation of the lining of the rectum.
Proctitis - Major causes:
- N.gono.
- C.trachomatis D-K.
- C.trachomatis L1-L3 ==> LGN.
- Early syph.
- HSV-1/2.
LGV resurgence?
LGV has made resurgence in the USA and Western Europe in the last few years.
==> May cause strictures resembling Crohn disease.
Proctitis - All causes are …?
INDISTINGUISHABLE based on symptoms.
==> Testing for all the previous pathogens should be considered.
Proctitis - Dx:
NAA tests have the highest Se to detect N.gono and C.trachomatis (even though NOT FDA cleared for extragenital sites).
==> Culture or PCR for HSV.
==> Serology for syph.
Empiric Tx of proctitis:
Ceftriaxone + Doxycycline.
==> May be considered until test results are available.
Condylomata Acuminata (Anogenital Warts) - Basic info:
- HPV the cause.
- MC viral STD in the USA ==> Most infections asymptomatic and self-limited.
- High-risk types 16, 18, 31, 33, 35 ==> Cervical neoplasia (also dysplastic and neoplastic anal lesions).
==> Low risk HPV 6/11 RARELY associated with neoplasia, but cause 90% of warts.
Condylomata acuminata (Anogenital warts) - CP:
- Most infections are asymptomatic.
- Exophytic verrucous white or pigmented lesions.
- Symptoms vary according to site and size of the lesions.
Condylomata acuminata - Dx:
Visual inspection.
==> Evaluation may include: Anoscopy, sigmoidoscopy, colposcopy, and/or vulvovaginal exam.
==> Acetic acid 5% can be applied to facilitate identification.
Condylomata acuminata - Bx:
Serves to evaluate for dysplasia.
Condylomata acuminata - HPV DNA used in conjunction with the …?
PAP smear in women older than 30yr of age.
Condylomata acuminata - Tx:
- Depends on size, location, patient and provider preference.
- Tx include ==> Surgical removal, cryotherapy, or topical therapy with podophyllin, imiquimod, or trichloroacetic acid.
Condylomata acuminata - Prevention:
HPV virus-like-particle quadrivalent vaccine for types 6, 11, 16, 18 + Bivalent vaccine for types 16, 18 are recommended for ALL females ages 9-26.
==> Quadrivalent vaccine may be given to males ages 9-26yr.
==> Also effective in HIV-infected persons with CD4 counts greater than 200cell/mm3.