M19: Disease Transmission II: STIs

Question 1

The Burden of Sexually Transmitted Infections:

Young people, aged 15-24, account for 50% of the new infections. The number of new infections is roughly _ among young women and men.

The eight most common STIs are (in order from highest incidence): (8). The CDC conservatively estimates that the lifetime cost of treating these eight STIs in just one year is $15.6B, especially since some STDs (like HIV) require lifelong treatment and care. The annual cost of curable STIs is also significant at $742M.

Concerning issues such as increasing _ in Neisseria gonorrhea and increasing _ of Hepatitis C in the MSM population pose additional challenges in the management of STIs.

The very nature of the anatomic differences between the male and female reproductive organs can result in two distinct STI pathologies. For example, in males, Chlamydia or gonorrheal disease is typically manifested as _, while in females, the pathogens may ascend to the upper reproductive tract to produce _.

A combination of biomedical, behavioral, and structural interventions are necessary in the management and prevention of these diseases.

Answer 1

equal

HPV, Chlamydia, Trichomoniasis, Gonorrhea, HSV-2, Syphilis, HIV, and Hepatitis B

antimicrobial resistance
sexual transmission

uncomplicated urethritis
pelvic inflammatory disease (PID)

Question 2

Syndromes of STIs in Females:
No symptoms, but at risk for STD

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 2

C. trachomatis (Ct), N. gonorrhoeae (Ng), HPV, HSV, HIV, HBV, others

None or subtle

Cervical swab or urine for Ct and Ng; HIV, syphilis serology; Pap smear; pregnancy test if missed period; bimanual examination if pelvic discomfort

If known contact with STD, treat according to contact guidelines for index STD regardless of findings. Otherwise, treat according to results of screening test

Question 3

Syndromes of STIs in Females:
Vaginitis/vaginosis

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 3

Yeast (Y), bacterial vaginosis (BV), Trichomonas vaginalis (TV)

Y: itching, redness, clumpy white discharge BV: amine odor, discharge TV: itching, redness, discharge

Vaginal swab for pH test, amide odor whiff test, wet mount, Gram stain Cervical swab or urine for Ct and Ng

Y: Topical imidazole or oral fluconazole BV or TV: metronidazole

Question 4

Syndromes of STIs in Females:
Cervicitis

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 4

C. trachomatis, N. gonorrhoeae, HSV

Genital discharge, lower abdominal pain, intermenstrual bleeding

Vaginal swab for pH test, amide odor whiff test, wet mount, Gram stain Cervical swab or urine for Ct and Ng

Give empirical treatment for Ct and Ng.

Question 5

Syndromes of STIs in Females:
Pelvic inflammatory disease

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 5

C. trachomatis, N. gonorrhoeae, Enterobacteriaceae, anaerobic bacteria

Can be subtle Lower abdominal pain, deep dyspareunia, abnormal bleeding, tenderness on cervical motion

Can be subtle Lower abdominal pain, deep dyspareunia, abnormal bleeding, tenderness on cervical motion

Treat with antibiotic regimen active against all major causes Hospitalize if (1) surgical emergency cannot be ruled out, (2) severe illness, (3) tubo-ovarian abscess, (4) failed oral therapy

Question 6

Syndromes of STIs in Females:
Genital ulcer or vesicle

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 6

HSV, Treponema pallidum, Haemophilus ducreyi

Painful or painless ulcers or vesicles + inguinal lymphadenopathy

HSV: Swab base of unroofed blister for HSV Syphilis: serology

HSV: acyclovir Syphilis: benzathine penicillin

Question 7

Syndromes of STIs in Females:
Papular genital lesions

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 7

HPV, Molluscum contagiosum, condylomata (CL) (secondary syphilis)

HPV, Molluscum contagiosum, condylomata (CL) (secondary syphilis)

HPV: direct exam using magnification, Pap smear Syphilis: serology

HPV: liquid nitrogen, podophyllotoxin, others Syphilis: benzathine penicillin

Question 8

Syndromes of STIs in Males:
No symptoms, but at risk for STD

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 8

C. trachomatis (Ct), N. gonorrhoeae (Ng), HPV, HSV, HIV, HBV, others

None or subtle

Urethral swab or urine for Ct and Ng; HIV, syphilis serology; examine for ulcers and papules (HSV culture if ulcerative lesions present); palpate for scrotal and inguinal nodes

If known contact with STD, treat according to contact guidelines for index STD regardless of findings. Otherwise, treat according to results of screening test.

Question 9

Syndromes of STIs in Males:
Urethritis

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 9

C. trachomatis (Ct), N. gonorrhoeae (Ng), HSV

Urethral discharge, dysuria, irritation of distal urethra or meatus

Urethral swab for Gram stain, culture for Ng, test for Ct (urine PCR)

Give empirical treatment for Ct and Ng.

Question 10

Syndromes of STIs in Males:
Epididymitis

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 10

C. trachomatis, N. gonorrhoeae, Enterobacteriaceae

Unilateral scrotal swelling and/or tenderness

Urethral swab for Gram stain, culture for Ng, test for Ct (urine PCR) Midstream urine collection for bacterial culture

Give empirical treatment for Ct and Ng, and consider use of agent effective against urinary tract pathogens.

Question 11

Syndromes of STIs in Males:
Proctitis

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 11

C. trachomatis, N. gonorrhoeae, HSV

Anorectal pain (+ discharge), tenesmus

Anal swab for Ct and Ng, Gram stain Swab of vesicular lesions for HSV culture

If no indication of HSV, treat empirically for Ct and Ng.

Question 12

Syndromes of STIs in Males:
Genital ulcer or vesicle

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 12

HSV, Treponema pallidum, Haemophilus ducreyi

Painful or painless ulcers or vesicles + inguinal lymphadenopathy

HSV: Swab base of unroofed blister for HSV Syphilis: serology

HSV: acyclovir Syphilis: benzathine penicillin

Question 13

Syndromes of STIs in Males:
Papular genital lesions

Causes

Symptoms/Signs

Diagnostic Testing

Treatment

Answer 13

HPV, Molluscum contagiosum, condylomata (CL) (secondary syphilis)

HPV, Molluscum contagiosum, condylomata (CL) (secondary syphilis)

HPV: direct exam Syphilis: serology

HPV: liquid nitrogen, podophyllotoxin, others Syphilis: benzathine penicillin

Question 14

Chlamydia trachomatis Infection:
Biology and Life Cycle

a. They are (obligate / facultative) (intracellular / extracellular) pathogens that have an outer membrane that contains _ and membrane proteins but have no _ layer.
b. Although they contain DNA, RNA, and ribosomes, during growth and replication, they obtain _ compounds from the host cell, hence they have considered as _.
c. The chlamydial genome encodes an abundant protein called the _ which is a transmembrane protein with surface antigenic components and is the major determinant of serologic classification.
d. The developmental cycle of chlamydiae set them apart from other bacteria, and involves two highly specialized morphologic forms: the _ and the _.
e. The developmental cycle initially involves the attachment and penetration of the _ to susceptible host cells. Evidence exists that chlamydiae may exploit multiple mechanisms of entry. One documented mechanism is by _

Answer 14

a. obligate, intracellular, lipopolysaccharide (LPS), peptidoglycan
b. high-energy phosphate, energy parasites
c. major outer membrane protein (MOMP or OmpA)

d. extracellular form or elementary body (EB)
replicative form or reticulate body (RB)

e. EB, receptor mediated endocytosis

Question 15

Chlamydia trachomatis Infection:
Biology and Life Cycle

f. Once inside the cell, the EB prevents fusion of the _ with _, protecting itself from _.
g. It reorganizes into the metabolically active and dividing form, the _, at some time within the first 6-8 hours after _.
h. At the RB stage, chlamydiae synthesize their own DNA, RNA, and proteins using the _. As the RB divides by _, if fills the endosome, now a cytoplasmic inclusion, with its _.
i. After 48-72 hours, multiplication ceases and _ occurs as the RBs transform to new infectious _. RBs (are / are not) stable outside the host cell.
j. The EBs are then released from the cell by _, by a process of _, or by _ of the whole inclusion, leaving the whole cell intact. The latter may explain the frequency of asymptomatic or subclinical chlamydial infections.
k. The release of the EBs allows _

Answer 15

f. endosome with lysosomes, enzymatic destruction
g. RB, entering the host cell
h. host-cell pool of precursors, binary fission, progeny
i. nucleoid condensation, EBs, are not
j. cytolysis, exocytosis, extrusion
k. infection of new host cells to occur.

Question 16

Chlamydia trachomatis Infection:
Epidemiology and Classification

a. There is an estimated 3M new cases of Chlamydia in the US annually, making it the most _ in the US. The direct and indirect cost of chlamydial infection, including costs of treating complications, total ~$2.4B.
b. Many men and most women infected are either _ and presentation for diagnosis is a result of screening or a contact being symptomatic.
c. In screening programs, _ age, being _, a home-of-record from the _, _ sex partner, _ sex partner, lack of _, and a _ are correlates of infection.
d. The family _ consists of the genus Chlamydia and the genus _. These are some of the most widespread bacterial pathogens in the world and there are several species which infect a variety of hosts based on tissue tropism.

Answer 16

a. commonly reported notifiable disease
b. asymptomatic
c. young, African American, south, more than one, a new, condom use, history of having an STD
d. Chlamydiaceae, Chlamydophila

Question 17

Chlamydia trachomatis Infection:
Epidemiology and Classification

e. There are at least 18 _ of C. trachomatis with several distinctive clinical patterns of disease
f. C. trachomatis _ is prevalent in Africa, Asia, and South America. Outbreaks have been reported in Europe and North America, particularly in MSM.
g. Chlamydophila pneumonia infects the human _ and causes _ and _. Chlamydophila psittaci is a bird pathogen but can cause _ infection of humans resulting in _.

Answer 17

e. serovars
f. biovar LGV

g. respiratory tract
bronchitis and pneumonia
zoonotic
pneumonia (psittacosis)

Question 18

Chlamydia trachomatis Infection:
Epidemiology and Classification

Disease(s) for Serovars A-C

Disease(s) for Serovars D-K

Disease(s) for Serovars L1-L3

Answer 18

Trachoma

non-gonococcal urethritis (NGU), epididymitis, mucopurulent cervicitis, pelvic inflammatory disease, conjunctivitis, infant conjunctivitis and pneumonia

lymphogranuloma venereum (LGV)

Question 19

Chlamydia trachomatis Infection:
Pathogenesis

a. All chlamydiae share a common genus-specific antigen found on _. C. trachomatis strains also share species-specific and type-specific antigens on the _.
b. LGV strains have broader tissue and host spectrum. They cause systemic infection involving _ tissues and have been shown in vitro to replicate within _. On the other hand, non-LGV strains are confined mostly to _.
c. Natural infection with C. trachomatis appears to confer very little protection against _ and that which is conferred is (short / long) lived.

However, there is a strong (direct / inverse) relationship between age and susceptibility to chlamydial infection even when corrected for frequency of sexual contact, suggesting effective _ eventually develops.

Recurrent infections with chlamydiae result in repeated _ insults, and consequent increased _ and _.

Answer 19

a. LPS, MOMP
b. lymphoid, macrophages, mucosal epithelial cells
c. reinfection, short

inverse, adaptive immunity

inflammatory, scarring and tissue damage

Question 20

Chlamydia trachomatis Infection:
Pathogenesis

d. The disease process and clinical manifestations of chlamydial infections is likely due to the combined effects of _ from chlamydial replication and the _ responses to the pathogen as well as the _ from destroyed host cells.
i. C. trachomatis serovars A through K initially infect and grow within epithelial cells of the _ and _; resident macrophages and dendritic cells are also exposed to released _ but do not sufficiently support _ development.
ii. Inflammatory mediators and chemokines produced by infected epithelial cells serve as initial triggers for an influx of _ including (5).
iii. As the host immune response develops, active sites of infection show an infiltration of _, _, and _.

The chronic inflammatory process leads to _ necrosis, _ proliferation, and eventual _ formation. Thus, the serious sequelae of C. trachomatis infections are mediated by the host immune response.

Answer 20

d. tissue damage, inflammatory, necrotic material
i. ocular and genital mucosae, EBs, bacterial
ii. leukocytes, neutrophils, natural killer cells, dendritic cells, monocytes, and lymphocytes
iii. lymphocytes, plasma cells and macrophages

epithelial cell, fibroblast, scar tissue

Question 21

Chlamydia trachomatis Infection:
Clinical Manifestations:
Infections in Males

i. Urethritis: The patient complains of _ or note of a clear or mucopurulent _ at least 7-14 days following contact with an infected partner. Some patients may deny the presence of discharge but may note _ in the morning.
ii. The primary complications of chlamydial urethritis in men are:
1. _
2. _ including _ syndrome:

Approximately 1% of men with non-gonococcal urethritis develop an acute aseptic arthritis syndrome referred to a _. A third of the cases have the full complex of Reiter’s syndrome which consists of the triad of _, _, and _. Most patients carry the histocompatibility antigen _.

3. Transmission to _
   iii. _ infection has been demonstrated in 3-6% of men and women attending STD clinics and correlates with a recent history of orogenital contact.

Answer 21

i. dysuria, urethral discharge, stained underwear
1. Epididymitis
2. Reactive arthritis, Reiter’s

sexually reactive arthritis
arthritis, urethritis, and conjunctivitis
HLA-B27

3. women
   iii. Pharyngeal

Question 22

Chlamydia trachomatis Infection:
Clinical Manifestations:
Infections in Females

i. Urethritis, cervicitis: The patient complains of (5). The cervix can appear normal or exhibit (4). Some women may develop ascending infection of the genital tract resulting in _ (infection of the uterine tissues) and _ (infection of the Fallopian tubes).
ii. Bartholinitis: Like gonococcal infection, C. trachomatis may cause an exudative infection of _.
iii. Pelvic Inflammatory Disease (PID)
1. A sexually transmitted infection ascends from the _ and _ to involve the (4).
2. Lower _ pain, usually _, is the most common presenting symptom.
3. Pain may be associated with (8)
4. PID may lead to (3).
5. It is more commonly present in a subclinical form but continues to lead to associated long-term sequelae of _ and _.
6. The spectrum of PID associated with C. trachomatis infection ranges from _, _ disease with perihepatitis and ascites (Fitz-Hugh-Curtis syndrome) to _ or _ disease.

Answer 22

i. dysuria/pyuria, cervicovaginal discharge, mild abdominal pain, intermittent bleeding, and dyspareunia
edema, erythema, friability, or mucopurulent discharge
endometritis
salpingitis

ii. Bartholin’s ducts

1. vagina and cervix
   uterus, Fallopian tubes, ovaries, and peritoneal tissues
2. abdominal, bilateral
3. vaginal discharge, abnormal uterine bleeding, dysuria, dyspareunia, nausea, vomiting, fever, or other constitutional symptoms.
4. tubal infertility, chronic pelvic pain, and ectopic pregnancy
5. infertility and ectopic pregnancy
6. acute, severe
   asymptomatic or “silent”

Question 23

Chlamydia trachomatis Infection:
Clinical Manifestations:
Lymphogranuloma venereum (LGV)

i. This is caused by _ (L1-L3).
ii. The first symptom is the development of a _: a small painless _ or _ at the site of infection (penis or vagina).
iii. The patients then develop (3) followed by inflammation of the _. The LN can become _, _, and can eventually _. _ can occur due to obstruction of the lymphatics.
iv. _ can occur in both sexes followed by _, _, and in females, formation of a _. The early symptoms of rectal infection are _ and _. Early symptoms also include (3).

Answer 23

i. C. trachomatis biovar LGV

ii. primary lesion
papule or ulcer

iii. fever, headache, and myalgia
draining lymph nodes (LN)
enlarged, painful, rupture
Edema

iv. Proctitis
rectal damage, strictures, rectovaginal fistula
anal pruritus and a mucoid rectal discharge
fever, rectal pain, and tenesmus

Question 24

Chlamydia trachomatis Infection:
Clinical Manifestations:
Infections in Newborns

i. _: This is the major clinical manifestation of neonatal chlamydial infection. It typically presents as a _ becoming progressively _. The incubation period is 5-14 days after birth but may be as late as 6 weeks of age.
ii. _: This typically occurs between 4-11 weeks of age. Symptoms of _ and _ without _ gradually worsen over a week or more. Infants are usually symptomatic for 3 or more weeks before they are brought to the clinic/hospital since most are only moderately ill and are afebrile.

Answer 24

Conjunctivitis
watery ocular discharge
purulent

Pneumonia
nasal congestion and cough without fever

Question 25

Chlamydia trachomatis Infection:
Diagnosis

a. _: This may be used for urine, vaginal and endocervical swabs, and rectal samples.
b. Isolation of organism in _
c. Examination of clinical specimens for inclusion bodies by _

Answer 25

Nucleic Acid Amplification Test (NAAT; most commonly used)

cell culture

immunofluorescence microscopy

Question 26

Chlamydia trachomatis Infection:
Treatment and Prevention

a. _ (single dose) or _ (1 week course); consider concurrent treatment for gonococcal infection if prevalence of gonorrhea is high (>5%) in patient population where infection was likely acquired
b. In pregnant women: _ (single dose) or _ (1 week course)
c. For LGV: _ for at least 3 weeks
d. Chlamydial resistance to conventional antibiotics (has / has not) emerged
e. _ (abstinence, mutual monogamy with an uninfected partner, limiting number of sexual partners, etc.) and _ should be emphasized

Answer 26

a. Azithromycin or Doxycycline
b. Azithromycin or Amoxicillin
c. doxycycline
d. has not
e. Behavioral modification and barrier protection

Question 27

Chlamydia trachomatis Infection:
Treatment and Prevention

f. Universal screening of _ should be done annually since it has been found to reduce the incidence of PID. For women >25, screening should be done if _ are present. _ women should be screened at first prenatal visit.
g. Screening of sexually active young men should be considered in clinical settings with a high prevalence of _ (adolescent clinics, correctional facilities, STD clinics)
h. Sex partners should be evaluated, tested, and treated if they _
i. The most recent sex partner should be evaluated and treated even if _
j. Patients should be instructed to _ until they and their sex partners have completed 7 days after a single dose of azithromycin or until completion of the 7 day regimen.

Answer 27

f. sexually active women ≤25
risk factors
Pregnant

g. infection
h. had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms of diagnosis.
i. the time of the last sexual contact was >60 days before symptoms onset or diagnosis.
j. abstain from sexual intercourse

Question 28

Syphilis:
The Pathogen

a. Treponema pallidum causes three infections of major public health importance: (3). Three morphologically identical subspecies of T. pallidum cause these infections.
b. T. pallidum subspecies pallidum is the causative agent of _, a multifaceted disease of humans that progresses through a series of sequential stages.
c. Treponemes are _ that exhibit _ locomotion through the use of their _.
d. The outer membrane lacks the classical _ found in other gram negative rods. The outer sheath contains a series of complex _, similar to those found on various host cells and tissues that may aid in allowing the organism to evade host immunity.

Answer 28

a. syphilis, yaws, and bejel
b. syphilis

c. tapered, thin spiral rods
corkscrew
endoflagella

d. LPS
glycosaminoglycans

Question 29

Syphilis:
Epidemiology

a. The major routes of transmission are _ and _. They are most contagious during the _ and _ stages.
b. Despite a historic low of syphilis cases in the US in 2000, rates of P&S syphilis increased during 2004-2008 and continued to increase in _, specifically among _. In 2011, there were 13,970 P&S syphilis cases in the US (4.5 per 100,000 persons) and 72% of the cases were MSM.
c. The increasing rate in the _ population has also been observed in major metropolitan areas in the Southeast.
d. The rate of congenital syphilis increased from 2006-2008 but decreased from 2008-2011. This decrease is associated with the decrease in rate of P&S syphilis among women that occurred since 2008.

Answer 29

a. sexual and vertical
primary and secondary (P&S)

b. men, MSM
c. low socioeconomic, African American heterosexual

Question 30

Syphilis:
Pathogenesis

a. _ are the sole reservoir for T. pallidum. Infection is initiated by the penetration of _ through minor _ in the skin or intact mucous membranes, or by _ transmission from mother to fetus
b. Within a few hours to days, the organisms _. It is believed that the active motility of the organism is essential for _ and _.
c. In P&S disease, infectious treponemes are demonstrated easily in _. These heal completely whereas _ result in irreversible tissue destruction and fibrosis. Invasion of the _ can occur during any stage.
d. Tertiary lesions consist of _ and _ and _ disease. _ are large granulomatous lesions with a central necrotic mass surrounded by plasma cells, lymphocytes, and monocytes. Demonstration of the organism in these lesions is difficult since the lesions are thought to represent an _. _ is associated with pathologic changes in the proximal aorta.

Answer 30

a. Humans
treponemes
abrasions
transplacental

b. disseminate
invasion and dissemination

c. lesions
tertiary lesions
central nervous system (CNS)

d. gummas and cardiovascular and CNS
Gummas
inflammatory response to a few organisms
Cardiovascular syphilis

Question 31

Syphilis:
Clinical Manifestations:
Primary Syphilis

i. At the site of entry, the initial _ of syphilis appears around 10-90 days (average of 3 weeks) after exposure. It is a _ that grows to a size of 0.5-1.5cm in diameter which ulcerates in about a week producing a round or slightly elongated ulcer, 1-2cm with an indurated margin. This lesion is called a _. It is painless and has a clear base.
ii. Chancres may occur in the _, _ areas, and the _. Women may not seek care for primary disease because the _ in the vagina or cervix is not visible.
iii. Painless non-suppurative enlargement of the local _ accompanies the chancre and can persist for months.
iv. Primary lesions contain infectious _. _ begins within hours after superficial invasion and continues throughout the primary and secondary disease stages.

Answer 31

i. lesion
papule
chancre

ii. penis, vagina/cervix, perianal/ anal/ rectal areas, and the oral cavity (usually the tongue)
chancre

iii. lymph nodes

iv. treponemes
Hematogenous dissemination

Question 32

Syphilis:
Clinical Manifestations:
Secondary Syphilis

i. The onset of secondary syphilis is highly variable but typically occurs 2-8 weeks after the disappearance of a _. Many patients do not recall a history of a primary lesion.
ii. Secondary syphilis typically presents with (5). Although the cutaneous manifestations may be diverse, the classic presentation is a _ that often, but not always, involves _ and _.
iii. Other cutaneous manifestations include _ which can be seen in ~10% of patients. These are raised, enlarged, broad, whitish to gray lesions occur in _, _ areas. These lesions are teeming with _. Patchy _ (thinning of hair) can also be seen and is caused by syphilic involvement of the hair follicles.
iv. _ is found in 85% of patients. Other organs may be involved, and patients may present with (3). CNS involvement may manifest as an aseptic _ picture.

Answer 32

i. chancre

ii. rash, fever, headache, pharyngitis, and lymphadenopathy
diffuse maculopapular rash
palms and soles

iii. condyloma lata
warm, moist
spirochetes
alopecia

iv. Painless, generalized lymphadenopathy
uveitis, hepatitis, or glomerulonephritis
meningitis

Question 33

Syphilis:
Clinical Manifestations:
Latent Syphilis

i. Early latent: Without treatment, manifestations of secondary syphilis _. The disease enters a _ phase characterized by a _. This stage is defined as the _ period during the first year after initial syphilis infection.
ii. _ of secondary lesions occur in 25% of cases, usually within the first year.
iii. Late latent: This is the _ phase greater than 1 year after initial infection. Unlike early latent syphilis, this stage is not thought to be _ (except in pregnant women) and would require a longer duration of _ compared to early latent syphilis.

Answer 33

i. resolve within a few weeks
latent
lack of clinical signs of syphilis
asymptomatic

ii. Relapses

iii. asymptomatic
infectious
treatment

Question 34

Syphilis:
Clinical Manifestations:
Tertiary Syphilis

i. Without treatment, approximately 30% of patients progress to the _ stage within 1-20 years of infection. The symptoms of tertiary syphilis may be divided into three main groups: (3).
ii. Cardiovascular: Patients will have pathologic lesions of the _ and clinically presents as an ascending (3)
iii. Gummas: These are _ lesions which destroy (3). These lesions may occur on the _ (as nodular or noduloulcerative lesions) as well as in the (5).

Answer 34

i. tertiary
neurosyphilis, cardiovascular syphilis, and late benign (or gummas)

ii. aortic vasovasorum
aortic aneurysm, aortic insufficiency, or coronary ostial stenosis

iii. granulomatous
soft tissue, cartilage, and bone
skin
skeleton, upper respiratory tract, oral cavity and digestive tract, and myocardium

Question 35

Syphilis:
Clinical Manifestations:
Tertiary Syphilis

iv. Neurosyphilis
1. Early forms of neurosyphilis present as _ or _ (presenting as a stroke-like syndrome)
2. Late forms may present as general _ (also known as dementia paralytica or general paresis of the insane) which is associated with direct invasion of the _ by T. pallidum. The clinical picture is a combination of psychiatric manifestations and neurologic findings.
3. Another late manifestation is _ which typically presents as (3). Loss of _ sense and inability to feel passive movement in _ are among the first detectable signs. Sluggish _ reactivity to light is also an early finding.
4. _, which is often seen in tabes, may appear as an isolated manifestation of neurosyphilis.

Answer 35

1. acute meningitis or meningovascular syphilis
2. paresis
   cerebrum

3. tabes dorsalis
lightning pains, parethesias, and ataxia
vibration 
joints 
pupillary 

4. Optic atrophy

Question 36

Syphilis:
Clinical Manifestations:
Congenital Syphilis

i. Congenital syphilis can cause (4) in children who survive. Congenital syphilis lacks a _ stage as it is a consequence of _ and is similar to secondary syphilis. Transmission can occur during any stage of syphilis, but the risk is much higher when the pregnant woman is in the _ or _ stages.
ii. Fetal infection can occur during any trimester of pregnancy. The typical stillborn or highly symptomatic newborn is _, with _, and often with _ and _.
iii. Late onset disease is seen after the patient is 2 years of age. Malformation in _ (frontal bossing, saddle nose, saber shins) and _ (Hutchinson incisors) and _ deficits (eighth nerve deafness) are observed.

Answer 36

i. stillbirth, death soon after birth, and physical deformity and neurological complications
primary
hematogenous dissemination
primary or secondary

ii. premature
hepatosplenomegaly
pneumonia and skin lesions

iii. bones
teeth
neurologic

Question 37

Syphilis:
Diagnosis

a. Detailed history and complete physical exam in crucial
i. History of _ and _
ii. Typical _ and _ of syphilis in the past year
iii. Date and results of most recent _ for syphilis
iv. Complete _ exam; examination of _; evaluating _
v. Examination of (3) areas
vi. Complete _ exam
b. _: This is the most specific and sensitive method for verifying the diagnosis of primary syphilis. It may also be occasionally used in cases of condyloma lata. This method has no place in diagnosing late syphilis.

Answer 37

i. syphilis and sexual history
ii. signs and symptoms
iii. serologic tests

iv. skin
oral cavity
lymphadenopathy

v. genital, perineal, anal areas
vi. neurologic
b. Darkfield microscopy

Question 38

Syphilis:
Diagnosis

c. Serologic tests
i. Non-treponemal tests detect _ and _ directed against a _ antigen. This is a component of mammalian cell membranes that is presumably modified by _. These include _ and _.
ii. Nontreponemal test titers usually correlate with _ and results are reported (qualitatively / quantitatively). These tests usually (are reactive for life / become non-reactive with time after treatment)
iii. Treponemal tests measure _ directed against _ antigens. These include _ and _.
iv. These are (qualitative / quantitative) tests and usually (are reactive for life / become non-reactive with time after treatment). These tests correlate poorly with disease activity, and should not be used to assess treatment response. Some clinical laboratories have used these tests to screen samples for syphilis.
v. Persons with a positive treponemal screening test should have a standard _ performed to guide patient management decisions.
vi. Both treponemal and non-treponemal tests may be (positive / negative) in primary syphilis but they are almost always (positive / negative) in secondary and early latent syphilis. Treponemal tests are almost always (positive / negative) in late syphilis irrespective of treatment history.

Answer 38

i. IgM and IgG antibodies
cardiolipin-lecithin-cholesterol
T. pallidum
VDRL (venereal disease research lab) and RPR (rapid plasma reagin)

ii. disease activity
quantitatively
become non-reactive with time after treatment

iii. antibody
T. pallidum
FTA-ABS (fluorescent treponemal antibody-absorbed test) and MHA-TP (microhemagglutination assay-T. pallidum test)

iv. qualitative
are reactive for life

v. non-treponemal test with titer

vi. negative
positive
positive

Question 39

Syphilis:
Treatment and Prevention

a. _ is the preferred drug for treatment of all stages of syphilis.
b. _ dose(s) is/are given in primary, secondary, and early latent syphilis. _ dose(s) is/are given (at weekly intervals) for late latent and tertiary syphilis.
c. For neurosyphilis, treatment duration is _ days.
d. For penicillin allergic patients, _ may be used, except for pregnant patients. These patients should be _.
e. Pregnant women should be screened and counseled at the first prenatal visit. No infant should leave the hospital without the maternal _ status having been determined at least once during pregnancy and preferably again at delivery.
f. Other populations should be screened based on the _ of syphilis and the patient’s _.
g. Presumptive treatment should be given to persons _, because they might be infected even if seronegative.

Answer 39

a. Penicillin G

b. A single
Three

c. 10-14

d. doxycycline
desensitized to penicillin

e. serologic

f. local prevalence
risk factors

g. exposed within 90 days preceding a sex partner’s diagnosis of primary, secondary, or early latent syphilis