Obj 36: STIs and UTIs Flashcards
A 26-year-old G2P2 woman presents with a new onset of vulvar burning and irritation. She is sexually active with a new male partner. She is using oral contraception for birth control and did not use a condom. She thought she had a cold about 10 days ago. Which of the following is the most likely diagnosis in this patient?
A. Herpes simplex virus
B. Primary syphilis
C. Secondary syphilis
D. Human immunodeficiency virus
E. Trichomonas
A. The patient is most likely infected with herpes. Herpes simplex virus is a highly contagious DNA virus. Initial infection is characterized by viral-like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as acyclovir, can decrease viral shedding and shorten the course of the outbreak somewhat. These medications can be administered topically or orally.
Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. This patient’s symptoms are less consistent with syphilis, but she should still be tested for it. Human immunodeficiency virus is an RNA retrovirus transmitted via sexual contact or sharing intravenous needles. Vulvar burning, irritation or lesions are not typically noted with this disease, although generalized malaise can be.
HIV can present with many different signs and symptoms, therefore risk factors should be considered, and testing offered. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It does not have a systemic manifestation.
A 33-year-old G3P3 woman presents to the office complaining of a new onset vaginal discharge of four days duration. The discharge is thick and white. She has noted painful intercourse and itching since the discharge began. Her vital signs are: blood pressure 120/76 and pulse 78. The pelvic examination reveals excoriations on the perineum, thick white discharge, and is otherwise non-contributory. What is the most likely diagnosis in this patient?
A. Herpes simplex virus
B. Primary syphilis
C. Candida vaginalis
D. Bacterial vaginosis
E. Trichomonas
C. The patient is most likely has candida vaginalis. Clinically women have itching and thick white cottage cheese like discharge. They may also have burning with urination and pain during intercourse.
Herpes simplex viral infections are characterized by viral like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well.
Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias.
Bacterial vaginosis is due to an overgrowth of anaerobic bacteria and characterized by a grayish / opaque foul-smelling discharge. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific yellow or greenish vaginal discharge. It does not have a systemic manifestation.
A 32-year-old G3P1 woman presents to your office today because of exposure to hepatitis B. She had vaginal and anal intercourse with a new partner three days ago and did not use condoms. The partner informed her today he was recently diagnosed with acute hepatitis B acquired from intravenous drug use and needle sharing. She has no prior history of hepatitis B infection and has not been vaccinated. She is currently asymptomatic and her examination is normal. Her urine pregnancy test is negative. What is the next best step in the management of this patient?
A. Check AST, ALT, and HBsAg
B. Administer HBIG one dose
C. Administer HBIG two doses
D. Administer HBIG and start hepatitis B vaccine series
E. Administer hepatitis B vaccine series only
D. It is estimated that 38% of hepatitis B cases worldwide are acquired from sexual transmission. Post-exposure prophlaxis should be inititated as soon as possible but not later than 7 days after blood contact and within 14 days after sexual exposure. In individuals who are unvaccinated but exposed to persons who are HBsAG positive, recommendations are to receive one dose of HBIG (Hepatitis B Immune Globulin) and the HBV (Hepatitis B Vaccine Series).
If the source is HBsAG negative or unknown status, then only the HBV series is used. If the exposed individual has been vaccinated and is a responder then no further treatment is necessary. If the exposed individual is vaccinated and a non-responder, then HBIG plus HBV or HBIG times two doses is used. Because the incubation period for the virus is six weeks to six months, checking liver function and immunologic status at this time is not indicated
A 17-year-old G0 sexually active female presents to the emergency department with pelvic pain that began 24 hours ago. She reports menarche at the age of 15 and coitarche soon thereafter. She has had four male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60; pulse 100; and temperature 102.0°F (38.9°C). On speculum examination, you note a foul-smelling mucopurulent discharge from her cervical os and she has significant tenderness with manipulation of her uterus. What is the next best step in the management of this patient?
A. Outpatient treatment with oral broad spectrum antibiotics
B. Outpatient treatment with intramuscular and oral broad spectrum antibiotics
C. Intravenous antibiotics and dilation and curettage
D. Inpatient treatment, laparoscopy with pelvic lavage
E. Inpatient treatment and intravenous antibiotics
E. The most likely cause of the symptoms and signs in this patient is infection with a sexually transmitted organism. The most likely organisms are both N. gonorrhoeae and chlamydia, and the patient should be treated empirically for both after appropriate blood and cervical cultures are obtained. There is no evidence that adolescents have better outcomes from inpatient therapy. However, since the patient also has a high fever, inpatient admission is recommended for aggressive intravenous antibiotic therapy in an effort to prevent scarring of her fallopian tubes and possible future infertility.
A 36-year-old G0 woman presents to the emergency department accompanied by her female partner. The patient notes severe abdominal pain. She states that this pain began 2-3 days ago and was associated with diarrhea as well as some nausea. It has gotten progressively worse and she has now developed a fever. Neither her partner, nor other close contacts, report any type of viral illness. She had her appendix removed as a teenager. On examination, her temperature is 102.0°F (38.9°C), her abdomen is tender with mild guarding and rebound, and she has an elevated white count. On pelvic examination, she is exquisitely tender, such that you cannot complete the examination. Pelvic ultrasound demonstrates bilateral 3-4 cm complex masses. What is the most likely underlying pathogenesis of her illness?
A. Diverticulitis
B. Gastroenteritis
C. Reactivation of an old infection
D. Ascending infection
E. Pyelonephritis
D. Although salpingitis is most often caused by sexually transmitted agents such as gonorrhea and chlamydia, any ascending infection from the genitourinary tract or gastrointestinal tract can be causative. The infection is polymicrobial consisting of aerobic and anaerobic organisms such as E. coli, Klebsiella, G. vaginalis, Prevotella, Group B streptococcus and/or enterococcus. Although diverticulitis and gastroenteritis should be part of the differential diagnosis initially, the specific findings on examination and ultrasound are more suggestive of bilateral tubo-ovarian abscesses. Even though this patient does not have the typical risk factors for salpingitis, the diagnosis should be considered and explained to the patient in a sensitive and respectful manner. The patient should also be questioned separate from her partner regarding the possibility of other sexual contacts.
A 16-year-old G0 female presents to the emergency department with a two-day history of abdominal pain. She is sexually active with a new partner and is not using any form of contraception. Temperature is 101.8°F (38.8°C). On examination, she has lower abdominal tenderness and guarding. On pelvic exam, she has diffuse tenderness over the uterus and bilateral adnexal tenderness. Beta-hCG is <5. What is the most likely diagnosis for this patient?
A. Ectopic pregnancy
B. Appendicitis
C. Acute cystitis
D. Endometriosis
E. Acute salpingitis
E. The signs and symptoms of acute salpingitis can vary and be very subtle with mild pain and tenderness, or the patient can present in much more dramatic fashion with high fever, mucopurulent cervical discharge and severe pain. Important diagnostic criteria include lower abdominal tenderness, uterine/adnexal tenderness and mucopurulent cervicitis.
A 16-year-old G0 female presents to the emergency department with a two-day history of abdominal pain, nausea and vomiting. She is sexually active with a new partner and is not using any form of contraception. On examination, her temperature is 100.2°F (37.9°C), and she has bilateral lower quadrant pain, with slight rebound and guarding. On pelvic examination, she has purulent cervical discharge and cervical motion tenderness. Her white count is 14,000/mcL. What is the most appropriate next step in the management of this patient?
A. Oral amoxicillin clavunate and doxycycline
B. Oral metronidazole and doxycycline
C. IV metronidazole and doxycycline
D. IV cefotetan and doxycycline
E. No treatment until culture results are back
D. Although some patients can be treated with an outpatient regimen, this patient should be hospitalized for IV treatment, as she has nausea and vomiting so she might not be able to tolerate oral medications. While adolescents have no better outcomes from inpatient vs outpatient therapy, each patient should be assessed for compliance. It is important to treat aggressively in order to prevent the long-term sequelae of acute salpingitis. You would not wait for culture results before initiating treatment. Her recent sexual contacts should also be informed (by her and/or with her consent) and treated. According to the 2010 CDC treatment guidelines, there are two options for parenteral antibiotics covering both gonorrhea and chlamydia. Cefotetan or cefoxitin PLUS doxycycline or clindamycin PLUS gentamicin. For outpatient treatment, the 2010 CDC guidelines recommend ceftriaxone, cefoxitin, or other third-generation cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or WITHOUT metronidazole. There are alternative oral regimens as well. http://www.cdc.gov/std/treatment/2010/pid.htm
A 32-year-old G0 woman comes to your office because she has been unable to conceive for one year. She is currently in a mutually monogamous relationship with her husband, has intercourse three times per week, and has no dyspareunia. Her menstrual cycles occur every 26-34 days. She has had seven sexual partners in the past. She was treated for multiple sexually transmitted infections including gonorrhea, chlamydia and pelvic inflammatory disease in her early twenties. She had an abnormal Pap test about four years ago and was treated with a LEEP. What is the most likely underlying cause of infertility in this patient?
A. Luteal phase defect
B. Cervical stenosis
C. Ovulatory dysfunction
D. Tubal disease
E. Endometriosis
D. The rate of tubal infertility has been reported as 12% after one episode of PID, 25% after 2 episodes and 50% after three episodes.
Salpingitis can develop in 15-30% of women with inadequately treated gonococcal or chlamydial infections and can result in significant long-term sequelae, such as chronic pelvic pain, hydrosalpinx, tubal scarring and ectopic pregnancy. Given this patient’s history, her inability to conceive is most likely due to the long-term sequelae of a sexually transmitted infection. Although the patient had a LEEP, risk for cervical stenosis is low. She is having regular cycles; therefore, anovulation and luteal phase defect is less likely. This case emphasizes the importance of aggressive screening and treatment protocols for sexually transmitted infections, as well as counseling regarding abstinence and safer sex practices. While endometriosis can cause tubal occlusion, her clinical presentation is not consistent with endometriosis.
A 26-year-old G2P2 woman presents with urinary urgency and dysuria for the past three days. She has a history of a urinary tract infection once. She is sexually active and uses condoms for contraception. She is otherwise healthy and does not take any medications or supplements. She does not have fever, chills, flank pain or vaginal discharge. Which of the following organisms is the most likely cause of this patient’s symptoms?
A. Enterococcus faecalis
B. Klebsiella pneumoniae
C. Proteus mirabilis
D. Staphylococcus saprophyticus
E. Escherichia coli
E. Acute cystitis in a healthy, non-pregnant woman is considered uncomplicated and is very common. Escherichia coli causes 80 to 85 percent of cases. The other major pathogens are Staphylococcus saprophyticus, Klebsiella pneumoniae, Enterococcus faecalis and Proteus mirabilis. The physician must consider antibiotic resistance when determining treatment.
A 19-year-old G0 woman presents to the office with a two-week history of low pelvic pain and cramping. She has a new sexual partner and is on oral contraception and uses condoms. She is one week into her cycle. She has noted no vaginal discharge, itch or odor. She denies fevers or chills. She does note that she is on a new diet and has started drinking lots of water. As such, she notes that she is urinating much more frequently. Her examination is entirely unremarkable. Which of the following is the most appropriate next step in the management of this patient?
A. Pelvic ultrasound
B. Pap test
C. Wet prep
D. Urinalysis
E. Testing for chlamydia
D. Mildly symptomatic or asymptomatic urinary tract infections are common in female patients. Urinary tract infection must be considered in patients who present with low pelvic pain, urinary frequency, urinary urgency, hematuria or new issues with incontinence. While yearly screening for chlamydia is recommended for patients less than 25 years old, this patient’s symptoms are most consistent with a UTI. A pelvic ultrasound is not indicated at this point.
