Sec 32 Sexually Transmitted Diseases Flashcards
Etiologic agent: Syphilis
Treponema pallidum pallidum
Etiologic agent: Chancroid
Haemophilus ducreyi
Etiologic agent: Lymphogranuloma venereum
Chlamydia trachomatis
Etiologic agent: Granuloma inguinale
Klebsiella granulomatis
Etiologic agent: Gonorrhea
Neisseria gonorrheae
Etiologic agent: Chlamydia
Chlamydia trachomatis
Etiologic agent: Genital mycoplasma
Mycoplasma sp.
Ureaplasma sp.
Etiologic agent: Trichomoniasis
Trichomonas vaginalis
Etiologic agent: Bacterial vaginosis
Polymicrobial
Characterized by one or more chancres in presence of laboratory evidence
Primary syphilis
Starts as a dusky red macule that evolves into a papule then to a round-to-oval ulcer with sharply demarcated regular, raised borders that are indurated giving a cartilaginous feel
Chancre
Retraction of the foreskin when a chancre is present on the underside causes foreskin to flip suddenly
Dory flap
Unilateral labial swelling with rubbery consistency and intact surface indicative of deep-seated chancre
Edema induratum
Characterized by localized or diffuse mucocutaneous lesions, often with generalized lymphadenopathy in the presence of laboratory evidence from tissues or sera
Secondary syphilis
Lesions of secondary syphilis that erupts 3-12 weeks after the chancre erupts
Syphilids
Erythematous macules in secondary syphilis
Roseola syphilitica
A white scaly ring on the surface of papulosquamous lesions in secondary syphilis
Biette’s collarette
Seborrheic dermatitis-like lesions around the hairline in secondary syphilis
Crown of Venus
corona veneris
Plantar lesions mistaken for calluses in secondary syphilis
Clavi syphilitici
Confluence of mucous patches on the tongue in secondary syphilis
Plaques fauches en prairie
Rare manifestation that presents as crusted or scaly papules and plaques that can ulcerate or become necrotic with lesions described as rupioid
Malignant lues
Without treatment, the secondary stage recedes in
4-12 weeks
Hallmark of late benign syphilis
Gumma
Nontender pink to dusky red granulomatous nodular lesion with variable central necrosis which commonly affect skin or mucous membranes common in scalp, forehead, buttocks, presternal, supraclavicular or pretibial areas
Gumma
Two syndromes commonly associated with late neurosyphilis
- Dementia paralytica
2. Tabes dorsalis
Presents with sensory ataxia and bowel & bladder dysfunction resulting from damage to the posterior columns of the spinal cord which can be accompanied by an Argyll-Robertson pupil (accommodates but does not react to light)
Tabes dorsalis
Presents as a rapidly progressive dementia accompanied by personality changes in late tertiary syphilis
Dementia paralytica
Treatment: Primary or Secondary or Early latent syphilis
Benzathine penicillin G 2.4 M units IM single dose (both HIV-uninfected and -infected)
Alt - Doxycycline 100mg orally BID for 14 days
Etiologic agent: Pinta
Treponema carateum
Etiologic agent: Yaws
Treponema pallidum pertenue
Etiologic agent: Bejel or Endemic syphilis
Treponema pallidum endemicum
Treatment: Nonvenereal treponematoses
Benzathine penicillin G 1.2 M units IM single dose (>10 years old
Benzathine penicillin G 0.6 M units IM single dose(<10 years old)
Treatment: Chancroid
Azithromycin 1g orally single dose
Ceftriaxone 250mg IM single dose
Ciprofloxacin 500mg orally BID for 3 days
Erythromycin 500mg orally QID for 7 days
Treatment: Lymphogranuloma venereum
Doxycycline 100mg orally BID for 3 weeks (1st line)
Erythromycin 500mg orally QID for 3 weeks (2nd line)
Azithromycin 1g orally once weekly for 3 weeks (3rd line)
Treatment: Granuloma inguinale
Doxycycline 100 BID orally for 3 weeks or until lesions heal (CDC)
Azithromycin 1g on Day 1 then 500mg OD for 3 weeks or until lesions heal (WHO)
Treatment: Uncomplicated Gonococcal infection
Ceftriaxone 125mg IM single dose or
Cefixime 400mg PO single dose
Treatment: Disseminated Gonococcal infection
Ceftriaxone 1g IM or IV every 24 hours until improvement noted
Treatment: Gonococcal infection in Neonates
Ceftriaxone 25-50 mkday IV or IM OD for 7 days (10-14 days if with meningitis)
Treatment: Chlamydia
Azithromycin 1g PO single dose or
Doxycycline 100mg PO BID for 7 days
Treatment: Trichomoniasis
Metronidazole 2g PO single dose or
Tinidazole 2g PO single dose
Treatment: Bacterial vaginosis
Metronidazole 500mg PO BID for 7 days
or
Metronidazole gel 0.75% 5g intravaginal OD for 5 days
or
Clindamycin cream 5% 5g intravaginal OD for 7 days
Ranges in diameter from a few millimeters to 2 cm and is sharply demarcated with regular, raised borders that are indurated, giving the lesion a cartilaginous feel; base is usually clean, and is classically not painful
Hunterian chancre or “ulcus durum” (hard
ulcer)
Relapses of primary syphilis
Monorecidive syphilis or chancre redux
Present as moist, flat, well-demarcated papules or plaques with macerated or eroded surfaces in intertriginous areas, commonly in the labial folds in females or in the perianal region in all patients
Condyloma lata
Pigmentary changes in Syphilis from inhibition of melanogenesis
Leukoderma colli syphiliticum or, if on the neck, “necklace of Venus”
A type of mucous patch of secondary syphilis that can be present at the angle of the mouth, with a characteristic slit traversing its center
Split papule
An asymptomatic stage with no clinical findings, with seroreactivity by definition the only evidence of infection; which is a diagnosis of exclusion
Latent syphilis
Refers to a solitary gumma of the penis
Pseudochancre redux
Responsible for most deaths caused by syphilis
Cardiovascular manifestations:
Syphilitic aortitis leading to aortic regurgitation
Coronaryostial stenosis
Saccular aneurysm
Any stage of infection and a reactive CSF-VDRL
Confirmed Neurosyphilis
Any stage of infection, a nonreactive CSF-VDRL, elevated protein or white blood count without other known causes of those abnormalities, and clinical symptoms or signs of neurosyphilis without other known causes for those symptoms or signs
Probable Neurosyphilis
Most common ophthalmic manifestation of early neurosyphilis, presenting as eye pain, redness, and photophobia
Uveitis
Most common manifestation of otologic syphilis
Sensorineural hearing loss
Refers to syphilis caused by infection in utero with T. pallidum
Congenital syphilis
Signs of disease in an infant or child with specific laboratory evidence of infection with T. pallidum
Confirmed Congenital syphilis
Condition affecting an infant whose mother had
untreated or inadequately treated syphilis at delivery,
regardless of signs in the infant, or an infant or child
who has a reactive treponemal test for syphilis and evidence of congenital syphilis on physical examination
or radiographs of long bones, a reactive CSF-VDRL,
an elevated CSF cell count or protein (without other
known cause), or a reactive FTA-ABS IgM antibody
test or IgM enzyme-linked immunosorbent assay
Probable Congenital syphilis
Probability of transmission of Syphilis infection
70-100% in primary syphilis
40% for early latent syphilis
10% for late latent syphilis
Syphilis in a child aged <2 years
Early congenital syphilis
Early congenital syphilis
Persistent rhinitis (“snuffles”) Hydrops fetalis (edema) Lymphadenopathy Neurosyphilis, Leukocytosis, thrombocytopenia Periostitis and osteochondritis, with the pain associated with osteochondritic lesions causing the infantto refuse to move the affected anatomic area (“pseudoparalysis of Parrot”) Bullous rash (“syphilitic pemphigus”)
Child with Syphilis at least 2 years old that typically
manifests over the first two decades of life
Late congenital syphilis
Late congenital syphilis
Scars (“rhagades”) resulting from cutaneous fissures
Saddle-nose deformity, resulting from destruction of nasal cartilage from snuffles
Frontal bossing (Olympian brow)
Thickening of the sternoclavicular portion of the clavicle (Higoumenakis sign)
Anterior bowing of the midtibia (saber shins),
Scaphoid scapula
Peg-shaped notched central incisors (Hutchinson teeth) Mulberry molars
Hutchinson triad
Hutchinson teeth
Interstitial keratitis
Eighth nerve deafness
Diagnostic test of choice in chancres, moist lesions of secondary syphilis (condylomata lata and mucous patches), and the discharge from rhinitis in congenital syphilis
Darkfield microscopy
Histopathology: granulomas with central zones of acellular necrosis; endarteritis obliterans
and angiocentric plasma cell infiltrates of dermal
blood vessels can also be present
Tertiary syphilis
Nontreponemal tests
Venereal Disease Research Laboratory (VDRL)
Rapid plasma reagin (RPR)
In a small percent of secondary syphilis cases, very high antibody titers inhibit test reactivity, producing a false-negative result called
Prozone phenomenon
Treponemal tests
T. pallidum particle agglutination (TPPA) test
Microhemagglutination assay for T. pallidum (MHA-TP)
Fluorescent treponemal antibody absorption assay
(FTA-ABS)
T. pallidum haemagglutination test (TPHA)
Treponemal enzyme immunoassays (EIAs)
Immunochemiluminescence assays
Treatment: Penicillin-allergic persons with syphilis who are not pregnant and do not have neurosyphilis
Doxycyline
Treatment success in Syphilis is generally defined as
A fourfold decline in serologic nontreponemal titer (or reversion to nonreactive result) following appropriate treatment
A fourfold titer increase following appropriate treatment
indicates
Reinfection or treatment failure
Self-limited clinical syndrome consisting of fever, headache, flare of mucocutaneous lesions, tender lymphadenopathy, pharyngitis, malaise, myalgias, and leukocytosis which occurs within 12 hours of initiating therapy and resolves within 24–36 hours
Jarisch–Herxheimer reaction
Most benign of the endemic treponematoses with the skin being the only organ of involvement
Pinta
Most prevalent nonvenereal treponematosis and the most destructive and disfiguring skeletal involvement
Yaws
Second line treatment for Nonvenereal treponematoses
Erythromycin
Doxycyline
Tetracycline
Incubation period of chancroid
3-7 days no more than 10 days
Usually tender and or painful not indurated (soft chancre) with diameter varying from 1 mm to 2 cm
and most are found on the external or internal
surface of the prepuce, on the frenulum, or on the glans
Chancroid
Painful inguinal adenitis occurs in up to 50% of patients within a few days to 2 weeks after onset of the primary lesion usually unilateral with erythema
of the overlying skin
Buboes
The three classic etiologic agents for genital ulceratio
- H. ducreyi
- Treponema pallidum
- Herpes simplex
Single lesion extends peripherically and shows extensive ulceration
Giant chancroid
Lesion that becomes confluent, spreading
by extension and autoinoculation. The groin or thigh may be involved.
Large Serpiginous Ulcer
Ulcus molle serpiginosum
Variant caused by superinfection with
fusospirochetes. Rapid and profound
destruction of tissue can occur.
Phagedaenic Chancroid
Ulcus molle gangraenosum
Small ulcer that resolves spontaneously in a few days may be followed 2–3 weeks later by acute regional lymphadenitis.
Transient Chancroid
Chancre mou volant
Multiple small ulcers in a follicular distribution.
Follicular Chancroid
Granulomatous ulcerated papule may
resemble donovanosis or condylomata lata.
Papular Chancroid
Ulcus molle elevatum
Most frequent complaint in Chancroid
Local pain
Complications of Chancroid
Painful inguinal adenitis (up to 50%)
Spontaneous ruptures of inguinal buboes with occurrence of large abscesses and fistula formation
Spreading of Haemophilus ducreyi to distant sites
(kissing ulcers and/or extragenital lesions due to autoinoculation)
Esophageal lesions in HIV patients
Acute conjunctivitis
Bacterial superinfection (including anaerobs) leading
to extensive destruction
Scarring leading to phimosis
Erythema nudism
Enhanced HIV transmission
DOC for pregnant patients with Chancroid
Ceftriaxone
A sexually transmitted disease due to specific Chlamydia variants contracted by direct contact with infectious secretions
Lymphogranuloma venereum (LGV)
Two distinct morphologic forms of Chlamydiae
- the small metabolically inactive and infectious elementary body
- the larger metabolically active and noninfectious
reticulate body
5-to-8-mm painless erythematous papule(s) or small
herpetiform ulcers appear at the site of inoculation; heals within a few days, and may go unnoticed
Primary stage of LGV
Marked LN involvement and hematogenous dissemination
Secondary stage of LGV
Characterized by inguinal and/or femoral LN involvement and is the major presentation in
men
Acute genital syndrome (GS) or inguinal syndrome
Pathognomonic of LGV
Nodal enlargement on either side of the inguinal ligament, the “groove sign,”
Characterized by perirectal nodal involvement, acute hemorrhagic proctitis, and pronounced systemic symptoms
Acute anorectal syndrome
In women with untreated ArS, and includes rectal
strictures (most common) and abscesses, perineal
sinuses, rectovaginal fistulae (leading to “watering
can perineum”), and “lymphorrhoids” (perianal
outgrowths of lymphatic tissue)
Tertiary stage of LGV
Diagnostic of LGV
Positive on lymph node aspirate
Most commonly used test with titers greater than 1:256 are highly suggestive of LGV and titers below 1:32 exclude the diagnosis
Complement fixation test
The earliest diagnostic modality to identify LGV which consists of an intradermal skin test assessing delayed hypersensitivity to chlamydial antigens but no longer used because of its low sensitivity and limited specificity due to cross reaction with C. trachomatis D-K
Frei test
In Donovanosis, single or multiple papules or
nodules later develop and grow into a painless ulcer that may extend to the adjacent tissues and moist folds, forming
Kissing lesions
Commonly presents as beefy red, easily bleeding, foul-smelling ulcer, which may have hypertrophic or verrucous borders, with granulation tissue; may also present as soft, red nodules that eventually ulcerate
Granuoma inguinale
The infectious form in Chlamydiawhich enters host cells through endocytosis
Eelementary body
Most common manifestation of Chlamydia which is
characterized by a watery or mucoid discharge
from the urethra that may be accompanied by variably
severe dysuria in both men and women
Urethritis
Gonorrhea can also be transmitted vertically from
mother to child during normal vaginal birth, characteristically causing an inflammatory eye infection characterized by profuse, purulent ocular discharge
Ophthalmia neonatorum
The most common manifestation of gonococcal infection in men, characterized by a spontaneous, often
profuse, cloudy or purulent discharge from the penile
meatus
Urethritis
In some cases, there is so much soft tissue
inflammation that the entire distal penis becomes
swollen, so-called
Bull head clap
A manifestation of gonococcal infection
manifesting in those who practice unprotected
anoreceptive intercourse; symptoms may include a rectal mucopurulent discharge, pain on defecation, constipation, and tenesmus
Proctitis
Occurs in about 10-40% of uncomplicated
gonorrheal infections in women and is characterized
by fever, lower abdominal pain, back pain, vomiting,
vaginal bleeding, dyspareunia, and adnexal or cervical
tenderness during movement associated with a pelvic
examination
Pevic inflammatory disease
This involves inflammation of the liver capsule associated with genitourinary tract infection and may be present in up to one-fourth of women with PID caused by either N. gonorrhoeae or C. trachomatis. Presenting symptoms include right upper quadrant pain and tenderness with abnormal liver function tests.
Fitz-Hugh-Curtis syndrome
Spread of infection from the primary site of inoculation to other parts of the body through the bloodstream leads to this which occurs in 0.5-3% of cases and is associated with a classic triad of dermatitis,
migratory polyarthritis, and tenosynovitis.
Disseminated gonococcal infection (DGI), also known as gonococcemia
The cutaneous lesions of DGI with concurrence of some degree of hemorrhage and necrosis
Gun metal gray
Considered diagnostic for infection with N. gonorrhoeae in symptomatic men
Gram stain of a urethral specimen that demonstrates
polymorphonuclear leukocytes with intracellular
Gram-negative diplococci
Gold standard diagnostic test for years for N. gonorrhoeae
Bacterial culture
Media for bacterial culture of N. gonorrhoeae
Modified Thayer-Martin medium
Permanent sequelae of gonococcal infection in women
Infertility
The area most commonly affected in men and women with Chlamydia
Urogenital tract infection
Can occur up to 1 month after symptoms of nongonococcal urethritis (NGU) with classic triad associated with this syndrome is NGU, arthritis, and conjunctivitis.
Reactive arthritis
Individuals with the haplotype are at increased risk of developing the reactive arthritis syndrome.
HLA-B27
Smallest, free-living, self-replicating bacteria, developed
by degenerative evolution from lactobacilli, and lack
a cell wall
Mycoplasma
STD caused by parasitic protozoan that infects mucosal epithelium, causing microulceration
Trichomoniasis
Specific sign of trichomoniasis with punctate hemorrhages may be seen on the vaginal wall and cervix
Colpitis macularis or “strawberry cervix”
Most common diagnostic test in Trichomoniasis
Saline wet mount
Drug-drug interaction with Imidazoles
Cimetidine
Warfarin
Phenytoin
Lithium
Most common vaginal infection in women of
childbearing age
Bacterial vaginosis
Apolymicrobial syndrome that occurs when
there is an imbalance of the bacterial flora normally
present in the vagina. The shift occurs from hydrogen
peroxide-producing lactobacilli to a greater concentration of bacterial organisms.
Bacterial vaginosis
Presents with fishy odor and thin, white or gray vaginal discharge; on physical examination, a milky, homogenous vaginal coating may be seen adherent to the vaginal wall
Bacterial vaginosis
Amstel criteria for diagnosing Bacterial vaginosis (3 of 4)
- thin, homogenous vaginal discharge
- a positive whiff test, which involves the production of a fishy odor when mixing vaginal fluid with 10% potassium hydroxide
- vaginal fluid pH greater than 4.5
- the presence of clue cells (epithelial cells covered with bacteria) on microscopic examination
