Sexually Transmitted Diseases Flashcards
Is the spread of most HSV due to symptomatic or asymptomatic shedding?
asymptomatic
What does HSV look like clinically?
- Burning or painful erythema, papules, multiple vesicular or ulcerative lesions – absent in many patients
- at least 50% caused by HSV-1. Recurrences = HSV-2 (nearly 100% patients)
How can you diagnose HSV?
- PCR of genital specimens is the test of choice –> but it is expensive
- Serologic assays are useful for future prophylaxis
- DFA
- Culture– less sensitive for recurrent lesions
Describe the treatment for HSV:
Antiviral drugs:
- Partially control signs and symptoms
- Shorten duration 3-4 w to 1w
- Suppressive therapy – reduce the frequency
- Don’t eradicate the virus
- Don’t affect the risk, frequency, severity of recurences after discontinuation
- Decrease the risk of genital HSV-2 transmission to susceptible partners
TOPICAL DRUGS OFFER LITTLE BENEFIT
What antiviral drugs are being used for the first clinical episode of genital herpes:
Acyclovir 400mg orally tid x 7-10 days
Acyclovir 200mg orally x5/d x 7-10days
Famciclovir 250mg orally tid x 7-10 days
Valacyclovir 1g orally bid x 7-10 days
What antiviral drugs are used for recurrent therapy?
Acyclovir 400-800mg orally bid
Famciclovir 250-500mg orally bid
Valacyclovir 1g orally qd
How should genital HSV be handled in pregnancy?
High risk (30-50%) for transmission to neonate among women acquiring genital HSV near the time of delivery
HSV-1 transmits 10-20 times more easily to the newborn but more likely to cause skin, eye, and mucous membrane infections. HSV-2 causes encephalitis and neurodevelopmental disability.
Low risk (<1%) in women with recurrent genital herpes at term or who acquire genital herpes during first half of pregnancy.
Seronegative women should abstain from sex with seropositive partners in the 3rd trimester
Women with genital herpetic lesions at the onset of labor C section (doesn’t eliminate 100% the risk)
Describe primary syphilis:
incubation 9-90 days. Lasts 2-4 weeks
At the site of inoculation – painless single papule painless clean ulcer with smooth base, with firm raised borders
Multiple chancre in HIV patients
Painless lymphadenopathy
Can be present at any site depending On inoculation (mouth, rectum)
Darkfield exam from the lesion is
the best way to diagnose syphilis in this stage
Describe secondary syphilis:
2-8 wks after the chancre Rash: macular maculopapular papular pustular syphilides (palmes and soles) Condyloma lata (weeping ulcers) Mucus patches – highly infectious LAN
Constitutional symptoms: Fever, malaise, weight loss, pharingitis, arthralgia
CNS involvement (40%) with spirochetes isolated from CSF: HA and meningismus; CSF: elevated protein, WBC
Abnormal LFTs
Describe Tertiary syphilis:
Gumma=granulomatous-like lesions
Aortitis and aortic aneurism
Neurosyphilis
Asymptomatic (CSF: elevated protein, low glucose, pleocytosis, +VDRL)
Meningovascular: hemiplegia, hemiparesis, seizures, aphasia
Parenchimatous: tabes dorsalis = ataxia, Argyll-Robertson pupil, impotence, incontinence, neuropathy
Optic atrophy gun barrel sight
Argyll-Robertson pupil – accomodates to near vision, but doesn’t react to light or painful stimuli “sex worker’s eye”
Describe nontreponemal tests:
: VDRL, RPR positive at 8-10d
Test for nonspecific reaginic antibodies directed against cardiolipin antigen
Useful for screening (inexpensive, sensitive)
Used to monitor response to treatment disappear following treatment
describe treponemal tests:
: FTA-ABS, TP-PA (positive at 4-5d)
Highly specific (differentiate from other trepanomatosis, cardilopin Ab like SLE)
Used to confirm + nontreponemal tests
Do not disappear following treatment
What is the treatment for syphilis?
It is the same for patients with and without HIV
Primary and early latent syphilis: Benzathine PCN 2.4 mil u x1, or Doxy 100mg BID x14 days for PEN allergy
Secondary and late latent syphilis: Benzathine PCN 2.4 mil u x 3 at one week interval, or Doxy 100mg BID x28 days
Tertiary without neurosyphilis: Benzathine PCN 2.4 mil u x 3 at one week interval
Tertiary with neurosyphilis: Aqueous PCN 24mil u/day x 14 days; if allergic to PCN desensitize
Patient with syphilis started on PCN develops HA, F and myalgia bed rest, NSAIDs, continue PCN.
What can you only use in pregnancy for in syphilis?
pcn G
What is a Jarish-Herxheimer Rxn?
fever, aggregation of clinical picture within hours, due to a sudden massive destruction of spirochetes, this is NOT a pcn allergy. DONT stop treatment. Most commonly occurs in early syphilis.
What is the difference between Gonoscoccal urethritis and nongonococcal urethritis?
Gonococcal urethritis: Neisseria gonorrhoeae 4 day incubation Abrupt onset Severe symptoms Significant discharge Purulent discharge (yellow)
Nongonococcal urethritis: Chlamydia trachomatis Ureaplasma, Mycoplasma, HSV, Adenovirus, Trichomonas 10-14 days incubation Gradual onset Mild symptoms Scanty discharge Mucoid discharge
What are patients routinely co-infected with?
N. gonorrhea and chlamydia
How do you make a diagnosis of urethritis?
Abnormal discharge
Urethral Gram stain: 5 or more WBC/immersion field; can document GNC (95% sensitivity, 99% specificity)
First void urine: 10 or more WBC/HPF or positive leukesterase
Nucleic acid amplification tests (NAATs)
- Sensitivity better than the culture
- Access in the clinic or any point of care
What is most common asymptomatic infection?
chlamydia
Annual screening of all sexually active women <25 years and women with risk factors
Screening in men in settings with high prevalence (STD clinic, correctional facility)
What do women with chlamydia commonly develop?
PID
What is the treatment for chlamydia?
Recommended:
Azithromycin 1 g orally x 1
Doxycycline 100 mg bid x 7d
Alternative:
Erythromycin 500 mg 4 times a day x 7d
Ofloxacin 300 mg bid x 7d
Levofloxacin 500 mg d x 7d
What is cervicitis?
- Purulent or mucopurulent endocervical discharge discharge (assess for HSV, T. vaginalis, Chlamydia, gonorrhea)
- Endocervical bleeding easily induced by passage of a cotton swab through the cervical os
- > 50% have asymtomatic endometritis
- Major sequelae in woman PID tubal infertility, ectopic pregnancy, chronic pelvic pain
Describe the classic triad for PID:
Fever > 101 F (38.3c)
Cervical or vaginal mucopurulent discharge
Cervical Motion Tenderness
what is PID?
a polymicrobial infection of the upper tract associated with sexually transmitted organisms (most commonly gonorrhea and chlamydia, among others). Age is inversely related to the rate of PID
Risk factors:
Multiple sexual partners
Acquisition of new partner in the previous 30 days
Frequent sexual intercourse with a single partner
