Sexually Transmitted Infections Flashcards
Most frequently reported bacterial STI and nationally notifiable disease in the U.S
Chlamydia
Incubation Period for chlamydia
Poorly defined, but typically 5-10 days
Chlamydia effect on neonates
debilitating – leading cause of infant blindness “trachoma”
What issue?
Known as a ‘silent’ infection because most infected people are asymptomatic & lack abnormal physical examination findings.
Chlamydia
Estimated that ~ ___% of men and ___-___% of women with laboratory confirmed chlamydial infection develop symptoms.
Men 10%
Women 5-30%
All sexually active women should be tested for GC/Chlam at what age and at what periodicity?
< 25 and anually
When should women over 25 y/o be tested for Gc/Chlam annually?
with risk factors (new or multiple sex partners or a sex partner with STD)
Presentation for what in women?
(1) Urethritis
-(a) Dysuria
-(b) Pyuria
-(c) Increased urinary frequency
(2) Cervicitis (most frequent clinical manifestation in female)
-(a) Increased vaginal discharge
-(b) Intermenstrual vaginal bleeding
-(c) Dyspareunia
Chlamydia
What Issue in males?
(1) Urethritis (most frequent clinical manifestation in males)
-(a) Mucoid or clear watery discharge.
-(b) Dysuria is most common complaint.
-(c) Scant discharge on underwear usually presents in the morning.
(2) Epididymitis
-(a) Unilateral testicular pain and tenderness with palpable
swelling of epididymis.
(3) Prostatitis
-(a) Pelvic pain
-(b) Pain with ejaculation
-(c) Dysuria
(4) Proctitis – Men who have sex with men (MSM)
-(a) Anorectal pain
-(b) Discharge
-(c) Rectal bleeding
Chlamydia
What is the most frequent presentation of chlamydia in men?
Urethritis
What is the most frequent presentation of chlamydia in women?
Cervicitis
Differential Diagnosis Chlamydia
(1) Neisseria gonorrhoeae
-(a) > 50% of co-infection rate with both organisms.
(2) Gardnerella Vaginalis (AKA Bacterial Vaginosis).
(3) Trichomonas
Neisseria gonorrhoeae has a co-infection rate of what % with Chlamydia?
> 50%
Gold standard for Chlamydia laboratory diagnosis is….
nucleic acid amplification
testing (NAAT).
Chlamydia- lab workup
Females: Endocervical swab specimen as part of annual screening or if _______
symptomatic
Chlamydia – Treatment
1. Preferred treatment: ________
2. Alternative treatment: _______
3. If concerned with co-infection: __________
- Doxycycline 100mg PO BID for 7 days
- Azithromycin 1g single dose (must observe patient taking med).
- ceftriaxone
Chlamydia – Treatment
Persons with chlamydia should abstain from sexual activity for how long?
7 days following single dose ABx
-or-
after completion of 7 day course of ABx
True/False
Patient should also be encouraged to contact recent sexual partners so they can be treated.
True
It is recommended that patients with laboratory-confirmed chlamydia
be retested ~ _______ months after treatment of an initial infection, regardless
of whether they believe that their sex partners were successfully
treated
3 months
True/False
IDC’s can give patients extra meds to take home to their spouse
False
Do NOT do this
Gonorrhea incubation period
1 – 14 days, however, can be as short as 2-4 days
True/False
Most males are symptomatic with gonorrhea, some males are asymptomatic making diagnosis difficult without labs
True
Presentation of what issue?(Males)
(1) Urethral Symptoms:
-(a) Dysuria
-(b) White/yellow/green urethral discharge
(2) Testicular Symptoms:
-(a) Epididymitis, manifesting as testicular or scrotal pain.
(3) Rectal Infection:
-(a) Discharge, anal itching, bleeding, or painful bowel
movements or may be asymptomatic.
(4) Throat:
-(a) A sore throat, but typically asymptomatic
Gonorrhea
True/False
Most women with gonorrhea are symptomatic
False
Asymptomatic
What issue?
Most women are asymptomatic
(1) Urethral:
-(a) Dysuria, increased vaginal discharge, or vaginal bleeding between periods.
-(b) Lower abdominal discomfort may be present.
-(c) Dyspareunia may be present.
-(d) However, symptoms are often so mild & nonspecific its mistaken for a bladder or vaginal infection.
(3) Rectal Infection:
-(a) Discharge, anal itching, bleeding, or painful bowel movements or may be asymptomatic.
(4) Throat:
-(a) a sore throat, but typically asymptomatic
Gonorrhea
Gonorrhea – Differential
(1) Chlamydia trachomatis; 50% of patients will test positive for both Chlamydia & Gonorrhea.
(2) Gardnerella Vaginalis (AKA Bacterial Vaginosis)
(3) Trichomonas
(4) Pelvic Inflammatory Disease
Gonorrhea CDC Recommended Treatment Regimen
(a) Ceftriaxone 500 mg IM in a single dose AND
(b) Doxycycline 100mg PO BID x 7 days.
(c) Alternative to Doxycycline: Azithromycin 1g orally in a
single dose
Syphilis Incubation Period
10 – 90 days; average is 21 days
Syphilis is historically called what?
The great pretender
What is the three phases of syphilis
Early stage:
(a) Primary Syphilis
(b) Secondary Syphilis
Latent Stage
(c) Tertiary Syphilis
What phase of Syphilis?
(1) Begins as a painless papule that proceeds to ulcerate into a 1- 2cm painless ulcer with raised margins. This is called a chancre.
-(a) Lymphadenopathy is typically appreciated in the inguinal lymph nodes.
-(b) Chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not, however, active lesions are infectious.
(2) Patients often don’t report this stage of syphilis because it is painless, and the chancre resolves relatively quickly.
(3) If the infected person does not receive adequate treatment their infection progresses to the secondary stage.
Primary Syphilis
What phase of Syphilis?
(1) Skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus) mark this stage of symptoms.
(2) Syphilitic rash is characterized by diffuse non-pruritic maculopapular eruption on the trunk and extremities that includes the palms and soles.
(3) Additional symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.
Secondary Syphilis
What phase of Syphilis?
(1) A period of no visible signs or symptoms of syphilis.
(2) Without treatment, the patient will continue to be infected but will not realize it.
-(a) Early latent syphilis
–1) Latent syphilis where infection occurred within the past 12 months.
-(b) Late latent syphilis
–1) Latent syphilis where infection occurred more than 12 months ago. Latent syphilis can last for years.
Latent Stage
-What phase of Syphilis?
(1) rare and develops in a subset of untreated syphilis infections that appear 10–30 years after infection and can be fatal.
(2) Symptoms vary depending on the organ system affected.
-(a) Cardiovascular syphilis – Aortitis
–1) Dilated ascending aorta leads to aortic valve regurgitation which can lead to heart failure.
-(b) Neurosyphilis
–1) General paresis – Early signs of cognitive changes and confusion that progress to dementia.
–2) Tabes dorsalis – Sensory ataxia and sudden bouts of brief stabbing pain that can affect the limbs, back and face. May also have abnormal pupillary responses (Argyll-Robertson pupil)
-(c) Gummatous syphilis – Very uncommon
–1) Granulomatous lesions with round or irregular shape that can appear on skin, bones, or internal organs.
Tertiary Syphilis
What is the standard used to diagnose syphilis
Serologic testing
What test is based on serum reactivity to cardiolipin cholesterol
lecithin antigen.
(a) Nonspecific therefore not definitive.
(b) Can be falsely positive (Lupus, mononucleosis, pregnancy).
(c) Need to be confirmed with treponemal test.
Nontreponemal tests (RPR)
What lab test
More complex and expensive to perform therefore usually
used to confirm syphilis.
Treponemal test (FTA-ABS)
What is the standard treatment for all stages of syphilis
Parental Penicillin G
Primary & Secondary syphilis Tx
(a) Penicillin G benzathine 2.4 million U IM once.
(b) PCN allergy: Doxycycline 100mg PO BID x 14 days
Tertiary syphilis Tx
(a) Penicillin G benzathine 2.4 million U IM once weekly for 3
weeks
(b) Doxycycline 100mg PO BID x 4 weeks
A patient reports to medical after receiving tx for syphilis with fever headache, myalgia, fever, rigors, diaphoresis, hypotension,
and worsening rash. What is happening? What is the tx?
Jarisch-Herxheimer reaction
-Typically resolves in 12-24hrs. NSAIDS or antipyretics can help reduce symptom severity.
Is there anyway to prevent Jarisch-Herxheimer reaction?
No
Syphilis – DDx
(1) Atopic Dermatitis (eczema)
(2) Psoriasis
(3) Allergic Contact Dermatitis
(4) Tinea Versicolor
(5) RMSF
(6) other maladies that cause bilateral eruptions on the palms and soles
Only a few maladies cause bilateral eruptions on the palms and soles, what are they?
(a) Dyshrdrosis
(b) RMSF
(c) Syphilis
True/False
Contacts can be treated presumptively for early syphilis, even if serologic test results are negative
True
What is the most common protozoan STI
Trichomoniasis
Trichomoniasis Incubation Period:
5 – 28 days
What issue? (Women)
(a) Range from acute, severe disease to asymptomatic carrier.
(b) HPI: Purulent, malodorous discharge, burning, pruritis, dysuria, dyspareunia.
(c) Physical exam: Erythematous vulva, petechiae cervix “strawberry cervix”, green-yellow malodorous frothy discharge.
Trichomonas
What issue? (men)
(a) Upwards of 75% of infected males are asymptomatic and can serve as carriers.
(b) HPI: Urethritis, clear or mucopurulent urethral discharge, dysuria.
(c) Some males may have symptoms of urethritis, epididymitis, or prostatitis.
Trichomonas
Trichomoniasis – Treatment
Metronidazole 2 g orally in a single dose,
-or-
Metronidazole 500 mg orally twice a day for 7 days.
What is contraindicated while treating with Metronidazole?
Why?
alcohol
to reduce the possibility of a disulfiram-like reaction
HSV Incubation Period
2 - 12 days; average is 4 days
HSV
Primary or Recurrent infection?
(a) Severe, painful genital ulcers
(b) Dysuria
(c) Fever
(d) Local inguinal lymphadenopathy
Primary infection
HSV
Primary or Recurrent infection?
(a) Unilateral small vesicular lesions on erythematous base or ulcerative lesions.
(b) May have mild tingling or shooting pains in buttocks and legs prior to recurrent episode
Recurrent infection
What are the preferred HSV tests for genital ulcers or other mucocutaneous lesions?
Cell culture and PCR
Failure to detect HSV by culture or PCR, especially in the absence of active lesions, does not indicate an absence of HSV infection…. Why?
because viral shedding is intermittent
True/False
all patients with first episodes of genital herpes should receive antiviral therapy
True
Acute treatment for Primary HSV Infection:
(a) Acyclovir 400 mg orally TID for 7–10 days
(b) Acyclovir 200 mg orally five times a day for 7–10 days
(c) Valacyclovir 1 g orally BID for 7–10 days
(d) Famciclovir 250 mg orally TID for 7–10 days
What % of patients with symptomatic primary infection will experience recurrent episodes of genital lesions.
Almost 100%
Effective episodic treatment requires initiation of therapy within how many days of lesion onset or during the prodromal period.
1 day
Recurrent Infection TX:
(a) Acyclovir 800 mg orally twice a day for 5 days
(b) Valacyclovir 1 g orally once a day for 5 days
What is the most common viral STI worldwide? 9-13% of
the global population infected
HPV
True/False
Condyloma acuminata may be found incidentally during routine female gynecological examinations.
True
What issue?
(1) Lesions are generally found in multiples & can coalesce into a larger lesion. However, solitary lesions are also possible.
(2) Oral lesions are typically present on the tongue
and lip.
(3) Anogenital lesions may be found on the penis, vulva, vagina, cervix, perineum, and the anal region.
(a) Usually appear as raised, skin-colored, fleshy papules that
range in size from 1-5 mm.
(b) They can be broad and flat, pedicled, or occasionally have a
cauliflower-like appearance.
Condyloma acuminata (HPV)
HPV - General Treatment
Topical therapies, cryotherapy, and surgical excision are
common treatment modalities.
Treatment can be delayed in what demographic and why?
Children, adolescents, and young, healthy adults, as lesions often resolve spontaneously over months to years.
Treatment should be pursued in what case?
-Lesions that persist for more than two years
-symptomatic
-cosmetic purposes
HPV - Topical Therapies
-Imiquimod cream 5%:
–Resolution typically seen in sixteen weeks
-Podophyllotoxin Solution (0.5% & 0.15%)
–Lesions can resolve after four weeks
HPV Clinician Applied Therapies
-Cryotherapy (Dermatology)
-Surgical excision (Dermatology)
HPV Infection is preventable with what vaccine?
Gardasil
What strains do Gardasil protect from?
-HPV6 & HPV11 (~90% of genital warts)
-HPV16, HPV18 (cause cervical cancer)
Who should get Gardasil?
All females and males 11 – 26 years of age.
Why isnt Gardasil as effective after age 26?
Vaccine provides less benefit, since more people have already been exposed to HPV
HPV complications
cancer
