Sexually Transmitted Infections Flashcards
Rx of Gonorrhoea?
Ceftriaxone IM or IV
What are the common causes of cervicitis or urethritis?
C.trachomatis
N. gonorrhoeae
Mycoplasma genitalium
Symptoms of cervicitis?
Usually asymptomatic with C and G!!
Discharge
friable membrane -> abnormal bleeding
Pain on sex
Rarer causes of cervicitis?
HSV; adenovirus; CMV;
bacterial vaginosis;
retained foreign body
Definition of PID?
Any inflammatory process
that involves the upper
genital tract, including
* Endometritis
* Salpingitis
* Oophoritis
* Tubo-ovarian abscess
* Pelvic peritonitis
* Perihepatitis
Causes of PID
▪ C. trachomatis
▪ N. gonorrhoeae
▪ Anaerobes (Bacteroides,
Fusobacterium spp)
▪ Gram neg. facultative aerobes
▪ Streptococci (S. agalactiae)
▪ M. genitalium
▪ Less common but reported: S.
pneumoniae; Haemophilus spp.
What drugs will you use to Rx the common causes of cervicitis?
Gram negatives - gonorrhoea - cef
Gram positives - cef/doxy
Chlamydia - doxy
Plus metronidazole! For endometrial anaerobes and M. genitalium
Common causes of urethritis?
– Chlamydia trachomatis
– Neisseria gonorrhoeae
RARE:
- Herpes
- Coliforms
- Trichomoniasis
- Mycoplasma genitalium
What can we no longer use to Rx gonorrhoea due to resistance?
Azithromycin
Alternative to Rx gonorrhoea if ceftriaxone not available?
Gentamicin and Azithromycin
First line Rx for chlamydia?
Doxycycline 1 week
Alternatives: azithromycin or levofloxacin
Rx of mycoplasma genitalium?
Doxycycline for 7/7 followed by azithromycin (moxi if azithromycin resistant)
Causes of proctitis?
- Gonorrhea
- C. trachomatis (LGV & non-LGV strains) - Serovars L1/L2/L3
- Herpes simplex virus
- CMV - colitis (immunocompromised)
- Ameobiasis - colitis
Rx of proctitis?
3 weeks of doxycycline
Symptoms of disseminated gonococcal infection?
Polyarthralgia, tenosynovitis, dermatitis, fever, GU symptoms
Single purulent vesicle with fever and painful knee. ∆?
Disseminated gonococcal infection
Pattern of arthritis in gonococcal disseminated infection?
Purulent arthritis - usually single joint, often knee, wrist, ankle
∆ of gonococcal infection?
Gram stain of skin lesion, urine, joint aspirate
Predominant bacteria in vagina?
Lactobacillus - produces lactic acid, pH 4.7
L. crispatus and L. jensenii
Common causes of vaginitis?
– Bacterial vaginosis (40%-45%)
– Vulvovaginal candidiasis (20%-25%)
– Trichomoniasis (15%-20%)
Vaginitis, Not responding to Rx, consider?
*Mucopurulent cervicitis
* Chemical irritation
* Herpes simplex virus
* Atrophic vaginitis
* Allergic reactions
* Lichen planus
* Desquamative inflammatory vaginitis
* Foreign bodies
Why give metronidazole for vaginal discharge?
Will treat trichomoniasis and bacterial vaginosis
When add in treatment for thrush in vaginal discharge?
vaginial itching
Yellow discharge likely diagnosis? Appearance on wet mount?
Trichomoniasis
Motile flagellated protozoa
What is bacterial vaginosis and what is crucial?
Loss of normal lactobacilli with bacterial anaerobes
pH is greater than 4.7
Gardenerella and others
Appearance of vaginal candida? Appearance on KOH wet mount?
Thick, clumpy, white “cottage
cheese, surrounding erythema
Occurs in normal vaginal pH
Pseudohyphae or spores if
non-albicans species
Appearance of bacterial vaginosis? and on wet mount?
Homogenous, adherent, thin, milky white; malodorous “foul fishy”
Association with contraction of HIV
Amsel criteria for what and what are the criterion?
BV
Clinical findings (Amsel criteria): >3 of
– homogeneous discharge
– pH >4.5
– clue cells (>20%)
– amine odor on addition of KOH (+whiff test)
Other tests than Amsel criteria for BV?
Gram stain findings (Nugent score)
PCR for gardenerella
Rx of bacterial vaginosis?
metronidazole topically or PV 7/7, clindamycin is alternative
Symptoms of trichomonad vaginalis?
Abnormal genital discharge - yellow, dysuria, urinary frequency, itching, burning, dyspareunia, NGU in men
Strawberry cervix
What Is trichomonas associated with?
HIV
Tests for trich?
PCR
Microscopy -
▪ Motile trichomonads
▪ pH > 4.5
Treatment of trich?
1 week of metronidazole
Treat partner too
Males only need single dose of metronidazole
What constitutes uncomplicated vulvovaginal candidasis? Rx?
Mild - mod symptoms
Not immunocompromised
Non-recurrent
Likely to be C. albicans
Fluconazole 150 mg PO, single dose
Any 3-7 day vaginal imidazole regimens
Rx of uncomplicated thrush during pregnancy?
Pregnancy: 7 days of vaginal imidazoles - NO fluconazole
Treatment of PID?
Ceftriaxone 250mg IM one dose stat
Doxycycline 100mg BID for 14 days
Metronidazole 400 TID for 14 days
Treatment of chlamydia/gonorrhoea?
Ceftriaxone 250mg IM one dose stat
Doxycycline 100mg BID for 7 days
Treatment of BV and trichomonas?
Metronidazole 400mg BID for 7 days
Atrophic vaginitis - cause? key features?
Seen in estrogen deficiency
Vagina appears smooth, thin, dry, pH 6-7
Recurrent vaginitis in older women? Purulent discharge?
Streptococcal Vaginitis
Strep pyogenes
Purulent vaginitis in perimenopausal women - diagnosis and Rx?
Desquamative inflammatory vaginitis
Often related to high pH - lack of oestrogen - trial oestrogen Rx
Clindamycin and steroids locally
Causes of genital ulcer disease?
Herpes
Syphilis
MPox
Chancroid
Lymphogranuloma venerum from chlamydia
Scabies
Do not forget non infective causes!
Difference between chancre of syphylis and chancroid?
Painless- syphylis, indurated border, clean base, single
Painful - chancroid
What are kissing lesions?
2 chancres close together
Chancroid
Painful and purulent
What is the organism for chancroid?
Haemophilis ducreyi
Beefy red lesions, aggressive, starting on penis?
Granuloma inguinale
Klebsiella granulomatis
See an ulcer - what classic of herpes?
Vesicles (HSV2)
Rx for chancroid?
Azithromycin or ciprofloxacin
Rx of syphylis?
Benzylpenicillin
Leading cause of genital ulcer disease?
Herpes (HSV 2)
Rx of herpes?
Acyclovir
Relationship between HSV and HIV?
HSV increases the risk of HIV-1 acquisition 2-3 fold
Life cycle herpes?
Primary inoculation - direct contact, does not need to be symptoms in partner.
Replicates in sensory ganglion
Latency
Reactivates at times of stress
Appearance of herpes?
- Vesicular first week
- Wet ulcer as they progress
Multiple lesions
Diagnosis of genital herpes?
PCR HSV
Culture not widely available
Serology in HSV?
Glycoprotein gG tests required
NOT IgM - get a lot of false positives
Western blot gold standard
Rx of HSV2?
Acyclovir
Famciclovir
Valacyclovir
7-10 days
Treatment can be extended if healing is incomplete after 10 days of therapy.
Genital HSV1 - how is this different?
Less frequent relapses
Cannot diagnose with serology - only PCR
Organism for syphylis?
Treponema pallidum
Difference between initial primary lesion of syphylis, herpes and chancroid?
Syphylis - inc period 9-90 days, single papule
HSV - inc period 2-7 days, multiple vesicles
Chrancroid - inc period 1-10 days, multiple pustule
Monkey pox caused by? Mode of transmission?
Mpox virus
Direct contact
How does monkey pox present?
What is this?
M.pox
Genital lesions common
What causes lymphogranuloma venereum?
Chlamydia species
Diffuse rash differentials?
Syphylis
VZV
Herpes - disseminated
Molluscum
Disseminated gonococcoal
Diagnosis of m.pox?
PCR. Aggressively scrub lesion
Patient presenting with proctitis - common presenting STIs?
Gonorrhoea
Chlamydia
HSV
Treatment for m.pox. Who should you rx?
Only high risk/Immunosuppressed
Vaccine for most
Cause of chancroid?
Hemophilus ducreyi
–small fastidious gram-negative rod
Erythematous papule evolves into ulcer
Often more than one ulcer present
Typically 1-2 cm, but can be larger, generally with erythematous base and clear margins (often undermined), purulent base
Inguinal lymphadenitis present ~50% of time
Diagnosis and Rx?
Chancroid
Azithromycin
Purulent base
How does LGV present?
Primary infection: genital ulcer, heals within few days – Very rarely diagnosed
Secondary infection
– Inguinal lymph node swelling/ bubo
LGV cause? Rx?
Serovars 1,2,3 of chlamydia trachomatis
Doxycycline
What is this?
Groove sign
2 inguinal lymph nodes
LGV
Beefy lesion on the penis, organism and Rx?
Donovanosis (Granuloma Inguinale)
Slow growing, non tender, bleeds easily
Klebsiella granulomatis
Rx: Azithromycin
Seen in Africa
Where is Chancroid still prevalent?
Sub Saharan Africa
What is this?
Syphilis
Treponema Pallidum
Trichomonas vaginalis - affects who?
Females!
Vagina is reservoir
Causes of non gonococcal urethrits?
chlamydia
Mycoplasma genitalium
Trichomonas
HSV
RARE RARE:
Coliforms (anal)
N.meningitidis
H.Influenza
EBV, adenovirus
Mx of mycoplasma genitalium?
Doxycycline 7/7
Moxifloxacin 2nd line
Transmission of monkey pox?
inoculation through broken skin, inhalation or via mucous membranes
What is WHO diagnostic criteria for Mpox?
unexplained rash pls one of fever/headache/malaise/LN plus AND
MSM/travel/contact hx
inc period for mpox?
5-21 days
Skin rash in M.pox?which one is infectious?
All of them highly infectious
On palms and soles
More peripheral
Difference in rash between respiratory or direct inoculation?
Respiratory - disseminated rash
Direct inoculation - can also be disseminated but can be local
Diagnosis of M.Pox?
PCR
Differentials of vesicular rash of mpox?
Chickenpox
Molluscum contangiosum
Disseminated gonococcal infection
Bacterial skin infections
Enterovirus
Measles
Syphilis
Complications of mpox?
Sec bacterial infection, pneumonia, encephalitis, keratitis
Two clades of mpox?
Clade 2 - west africa - low mortality
Clade 1 - central Africa - higher mortality
Vaccine for mpox?
Smallpox vaccine
85% effective
What type of viris is m.pox? What are the reservoir?
orthopox virus- large DNA genome
Rodents are reservoir
Outcome in HIV patients for m.pox?
30% mortality
