Sexually Transmitted Infections Flashcards
Risk Factors for STIs
11
- Unmarried status
- Residence in an urban area
- New sex partner(s)
- Multiple sexual partners (concurrent)
- History of a prior STI
- Illicit drug use
- Contact with sex workers
- Young age (15-24 YO)
- African-American race
- Admission to correctional facility or juvenile detention center
- Meeting partners on the internet
Etiology of genital ulcer?
4
- Herpes simplex virus (HSV)
- Treponema pallidum (syphilis)
- Haemophilus ducreyi (chancroid)
- Chlamydia trachomatis (lymphogranuloma venereum: LGV)
Noninfectious etiology of gential ulcers?
2
Behcet’s disease
Fixed drug reactions and trauma
Chancre of Syphilis
are dangrous why?
Its painless so they dont seek care
What is Chancroid: Haemophilus ducreyi caused by?
How are they different from chancre of syphilis?
Fastidious gram neg organism—developing countries STI
VERY PAINFUL
Why do you get Lymphogranuloma venereum
from Chlamydia?
What is the pt typically co-infected with?
Certain strains of Chlamydia spread to the lymph nodes
Patient usually co-infected w/ HIV
Also known as “climatic bubo”
Pathology of Behcet’s Disease?
Where do the lesions occur?
How can it be fatal?
What do we need to be carefule about in the history?
Rare immune-mediated small vessel systemic vasculitis
Lesions occur on multiple mucous membranes and eyes
Can involve internal organs and be fatal due to ruptured vascular aneurysms
Its immune mediated so we treat it way differently than an infection
What are the two herpes infections that we talk about?
Causative agents: HSV-1 and HSV-2
Types of HSV Infection
3?
PRimary
Non-primary
Recurrent
Describe a primary HSV infection?
infection in a patient without antibodies to HSV-1 or HSV-2
Describe a nonprimary HSV infection?
first episode infection due to acquiring genital HSV-1 w/ preexisting antibodies to HSV-2 or vice versa
Describe recurrent HSV infection?
reactivation of genital herpes in which the HSV type recovered in the lesion is the same type as the antibodies recovered in the serum
Symptoms of primary infection of HSV?
4
How do nonprimary symtpoms compare?
How do reccurrent symptoms compare?
What is something that we need to remember even if there is no noticable symptoms?
Systemic symptoms,
local pain/itching,
dysuria,
lymphadenopathy
less symptomatic than the first episode
less severe/shorter duration**
Asymptomatic shedding
What can dysuria be due to?
2
Dysuria can be due to acute urinary retention or more rarely to lumbosacral radiculomyelitis
How can HSV be transmitted and how conatgious is it?
What can we do to prevent transmission?
HSV-2 genital ulcer disease has been linked to an increased risk for acquiring what?
Highly transmittable!!!
Can be transmitted by oral-genital contact
Greater risk of acquiring HSV w/ male source
70% of transmission occurred during periods of asymptomatic shedding
Condom use 50% decline in transmission
HIV-1 infection (break in the skin)
How do we diagnose HSV?
3 lab tests
1 blood draw
How can we tell if theyve had a prior infection?
- Viral culture: if active lesions present
- Polymerase chain reaction (PCR): more sensitive
- Direct fluorescent antibody
- Type-specific antibody testing of serum
Helps to determine if the patient is at risk of acquisition
Determines if a patient has had evidence of prior infection (if theyve never had lesions)
Can do screening for HSV
What drugs treat HSV?
3
Whats the most successful time frame for treatment after primary gential HSV?
How does this help?3
Acyclovir (Zovirax)
Famcilovir (Famvir)—more bioavailable
Valacyclovir (Valtrex)—more bioavailable/BID
should be treated (within 72 hrs)
-decreases duration of symptoms, lesion time and viral shedding
Therapy for recurrent disease of HSV?
3 options
Chronic suppressive therapy: expensive and may not be covered by all insurance carriers
Episodic therapy: start at the first sign of prodromal symptoms usually take for 3 days
No intervention
Most common mode of transmission of HSV in pregnancy?
What can we use to treat it?
What is the best way to prevent transmisison?
When is the only time we do this?
from direct contact of the fetus w/ infected vaginal secretions during delivery
Acyclovir can be used to treat a primary infection
Prophylactic C-section:
Do if active lesions in birth canal
What so we need to tell the pt about their HSV infection?
Patients need to be educated that they may NOT have acquired the infection recently and that there has not necessarily been infidelity in a monogamous partner
Causative agent for syphillis?
How do we look at it in the lab?
Treponema palidum
Cannot be cultured
Can be seen with darkfield microscopy
How do we diagnose it?
2 kinds
Serologic tests
- Do titers first
- Treponemal test (confirm)
Nontreponemal: VDRL, RPR, TRUST/Reported as titers
Treponemal: (reported as “reactive” or “nonreactive”)
Fluorescent treponemal antibody absorption (FTA-ABS)
Microhemagglutination test for antibodies to T. pallidum (MHA-TP)
Treponema pallidum particle agglutination assay (TP-PA)
Trpeonema pallidum enzyme immunoassay (TP-EIA)
Syphilis—Who to Screen
5
- Patient w/ suspected disease
- Screening high-risk populations (e.g. patients w/ other STIs, persons w/ multiple sexual partners)
- Routine screening of pregnant women
- Commercial sex workers
- All sexually active HIV-infected patients at least annually; more frequent screening for those w/ multiple sex partners & unprotected intercourse
Primary and secondary syphilis produce what physical findings? 3
chancres,
mucous patches
condyloma lata
How can sphyllis be spread?
Pregnancy spread how?
kissing or touching a person who has active lesions on the lips, oral cavity, breasts or genitals
It can be acquired through passage through the placenta
Incubation period of sphyllis?
Incubation period of 2-3 wks from inoculation—a papule forms and soon ulcerates to the chancre
When do chancres heal?
Is lymphodenopathy unilateral or bilateral?
Chancre is usually painless
Chancres heal spontaneously within 3-6 wks even without treatment
Usually there is bilateral lymphadenopathy
Weeks to a few months later 25% of people w/ untreated infections will develop systemic illness:
9
(this is secondary syphillis phase)
- Rash: any form BUT vesicular, includes the palms/soles!!!
- Gray/white lesions warm moist areas—condyloma lata
- Systemic symptoms
- Lymphadenopathy
- Alopecia (Patchy)
- Hepatitis
- GI abnormalities (can be misdiagnosed as lymphoma)
- Musculoskeletal and renal abnormalities
- Ocular disease
When so early or late tertiary syphillis occur?
Early tertiary syphilis presents = 1 year
Late tertiary syphilis presents > 1year from initial infection
What systems are involved in tertiary syphilis?
3
- Subcutaneous tissues (gumma)—granulomas
- CV: ascending thoracic aorta becomes dilated aortic valve regurgitation occurs
- CNS: (most common)
What are the early CNS syptoms be for tertiary sphyllis?
Late CNS syptoms?
4
Early: meningitis, meningiovascular disease
Late: general paresis, tabes dorsalis, ocular, otosyphilis
If you suspect neurosyphilis what should you do?
What findings would make you suspect neurosphyllis?
3
Need to follow CSF during treatment to make sure there is a response. How
?
When suspected need to do lumbar puncture (LP)
- Lymphocytic pleocytosis
- Elevated protein
- CSF-VDRL and/or + FTA-ABS
Keep doing lumbar punctures
Treatment of Early Syphilis
2.4 million units of benzathine penicillin G IM
Treatment of Early Syphilis in pts allergic to PCN?
doxycycline 100mg BID for 14 days
Treatment for Late Syhphilis
2
Patients w/ gummas or CV involvement need to have an LP to r/o neurosyphilis before treatment
2.4 million units of benzathine penicillin G IM weekly for 3 weeks
Treatment for Neurosyphilis
Allergy option?
IV penicillin G either 3-4 million units q 4 hrs or 18-24 million units per day by continuous infusion for 10-14 days
Patients who are allergic to PCN should undergo PCN desensitization since PCN G is the drug of choice for treating neurosyphilis and an allergist should be consulted
Non-penicillin regimens are not recommended for patients w/ documents neurosyphilis
Monitoring Treatment
for syphillis?
What is evidence of a response to therapy?
What should we do before starting treatment?
If they arent getting better what do we need to differentiate between?
Patients need to be reexamined clinically and serologically at 6 and 12 months after treatment
A fourfold reduction in titer of the nontreponemal antibody test is evidence of a response to therapy
A titer should be drawn just prior to starting treatment and the same test and lab should be used for follow up
Treatment failure or reinfection**
What kind of virus is HPV?
Double-stranded DNA viruses Papillomavirus genus
HPV Manifestations
5
- Genital warts (condyloma acuminatum)
- Bowenoid papules and Bowen’s disease**
- Giant condyloma (Buschke-Lowenstein tumors)
- Intraepithelial neoplasia and/or carcinoma of the vagina, vulva, cervix, anus or penis
- Plays a role in squamous cell carcinomas of the head and neck particularly the oral cavity
What is bowen’s dz?
Whats the transitional state between genital warts and Bowen’s dz?
squamous cell cancer in situ
Bowenoid papules
What types of HPV strains account for 70% of all cervical cancers world wide?
HPV16 & HPV18
What strains cause about 90% of genital warts?
HPV6 & HPV11
Most HPV infections usually resolve within how many months?
6-12 months (including the carcinogenic HPV geno-types)
Steps of of cervical carcinogenesis
4
HPV acquisition
HPV persistence
Progression of persisting infection to precancerous lesion
Local invasion
Anogenital warts cause persistent infection especially w/ other risk factors (such as infection w/ HIV) can result in what?
How can it be spread?
the development of squamous cell carcinoma
Can be spread through toilet seat for example (fomite distribution)
Anogenital Warts Symptoms
7
- Asymptomatic
- Pruritis, burning
- Bleeding
- Tenderness, pain
- Discharge (women)
- Large condylomata can interfere w/ defecation, intercourse and vaginal delivery
- Lesions in the proximal anal canal may cause strictures
Anogenital Warts Diagnosis
How do we document the extent of involvement?
5
What will cause the lesions to turn white?
When do we consider biopsy?
2
Usually made by visual inspection
PE, anoscopy, sigmoidoscopy, colposcopy and/or vaginal speculum exam
5% acetic acid causes lesions to turn white
Biopsy can be considered:
- When diagnosis is uncertain or presence of atypical features
- Lesions that do not respond to treatment
Types of ablative therapy for anogenital warts therapy?
5
- Podophylliin (contraindicated in pregnancy)
- Imiguimod (Aldara)–also used for IEN vulva/anus
- Trichloroacetic acid (applied by provider)
- 5-fluoruracil (5-FU) (applied by provider)
- Intralesional injected alpha interferon
Types of Excisional therapy for anogenital warts therapy?
3
- Cryotherapy
- Laser therapy: requires anesthesia/risk of scarring
- Excisional procedures w/ knife or scissors:
- -requires anesthesia
- -risks of infection and hemorrhage
- -need to send specimen to path
Gardisil 9:
covers what?
16, 18, 31, 33, 45, 52, 58 (Cancers?)
6, 11 (protect against?)
What are the recommendations for gardisil vaccination?
Males 9-15
Females 9-26
Urethritis in Males What are the common causes and whats the most common cause?
3
- Gonorrhea common cause
- Chlamydia common concurrent infection or may be primary
- Trichomonas vaginalis—cause of “nongonococcal urthritis” (NGU)
How can we get discharge in gonorrhea?
How do we collect it?
What would we see?2
Usually can get discharge w/ milking the urethra
Urethral swab–+ WBC & + gram negative intracellular diplococci
What kind of organism is Trichomonas vaginalis?
Flagellated protozoan, humans only natural host
What is trichomoniasis associated with?
How is it transmitted?
Associated w/ a high prevalence of coinfection w/ other STIs
sexually only
Trichomoniasis Presentation in Women?
4
Asymptomatic carrier state
Symptomatic cases:
- Purulent, malodorous, thin discharge (70%)
- Burning, pruritus
- Dysuria, frequency—urethral involvement
- Dyspareunia, postcoital bleeding
Trichomoniasis Diagnosis?
Vaginal swab:
wet mount for microscopy in normal saline
can see motile trichomonads—diagnostic
Treatment for Trich?
Recurrent infections?
Pregnant women?
What do we have to educate the patient on if they have Trich?
Metronidazole (Flagyl):
Single oral dose of 2 gms
500 mg BID for 7 days (if recurrent infection)
ONly treat if symptomatic
No intercourse until all parties have been treated!
How do we diagnose and treat Trich in men?
Why do we treat then?
Usually transient w/ spontaneous resolution and asymptomatic
Symptoms are typical for urethritis
No definitive diagnostic tests; low yield w/ swabs for motile organisms
Treatment is usually because of + female diagnosis or empirically for NGU!!!!
Gonorrhea Manifestations
in women?
3
- Any portion of the genital tract (PID)
- Most common site is the cervix
- Urethritis
Gonorrhea Manifestations for men?
3
Urethritis
Epididymitis
Proctitis
Where else can gonorrhea infect besides genital?
Oropharyngeal infections: frequently asymptomatic
Disseminated Gonococcal Infection (DGI) manifestations?
3
tenosynovitis (multiple tendons are inflamed)
dermatitis (painless lesions)
polyarthralgias
Purulent arthritis without skin lesions can occur in DGI where are the most common places?
Unilateral or Bilateral
How do we diagnose it?
Usually just involves one joint.
Knees, wrists and ankles most common joints
Typically asymmetric
Tap the joint and culture fluid, have to do it quickly
Diagnosis of Gonorrhea 3
Whats the go to test? How do we collect it?
What is this not approved for?
- Culture: can be difficult—organism fastidious
- Gram stain: used primarily dx of urethritis in men
- Nucleic acid amplification testing (NAAT):
Recommended as the optimal method for diagnosis
Urine
Amplifies N. gonorrhoeae DNA or RNA sequences using various techniques
Samples: endocervix, vagina, urine, urethra in men
Not approved for nongenital sites (culture those)
Treatment of Gonorrhea
3
Ceftriaxone preferred treatment (resistance emerging!)
250mg IM single dose
KNOW THIS DOSE
PLUS: (to cover treatment of chlamydia*)
Azithromycin (Zithromax) 1 gram single dose
OR
Doxycline 100 mg BID for 7 days except in pregnant women
If allergic to Ceftriaxone in gonorrhea pts what should we treat with?
give azithromycin 2 gr single dose
Epididymitis Treatment
for men under 35 even if you only suspect it?
2
Ceftriaxone 250 mg IM + doxycycline 100 mg BID x 7 d
Chlamydia trachomitis is what kind of organism?
Small gram negative organism, oblique intracellular parasite
Why is reinfection or persistent infection is common in chlamydia?
Immunity to infection is not long-lived
Clinical Manifestations in Women with chlamydia?
4
- Asymptomatic!
- Cervicitis
- Urethritis
- PID**: 30% of women w/ chlamydia will develop PID if left untreated
Chlamydia Treatment
first line treatment? 2
Second line? 2
Azithromycin (Zithromax) 1 gr single dose
Doxycyline 100 mg BID for 7 days (cheap)
with ceftrixamine 250 IM fr gon
Ofloxacin for 7 days
Levofloxacin 7 days
-bones in babies
Pregnancy complications for chlamydia?
2
- If left untreated can increase risk of premature rupture of membranes and low birth weight
- Newborns can develop conjunctivitis & pneumonia (when mother is untreated)
Clinical Manifestations in Men for chlamydia? 3
How do we diagnose it?
Differential?3
- Urethritis
- Epididymitis:
- Proctitis: relatively uncommon, occurs MSM
Gram stain urethral secretions
Differential: testicular torsion, abscess, cancer
Chlamydia–Diagnosis
4
Whats the gold standard?
- Culture
- NAAT: vaginal, urethral, urine specimens (“gold standard”)
- Antigen detection: swab from cervix/urethra
- Genetic probe: swab from cervix/urethra
Pregnancy Routine early screening for:
7
Chlamydia Gonorrhea Syphilis Hepatitis B Offered test for HIV Take history for HSV Pap done to assess for HPV
