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Sexually transmitted infections Flashcards

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1
Q

List 6 common STI presentations in men

A 
Asymptomatic
Urethral discharge
Dysuria
Scrotal pain/swelling
Rash/sores
Systemic symptoms
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2
Q

List 8 common STI presentations in women

A 
Asymptomatic
Vaginal discharge (+/- urethral, rectal)
Ulceration (painful/painless)
Itching/ soreness 
"Lumps"
Abnormal bleeding, IMB/PCB
Pain - abdo/dyspareunia/dysuria
Systemic symptoms
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3
Q

What are the 5 most common causes of abnormal discharge?

A 
Gonorrhoea
Chlamydia
Trichomonas
Candida
Bacterial vaginosis
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4
Q

What are the 5 most common causes of genital ulceration?

A 
Syphilis
HSV
Lymphogranuloma venereum (LGV)
Chancroid
Donovanosis
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5
Q

What are the 4 most common causes of genital rashes, lumps and growths?

A

Genital warts (HPV)
Molluscum contagiosum
Scabies
Pubic lice

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6
Q

What’s the difference between painful and painless genital ulcers?

A

Painful: more likely to be herpes or chancroid (soft chancre)

Painless: more likely to be syphilis (hard chancre) or LGV or donovanosis (granuloma inguinale)

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7
Q

Which pathogen causes gonorrhoea?

A

Neisseria gonorrhoeae

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8
Q

Describe the microscopic features of Neisseria gonorrhoeae

A

Fastidious, facultatively intracellular gram negative diplococci. Coffee bean shaped. Grow on chocolate agar.

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9
Q

What is opthalmia neonatorum and how is it caused?

A

= neonatal conjunctivitis

Develops if mother’s gonorrhoea untreated and transfers to child from birth canal

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10
Q

How does gonorrhoea affect patients with complement deficiency?

A

Disseminated gonococcal infection - septicaemia, rash and/or arthritis

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11
Q

What is the gold standard to test to diagnose gonorrhoea?

A

Culture from urethral (sensitivity 95%) or rectal (sensitivity 20%) smears

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12
Q

How is gonorrhoea treated?

A

Ceftriaxone - 250mg single dose IM or Cefixime - 400mg single dose PO

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13
Q

How is resistant gonorrhoea treated?

A

Spectinomycin - 2g single dose IM

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14
Q

Name 3 ways in which an uncomplicated gonorrhoea infection can present in men

A 
Non-gonococcal urethritis (NGU)
     - Most common STI in Europe
     - Mucoid/mucopurulent discharge
Post-gonococcal urethritis (PGU)
     - Follows gonorrhoea treatment
     - Can be prevented by concomittant treatment with a tetracycline
Rectal proctitis
     - Mainly in MSM
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15
Q

How does an uncomplicated gonorrhoea infection present in women?

A

Mucopurulent cervicitis

- Erythema and oedema of the endocervix
- Abnormal vaginal discharge and bleeding
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16
Q

Name a complication of gonorrhoea in men

A

Prostatitis

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17
Q

Name a complication of gonorrhoea in women

A

PID (salpingitis)

 - Ascending infection
 - Most common cause of female infertility in Europe
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18
Q

Describe the microscopic features of Chlamydia trachomatis

A

Gram negative, obligate intracellular non-motile ovoid bacterium. Cannot be cultured on agar

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19
Q

In the UK, what percentage of under 25s have chlamydia?

A

10%

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20
Q

What proportion of chlamydia infections are asymptomatic?

A

50% in men

80% in women

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21
Q

Name the two forms Chlamydia trachomatis can take at different stages of its growth cycle

A
  • Elementary bodies (stable, extracellular)

- Reticulate particles (intracellular, metabolically active)

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22
Q

What is trachoma and which chlamydia serovars is it caused by?

A

Trachoma = eye infection which can lead to blindness. Caused by chlamydia serovars A, B and C

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23
Q

Which chlamydia serovars cause genital infection and opthalmia neonatorum?

A

Serovars D - K

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24
Q

List 3 complications of chlamydia in men

A

Epididymitis
Reiters syndrome (arthritis, conjunctivitis, urethritis)
Increased risk of infertility

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25
Q

What is Reiter’s syndrome?

A

A combination of reactive arthritis, conjunctivitis and urethritis. Often caused by chlamydia infection. More common in men.

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26
Q

List 6 complications of chlamydia in women

A 
PID
Tubal factor infertility
Increased risk of ectopic pregnancy
Increased risk of endometriosis
Chronic pelvic pain
Opthalmia neonatorum
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27
Q

What is the gold standard test for diagnosing chlamydia?

A

Nucleic acid amplification tests (NAATs)

High specificity and sensitivity

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28
Q

What is the treatment for uncomplicated chlamydia?

A

Azithromycin 1g (4 capsules) single stat dose
OR
Doxycycline 100mg BD for 7 days
OR
Erythromycin 500mg QDS for 7 days or BD for 2 weeks

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29
Q

When should doxycycline not be given?

A

In pregnancy - can disturb bone growth and cause tooth discolouration

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30
Q

In the world of STIs not lorry driving, what does LGV stand for?

A

Lympho-granuloma venereum

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31
Q

What is LGV?

A

Lymphatic infection with Chlamydia serovars L1, L2 and L3

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32
Q

Who is more likely to get LGV in the developed world? (recent outbreaks)

A

MSM

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33
Q

Describe the primary stage of early LGV

A 
3-12 days
Genital ulcer: painless, non-indurated
Balanitis (inflammation of the head of the penis/foreskin)
Proctitis
Cervicitis
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34
Q

Describe the secondary stage of early LGV

A

2-25 weeks
Inguinal buboes: painful, 2/3 unilateral, may rupture
Fever
Malaise
Proctocolitis
Hyperplasia of lymphoid tissue
Rarely: hepatitis, meningo-encephalitis, pneumonitis

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35
Q

Describe late LGV

A 
Inguinal lymphadenopathy
Abscess formation
Genital elephantiasis
Genital ulcers
Frozen pelvis
Rectal strictures
Perirectal abscesses and fistulae
Lymphorroids (peri-anal outgrowths of the upper rectum)
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36
Q

Describe the rectal symptoms presenting in the current LGV outbreak

A 
Pain
Tenesmus
Bleeding 
Mucous discharge
Proctitis
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37
Q

How is LGV diagnosed?

A
  • NAAT (currently unlicensed) - if positive, sent to lab at central health protection agency.
  • Confirmation of Chlamydia trachomatis by real time PCR on 2 platforms
  • Genotypic identification of L1, L2 or L3 serovar
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38
Q

What is the treatment for LGV?

A 
Doxycycline 100mg BD for 3 weeks
    OR
Erythromycin QDS for 3 weeks
    OR
Azithromycin 1g weekly for 3 weeks
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39
Q

Which bacterium causes syphilis?

A

Treponema pallidum

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40
Q

Describe the microscopic features of Treponema pallidum

A

Obligate gram negative spirochaete (spiral shaped). Can be seen in primary lesions by “dark-ground/dark-field” microscopy

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41
Q

Who tends to get syphilis?

A

Majority of cases in HIV positive pts. Often co-infected with hepC or another STI. Rising in UK

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42
Q

What is the diagnostic method of choice for Treponema pallidum?

A

Antibody detection

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43
Q

How can Treponema bacteria be directly detected? (NB these methods are much less commonly performed than antibody detection)

A

Darkfield microscopy

Multiplex real-time PCR

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44
Q

Describe the non-Treponemal antibody tests used in syphilis

This slide needs cutting up

A
  • Detect non-specific antigens
  • VDRL (venereal disease research laboratory) slide test: detects lipoidal antibody on both host and treponemal cells
  • Reagents contain cardiolipin, lecithin and cholesterol (can get biological false positives)
  • RPR (rapid plasma reagin) is a modified VDRL test
  • Positive RPR is indicative of treponemal infection
  • Useful in primary syphilis
  • Titre falls in response to treatment therefore can be used to monitor response.
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45
Q

Which sort of syphilis tests are more sensitive, treponemal or non-treponemal?

A

Non-treponemal

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46
Q

Which sort of syphilis tests are more specific, treponemal or non-treponemal?

A

Treponemal

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47
Q

Describe the Treponemal antibody tests used in syphilis

This slide needs cutting up

A
  • Detect antibodies against specific antigens from T. pallidum
  • Examples: Enzyme immunoassay (EIA), Fluorescent treponemal antibody (FTA), T. pallidum haemagglutination test (TPHA), T. pallidum particle agglutination test (TP-PA)
  • More specific than non-Treponemal test
  • Remains positive for years despite effective treatment
48
Q

Why are biological false positives common in the non-treponemal tests?

A

Because the reagents contain cardiolipin, lecithin and cholesterol

49
Q

Give four examples of treponemal tests for syphilis

A

Enzyme immunoassay (EIA)
Fluorescent treponemal antibody (FTA)
T. pallidum haemagglutination test (TPHA)
T. pallidum particle agglutination test (TP-PA)

50
Q

Does a positive treponemal test always indicate a syphilis infection?

A

No, although the test is specific for syphilis it remains positive for years despite effective treatment (test is for antibodies, so not dependent on presence of pathogen)

51
Q

Describe primary syphilis

A

Macule turns to papule turns to indurated painless genital ulcer
Ulcer appears 1-12 weeks after transmission
Often solitary
May persist 4-6 weeks as a chancre
Clean base with serous exudate
Regional adenopathy

52
Q

How long after transmission of syphilis does the primary stage of the disease appear?

A

1-12 weeks

53
Q

In primary syphilis are the genital ulcers painful or painless?

A

Painless

54
Q

Describe secondary syphilis

bollocks slide, someone fix please

A 
Most important part: -
1-6 months after primary infection
Systemic bacteraemia
Low grade fever and malaise
Symmetrical, non-pruritic, maculo-papular rash on back, trunk, arms, legs, palms, soles, face
Also good to know: -
Mucosal lesions
Uveitis
Choroidoretinitis (inflammation of the choroid and retina)
Alopecia
"Snail trail" oral ulcers
Condyloma acuminate (genital warts)
Can have neurological involvement: aseptic meningitis, cranial nerve palsies, optic neuritis, acute nerve deafness
55
Q

What are “snail trail” oral ulcers a sign of?

A

Secondary syphilis

56
Q

Without treatment, what proportion of people with syphilis go on to develop a tertiary infection?

A

Approx 1/3

57
Q

Name the three possible types of tertiary syphilis

A 
Gummatous syphilis (15% of primary infections) 
Late neurosyphilis (6.5%)
Cardiovascular syphilis (10%)
58
Q

Describe gummatous tertiary syphilis

A

Rare
Occurs 2-40 years later
Formation of chronic “gummas” - soft, tumor-like balls of inflammation
Particularly affects skin, bone, liver and mucosa but can occur anywhere
Spirochaetes (the bacteria) scanty - this is why there is a strong DTH response

59
Q

What is a DTH reaction and how does it predict the course of a syphilis infection?

A

DTH = delayed type hypersensitivity

A strong DTH response is associated with clearance of the infecting organisms in a well-developed chancre, whereas a cytotoxic T-cell response or strong humoral antibody response is associated with prolonged infection and progression to tertiary disease.

60
Q

Is tertiary syphilis infectious?

A

No

61
Q

Describe neurosyphilis

A 
Most common in people with HIV
Occurs 2-30 years later
Four different forms: asymptomatic, meningovascular, tabes dorsalis, and general paresis ("of the insane")
Can present with gumma
Spirochaetes in CSF
Small vessel vasculitis
Argyll-Robertson pupil
62
Q

What are the four forms of neurosyphilis?

A

Asymptomatic
Meningovascular
Tabes dorsalis
General paresis of the insane

63
Q

What is tabes dorsalis?

A

AKA syphilitic myelopathy
Slow demyelination of the nerves primarily in the dorsal columns (posterior columns) of the spinal cord.
Therefore affects proprioception, vibration sensation and discriminative touch.

64
Q

What is Argyll-Robertson pupil also known as?

A

Prostitute’s pupil

65
Q

What is Argyll-Robertson pupil/prostitute’s pupil?

A

Bilateral small pupils that constrict when the patient focuses on a near object, but do not constrict when exposed to bright light.

“Accommodates but does not react”

66
Q

What is the treatment for syphilis, at any stage?

A

Single dose IM benzathine penicillin (doxycycline if allergic)

67
Q

When is treatment considered successful?

A

Depends on a four fold reduction in RPR (rapid plasma reagin)

68
Q

Describe cardiovascular tertiary syphilis

A

10-30 years later
Un-/complicated aortitis
+++spirochaetes
+++inflammation

69
Q

Which reaction commonly occurs following treatment for syphilis?

A

Jarisch-Herxheimer reaction

  • Fever, headache, myalgia
  • Develops in hours and clears within 24 hours

Due to reaction to endotoxin-like products released by the death of spirochaetes.
Occurs in 50% primary and 90% secondary

70
Q

What is latent syphilis?

A

Occurs between secondary and tertiary stages. No obvious signs/symptoms but serological infection present

71
Q

Describe congenital syphilis

A

Can be passed from mother to child druing either pregnancy (via placenta) or birth

Features in first couple of years: hepatosplenomegaly, rash, fever, neurosyphilis, pnemonitis

Late congenital syphilis (presenting after 2 years old) occurs in 40%

72
Q

Which bacteria causes chancroid?

A

Haemophilus ducreyi

73
Q

Describe the microscopic features of Haemophilus ducreyi

A

Gram -ve coccobacillus (like Hib)

74
Q

Describe chancroid

A

Tropical ulcer disease causing multiple painful ulcers. More common in Africa, rare in UK

75
Q

How is chancroid (Haemophilus ducreyi) diagnosed?

A

Culture on chocolate agar

PCR

76
Q

What is Donovanosis also known as?

A

Granuloma inguinale

77
Q

Which bacterium causes Donovanosis/granuloma inguinale?

A

Klebsiella granulomatis

78
Q

Describe the microscopic features of Klebsiella granulomatis

A

Gram -ve bacillus

79
Q

Where does Donovanosis commonly occur?

A

Africa, India, Papau New Guinea, Australian aboriginal communities

80
Q

Describe Donovanosis

A

“Beefy” red appearance

Large, expanding ulcers. Start as papule or nodule that breaks down

81
Q

How is Donovanosis diagnosed?

A

Giemsa stain of biopsy/tissue crush shows Donovan bodies

82
Q

What kind of stain is used in the diagnosis of Donovanosis?

A

Giemsa stain

83
Q

What is the treatment for Donovanosis?

A

Azithromycin

84
Q

Name 3 non-viral enteric pathogens that can be sexually transmitted (through oro-anal contact)

A

Shigella
Salmonella
Giardia (protozoan)

Occasionally also strongyloides

85
Q

Which flagellated protozoan causes trichomoniasis?

A

Trichomonas vaginalis

86
Q

How is trichomoniasis diagnosed?

A

Wet prep microscopy

PCR

87
Q

How does trichomoniasis present?

A

Asymptomatic/urethritis in men

Discharge in women

88
Q

What risks is trichomoniasis associated with?

A

Increased risk of HIV acquisition and of pre-term labour

89
Q

What is the treatment for trichomoniasis?

A

Metronidazole

90
Q

Which polymicrobial disorder is associated with abnormal vaginal flora and a decrease in vaginal lactobacilli?

A

Bacterial vaginosis (BV)

91
Q

How does BV present?

A

Abnormal discharge and very strong odour.

Often recurrent

92
Q

Is BV an STI?

A

No but it may be “sexually associated”.

Also associated with overzealous hygiene practices (douching)

93
Q

How is BV diagnosed?

A

Microscopy of Gram stain
Raised pH
“Whiff test” :(
“Clue cells” on wet mount - epithelial cells coated in bacteria can be seen on microscopy of vaginal discharge with a drop of sodium chloride solution

94
Q

What is the main risk associated with BV in pregnancy?

A

Pre-term labour

95
Q

What causes candidiasis (thrush)?

A

Usually Candida albicans (yeast)

96
Q

How does thrush present?

A

Can be asymptomatic
White thick discharge, itching, soreness, redness
Vulvovaginitis in women; balanitis in men

97
Q

Is thrush sexually transmitted?

A

No, candida albicans can be part of normal flora

Recurrence may be associated with immunodeficiency or overzealous hygiene practices

98
Q

Give two examples of “hormonal disturbances” associated with increased risk of thrush?

A

Pregnancy

OCP

99
Q

How is thrush treated?

A

Topical/oral antifungals eg clotrimazole, fluconazole

100
Q

What sort of pathogen causes molluscum contagiosum?

A

Pox virus

101
Q

What kind of genetic material does the pox virus have?

A

dsDNA

102
Q

How is molluscum spread in children and which areas does it affect?

A

Spread by skin to skin contact, affects hands and faces. (should worry if genital involvement)

103
Q

How is molluscum spread in adults and which areas does it affect?

A

Sexual contact - genital lesions

104
Q

What does facial molluscum in adults indicate?

A

Immunocompromise - should assume HIV until proven otherwise. Can also cause giant lesions.

105
Q

How is molluscum treatment?

A

Cryotherapy, but treatment only required if destructive, otherwise self-limiting

106
Q

Which virus causes genital warts?

A

dsDNA human papillomavirus

107
Q

Which HPV strains cause visible genital warts?

A

HPV 6 and HPV 11

108
Q

Are HPV 6 and 11 associated with increased risk of cervical dysplasia?

A

No

109
Q

What is the incubation time for genital warts?

A

3 weeks - 8 months

110
Q

Genital warts are diagnosed by examination. What are their key dermatological features?

A 
Papular
Planar
Pedunculated
Carpet
Keratinised
Pigmented
111
Q

What is the treatment for genital warts?

A

At home: podophyllotoxin solution/cream (not suitable for pregnant women)

In clinic: 1st line cryotherapy; 2nd line imiquimod

However, can often recur after treatment

112
Q

Which strains of HPV are oncogenic?

A

16 and 18

113
Q

Name 6 types of cancer associated with HPV

A 
Cervical
Anal
Penile
Vulval
Head
Neck
114
Q

What change was made to the HPV vaccine in 2012?

A

Became quadrivalent - now includes 6 and 11 as well as 16 and 18

115
Q

Name 5 sexually transmitted viruses other than HPV

A 
HAV
HBV
HCV
Herpes
HIV
116
Q

How is Hep A sexually transmitted?

A

Oro-anal sex

117
Q

Who is most likely to contract hep C?

A

HIV +ve MSM

rarely hetero-sexually transmitted

Microbiology (27 decks)

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