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Year 3 Clinical > Sexually Transmitted Infections > Flashcards

Sexually Transmitted Infections Flashcards

1
Q

What is Chlamydia?

A

Gram -ve bacterium that is transmitted vaginally, orally or anally

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2
Q

Occurrence of Chlamydia

A

It is the most common STI and its incidence is highest in 20-24 year olds

Many patients are completely asymptomatic

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3
Q

Consequences of Chlamydia infection in women?

A

Pelvic Inflammatory Disease (PID) - pathogenesis is unclear but it occurs in 9% of women with Chlamydia; 1/2 of PID cases occur due to Chlamydia infection

An episode of PID increases the risk of ectopic pregnancy and carries a risk of tubal factor infertility

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4
Q

PC of Chlamydia in females?

A

Post-coital or inter-menstrual bleeding (common PC)

Lower abdominal pain and dyspareunia

Mucopurulent cervicitis (consider PID)

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5
Q

PC of Chlamydia in males?

A

Urethral discharge (more clear/milky than the green discharge in Gonorrhoea) and dysuria

Different sites can be infected:
• Urethritis
• Epididymo-orchitis
• Proctitis (inflammation of the rectum) - a sign of LYMPHOGRANULOMA VENEREUM (LGV)

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6
Q

Other complications of Chlamydia infection?

A

Tubal damage (infertility and ectopic pregnancy)

Chronic pelvic pain

Transmission to the neonate (can cause conjunctivitis, pneumonia, etc); consider this in neonates with ‘sticky eyes’

Adult conjunctivitis (not washing hands after bathroom)

Sexually-acquired reactive arthritis (SARA)

Reiter’s syndrome (triad); this is more common in men

Fitz-Hugh-Curtis syndrome - involves peri-hepatitis

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7
Q

What is LGV?

A

Caused by serovars L1-3 of Chlamydia trachomatis, when it travels from the site of inoculation, down the lymphatics, to multiply within the phagocytes of the lymph nodes

It is most commonly diagnosed in MSMs

There is a high risk of concurrent STIs, often HIV

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8
Q

PC of LGV?

A

PROCTITIS - rectal pain, discharge and bleeding

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9
Q

Ix for LGV?

A

Test 14 days following exposure

NAATS:
• Females - vulvovaginal swab
• Males - 1st pass urine

For MSMs, ADD RECTAL SWABS if they have had receptive anal intercourse

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10
Q

Treatment of LGV?

A

Azithromycin (1G stat) - this is preferred as the clinician can watch the patient take the medication, so there are no compliance issues

Doxycycline (100mg BD for 1 week) - used for patients with rectal infections

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11
Q

What is Gonorrhoea?

A

Caused by Neisseria gonorrhoea (a gram -ve INTRACELLULAR diplococcus)

Incubation period of urethral infection is short in men (2-5 days); this is shorted than Chlamydia

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12
Q

Risk of transmitting Gonorrhoea to a partner?

A

20% risk from an infected woman to a male partner

Much higher risk of transmission (50-90%) from an infected man to a female partner

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13
Q

Primary sites of infection with Gonorrhoea?

A

Mucous membranes of the urethra, endocervix, rectum and pharynx

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14
Q

PC of Gonorrhoea in males?

A

Urethral discharge, dysuria

Some patients are asymptomatic; however, patients are far more likely to be symptomatic than for Chlamydia

Pharyngeal and rectal infections are usually asymptomatic

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15
Q

PC of Gonorrhoea in females?

A

1/2 of affected females are ASYMPTOMATIC

Others will have:
• Increased / altered vaginal discharge
• Dysuria
• Pelvic pain (uncommon)

Pharyngeal and rectal infection are usually asymptomatic

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16
Q

Complications of Gonorrhoea?

A

Lower genital tract:
• Bartholinitis - inflammation of one/both of the Bartholin’s glands, located one on either side of the vaginal opening
• Tysonitis - inflammation of Tyson’s glands
• Periurethral abscess
• Rectal abscess
• Epididymitis
• Urethral stricture

Upper genital tract:
• Endometritis
• PID
• Hydrosalpinx
• Infertility
• Ectopic pregnancy
• Prostatitis
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17
Q

Diagnosis of Gonorrhoea?

A

Microscopy (high sensitivity is urethral; low sensitivity if endocervical)

Culture (high sensitivity in male urethra; lower sensitivity in female endocervix)

GOLD STANDARD test is NAAT (high sensitivity both symptomatic and asymptomatic patients)

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18
Q

Gram stain appearance of Gonorrhoea?

A

Predominant PMN cells

Intracellular appearance of kidney beans

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19
Q

Advantages of the microscopy, culture and NAATs for diagnosis of Gonorrhoea?

A

Microscopy - near patient diagnosis; allows timely treatment

Culture - allows antibiotic sensitivity checking and monitoring

NAATs - non-invasive specimens; less problems with transport, media and storage

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20
Q

Disadvantages of microscopy, culture and NAATs for diagnosis of Gonorrhoea?

A

Microscopy:
• Invasive specimens required
• Low sensitivity
• Requires confirmation

Culture:
• Invasive specimens
• Requires specific media and incubation

NAATs:
• Risk of false +ve
• +ve result should be confirmed by NAAT with different target

21
Q

Treatment of Gonorrhoea?

A

1st line - ceftriaxone 500mg IM

2nd line - cefixime 400mg PO (only if IM injection is contraindicated or refused by patient)

Azithromycin 1g is given regardless of the Chlamydia results

i.e: 1st line is Ceftriaxone + Azithromycin

Must do a TEST OF CURE in all patients

22
Q

Categories of genital herpes infection?

A
  • Primary infection
  • Non-primary first episode (exposed to a different type of HSV previously, so no antibodies to this one)
  • Recurrent infection
23
Q

Time course of primary infection with genital herpes?

A

Incubation period of 3-6 days; duration of 14-21 days

24
Q

PC of genital herpes?

A

Blistering and ulceration of the external genitalia (tend to be shallow)

Extreme pain and external dysuria

Vaginal or urethral discharge

Local lymphadenopathy

Fever and myalgia (prodrome symptoms)

25
Q

Occurrence of recurrent episodes of genital herpes?

A

More common with HSV-2 infection

26
Q

Symptoms of recurrent episodes of genital herpes?

A

Usually unilateral, with small blisters and ulcers

Minimal systemic symptoms

Resolves within 5-7 days

NOTE - often misdiagnosed as thrush (mild, localised anogenital tingling, burning or soreness); also, recurrences are not as severe as the 1st episode and symptoms usually resolve after a few days

27
Q

Ix for genital herpes?

A

Swab base of the ulcer (de-roofed) for HSV PCR

28
Q

Mx of genital herpes?

A

Oral anti-viral (aciclovir 400mg TDS for 5 days)

Consider topical lidocaine 5% ointment (if very painful)

Saline bathing

Analgesia

29
Q

Explain the concept of viral shedding

A

Viral shedding is the period during which the virus becomes active and contagious

Consistently higher following HSV-2, compared to HSV-1

It is more frequency during the 1st year of infection and in individuals with frequent recurrences; as each year passes, risk decreases

It is reduced by suppressive therapy

30
Q

Special circumstances ??

A

If the patient is pregnant, and in the final trimester, this may be cause for concern

If this is the patient’s 1st episode of HSV, they will have no antibodies and there is a risk of neonatal herpes

If this is a recurrent attack, the patient has antibodies so this is not cause for concern; O&G should still be informed

NOTE - must check for antibodies, as this will determine whether the attack is a recurrence; if there are no antibodies, this is a primary attack and there is a risk of neonatal herpes

31
Q

Occurrence of HPV?

A

Most common viral STI in the UK

Lifetime risk of acquiring the infection is as high as 80%, however only a small proportion develop warts as a result

32
Q

Types of HPV?

A

There are >200 types and many of these infect the anogenital epithelium

Low-risk types include HPV TYPES 6 AND 11 (>90% of genital herpes cases); type 1&2 cause palmar and plantar warts

High-risk types include HPV types 16, 18, 31, 33, 45, 52 and 58

33
Q

Clinical sequelae of of HPV infection?

A

Different genotypes are assoc. with different clinical sequelae:
• Latent infection
• Anogenital warts (types 6 & 11)
• Palmar and plantar warts (types 1 & 2)
• Cellular dysplasia / intraepithelial neoplasia

34
Q

Transmission of HPV?

A

Patient is likely to have acquired HPV from an asymptomatic partner

Transmission of >1 HPV type is common

35
Q

Incubation period of HPV?

A

3 weeks to 9 months

36
Q

Potential outcomes of HPV genital infection?

A
  1. Spontaneous clearance of warts
  2. Clearance with treatment
  3. Persistence despite treatment
37
Q

Treatment of HPV infection?

A

Wait; if 1 months pass since PC, unlikely to disappear themselves

1st line:
• Podophyllotoxic (Warticon) - this is cytotoxic; it is not licensed for extra-genital warts but is widely used for them regardless

2nd line:
• Imiquimod - an immune modifier that can be used on all anogenital warts

Cryotherapy - this is cytolytic; it may require repeat treatments

Electrocautery

38
Q

Prevention of HPV infection?

A

HPV vaccination for girls 11-13 years old

Going to be offered to MSM and people with HIV

39
Q

Cause of syphilis?

A

Treponema pallidum (a spirochaete)

40
Q

Transmission of syphilis?

A 
Usually via:
• Sexual contact
• Trans-placental / during birth
• Blood transfusions
• Non-sexual contact, e.g: healthcare workers
41
Q

Classifications of syphilis?

A

Congenital

Acquired - divided into:
• Early infectious (primary, secondary, early latent)
• Late non-infectious (late latent, tertiary)

NOTE - there is a dividing line of 2 years between the 2 categories of acquired syphilis

42
Q

Incubation period of primary syphilis?

A

9-90 days (average of 21 days)

43
Q

PC of primary syphilis?

A

Primary chancre (painless) at site of inoculation; these are mostly genital but can be extra-genital

Non-tender local lymphadenopathy

44
Q

Incubation period of secondary syphilis?

A

6 weeks to 6 months

45
Q

PC of secondary syphilis?

A

Skin (macular, follicular or pustular rash that is PALMOPLANTAR)

Lesions of mucous membranes

Generalised lymphadenopathy

Patchy alopecia

Condylomata lata - this is the most highly infectious lesion in syphilis; wart-line lesions that exude a serum teeming with treponemes

46
Q

Ix of syphilis?

A

Demonstration of Treponema pallidum (from lesions or infected lymph nodes):
• Dark field (ground) microscopy
vPCR

Serological testing - detects Abs to pathogenic treponemes

47
Q

Serological tests for syphilis?

A

Non-treponemal:
• VDRL (used in some centres)
• RPR (used in Tayside) - measures disease activity

Treponemal:
• TPPA
• ELISA/EIA (this is the SCREENING TEST)
• INNO-LIA 
• FTA antibodies

NOTE - ELISA is the screening test; if this is +ve, do TPPA, INNO-LIA, FTA antibodies

48
Q

Treatment of syphilis?

A

Early syphilis - 2.4 MU Benzathine penicillin X 1

Late syphilis - 2.4 MU Benzathine penicillin x 3, i.e: weekly for 3 weeks

49
Q

Serological follow-up of syphilis?

A

Done for both early syphilis and late syphilis

Continue until RPR is -ve or serofast:
• Titres should decrease four-fold by 3-6 months in early syphilis

If titres increase four-fold, this is serological relapse / reinfection

Year 3 Clinical (100 decks)

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