Sexually Transmitted Infections Flashcards
1
Q
Common causes of urethral infections? [3]
A
Gonorrhoeae, chlamydia, mycoplasma genitalium.
2
Q
Treatment of gonorrhoeae urethritis?
A
Ceftriaxone 250 mg IM + 1 g azithro
3
Q
Treatment of chlamydia urethritis?
A
Azithro 1 g once - Preferred in pregnancy
Doxy 100 mg BID - Contraindicated in 2nd and 3rd trimester
This is the treatment of MOST types and sites of chlamydia infection.
4
Q
Treatment of mycoplasma genitalium?
A
- Azithro 1 g [resistance 50%]
2. Moxifloxacin 400 mg qday for 14 days.
5
Q
Symptoms of BV?
A
Non-painful, non-pruritic discharge. May have fishy odor.
6
Q
Diagnosis of BV?
A
3/4 Amsel criteria
7
Q
Treatment of BV? [2]
A
- Flagyl 500 mg BID for 1 wk
- Clinda 300 mg TID for 1 wk [alt]
Topical preparations also okay.
8
Q
Presentation of trichomoniasis?
A
Dysuria, pain with intercourse, vaginal soreness with green-yellow frothy discharge.
9
Q
Diagnosis of trichomoniasis?
A
NAAT from vaginal, endocervical or urine
10
Q
Treatment of trichomoniasis?
A
Flagyl 2 grams 1x
11
Q
Vaginal candida presentation?
A
Vaginal dryness, pain with sex. White thick discharge without odor.
12
Q
Diagnosis of candida vaginitis?
A
Wet prep showing yeast
13
Q
Treatment of vaginal candida?
A
OTC clotrimazole
Fluconazole 150 1x
14
Q
How is chlamydia strains classified?
A
Divided into 3 biovars
Subtyped by serovars
15
Q
What are the 3 chlamydia biovars?
A
- Trachoma
- Genital tract
- Lymphogranuloma venereum
16
Q
What are the Trachoma serovars?
A
A-C
17
Q
What are the genital tract serovars?
A
D-K
18
Q
What are the Lymphogranuloma venereum serovars?
A
L1-L3
19
Q
What infection does chlamydia A-C cause?
A
Eye infection
20
Q
What infection does chlamydia D-K cause?
A
STI, causes urogenital and anorectal infections
21
Q
What infection does chlamydia L1-L3 cause?
A
Invasive urogenital and anorectal infections.
22
Q
Describe chlamydia’s life cycle
A
Biphasic
- Extracellular with infectious elementary body.
- Intracellular with non-infectious reticulate body.
Elementary bodies enter mucosal cells then differentiate into reticulate bodies in a membrane-bound compartment known as an inclusion.
23
Q
Presentation of D-K [genital tract] chlamydia cervicitis
A
- 85% have NO symptoms or signs
- May have vaginal discharge, intermentrual bleeding, postcoital bleeding.
- Cervical motion tenderness
24
Q
Complications of D-K [genital tract] chlamydia cervicitis [3]
A
- PID
- Ectopic pregnancy
- Perihepititis
25
Complications of D-K [genital tract] chlamydia urethritis? [3]
1. Epididymitis
2. Prostatitis
3. Reactive arthritis
26
Presentation of D-K [genital tract] chlamydia proctitis
1. Often no symptoms
27
NOTE
Perform NAAT for chlamydia on all person with urethritis
28
Work up of proctitis? [3]
1. All patients should undergo anoscopy to look for mucosal edema, easy bleeding, ulcerations, and to evaluate patency of rectal lumen.
2. Gram stain may show PMNs
3. NAAT for chlamydia
29
What WOMEN should be screened for chlamydia? [6]
1. ALL sexually active women <25
2. Sexually active women >25 with risk factors
3. 3 months after treatment of infection.
4. Pregnant women in 3rd trimester if <25
5. Pregnant women in 3rd trimester if >25 with risk factors.
6. Pregnant women 3-4 weeks after treatment for test of cure and rescreeen at 3 months.
30
What MEN should be screened for chlamydia?
1. MSM at site of exposure annually
| 2. MSM with HIV every 3-6 months
31
Describe the epidemiology of the LGV serovars of chlamydia
1. Uncommon STI
2. More common in Africa, Asia, India, South America
3. In developed countries causes mostly proctitis and procotocolitis in MSM
32
Presentation of genital infection of LGV serovar?
1. Transient genital ulcer(s) or papule(s)
2. Followed by tender inguinal/femoral lymphadenopathy [typically unilateral]
3. Bubo formation.
33
What is the Groove Sign
It is formed by swollen matted lymph nodes developing along the course of the inguinal ligament
34
Describe the proctitis of LGV.
Can mimic IBD
| Can lead to perirectal abscess, fissues, fever, malaise, weight loss, fatigue.
35
Diagnosis of LGV?
1. Detection of chlamydia on NAAT with exclusion of other causes of proctocolitis, lymphadenopathy, or genital ulcers.
2. Molecular testing for outer membrane protein A [ompA]
36
Treatment of LGV?
1. Doxy 100 mg BID for 21 days. [preferred]
2. Erythromycin 500 mg QID for 21 days [alt]
3. Aspiration/I+D of buboes to prevent development of ulcerations or fistulous tracts.
37
Medium to isolate N. gonorrhoeae from nonsterile sites?
Thayer-Martin [Requires CO2 enrichement]
38
Medium to isolate N. gonorrhoeae from sterile sites?
Chocolate agar [Requires CO2 enrichement]
39
N. gonorrhoeae virulence factors [2]
1. Type IV pili for attachment
| 2. Antigenic variation.
40
Complications of N. gonorrhoeae infection?
1. PID
2. Ectopic pregnancy
3. Infertility
4. Disseminated gonnococcal infection
41
How does a DGI present?
1. Petchial or pustular acral skin lesions [usually <12]
2. Asymmetric polyarthralgia
3. Tenosynovitis
4. Oligoarticular or monoarticular septic arthritis
5. Rarely endocarditis, perihepatitis, endocarditis
42
Diagnosis of N. gonorrhoeae?
1. Gram stain showing gram-negative intracellular diplococci is suggestive
2. + Leuk est in urine is suggestive
3. NAAT definitive
43
Presentation of gonococcal pharyngitis?
Most cases are ASYMPTOMATIC
| Suspect when there is pharyngitis and risk for exposure
44
Women N. gonorrhoeae screening guidelines?
1. All women <25 and sexually active.
2. Women >age of 25 with risk factors
3. 3 months following gonorrhoeae treatment.
4. <35 and living in correctional facility
45
Men N. gonorrhoeae screening guidelines?
ONLY MSM
1. Annually at sites of exposure.
2. Every 3-6 months if they have HIV
3. <30 and living in correction facility
--> 70% of infections occur in pharynx and rectum
46
Treatment of N. gonorrhoeae at cervix, urethra, rectum
1. Ceftriaxone 250 mg IM + azithro 1 g PO once
| 2. Cefixime 400 mg PO ONCE + aizthro 1 g PO once [alt]
47
Treatment of N. gonorrhoeae at the pharynx?
1. Ceftriaxone 250 mg IM + azithro 1 g PO once
| [There is cefixime resistance here]
48
How is M. genitalium cultured?
Requires Vero cells
| Takes months to grow
49
M. genitalium epidemiology
1. 15-20% of nongonococcal urethritis in MEN
| 2. Role in women is less well understood
50
M. genitalium diagnosis?
NAAT of urine, urethral, vaginal, and cervical swabs
51
When should M. genitalium be considered?
In persistent or recurrent cases of urethritis and possibly causes of persistent or current cervicitis and PID
52
Treatment of M. genitalium PID?
Moxifloxacin 400 mg for 14 days.
53
Where does trichomonas infect?
Squamous epithelium of the urogenital tract including the vagina, urethra and paraurethral glands.
54
How does trichomonas grow?
In broth culture [Diamond's TYI]
55
NOTE:
trichomonas is associated with increased risk of HIV acquisition.
56
Diagnosis of trichomonas?
1. NAAT from vaginal endocervical or urine specimens.
| 2. Wet mount sample from posterior fornix
57
Trichomonas screening?
Women with HIV yearly
| Risk factors.
58
Trichomonas treatment in normal ?
Flagyl 2 g 1x
59
When should flagyl 500 mg BID for 7 days be used to treat trichomonas?
1. If treatment failure with 1 gram regimen.
| 2. If the patient has HIV
60
Bacteria that cause BV? [6]
1. Gardnerella
2. Lactobacillus
3. Prevotella
4. Mobiluncus
5. Mycoplasma
6. Ureaplasma
61
Micro pearls of Syphilis [2]
1. Grows slowly, division time of 30 hours.
| 2. Cannot be cultured
62
Time of exposure to Syphilis until time of first symptoms?
3 weeks!
63
Describe the presentation and course of primary Syphilis
- Localized, non-tender, clean based, indurated ulcer at site of inoculation known as a chancre
- May have accompanied tender or non-tender lymphadenopathy.
- Primary lesion will resolve with OR without treatment in 3-6 weeks.
64
Describe the presentation and course of secondary Syphilis
- Painless, macular rash located on the palms of the hands or soles of the feet
- May involve mucous membranes
- Condyloma lata may occur and be very infective
- Diffuse lymphadenopathy
- Nephrotic syndrome
- Hepatitis [ALK phos high out of proportion to AST and ALT]
- Gastritis
- Periositis
- Hepatosplenomegaly
65
What is latent syphilis
- Asymptomatic period that occurs after resolution of manifestations of secondary syphilis
66
What is the difference between early and late latent?
Early is <1 year, late is >1 year
67
What is tertiary syphilis?
- 1/3 of those with untreated syphilis will develop manifestations following secondary disease.
- These include neurologic, cardiovascular, and gummatous complications.
68
What are the cardio complications of tertiary syphilis? [3]
1. Ascending AA
2. Aortic valve insufficiency
3. CAD
69
What are the gummatous complications of tertiary syphilis?
1. Mass effect due to granuloma
70
What are the neurologic complications of tertiary syphilis? [3]
1. General paresis
- Dementia
- Seizures
- Psychiatric Syndrome
2. Tabes dorsalis
- Abrupt and severe radicular pain
- Ataxia
- Loss or proprioception
- Impaired vibratory sense
3. Argyll-Robinson pupils
71
Neurologic manifestations of syphilis that can occur at any stage?
1. Uveitis
2. CN palsies
3. Aseptic meningitis
4. Stroke-like meningovascular syphilis
72
What are nontreponemal tests?
They are based on antigens synthesized from lecithin, cholesterol, and cardiolipin that react with antibodies produced in response to syphilis infection.
They are quantitative tests used to detect infection and response to therapy.
73
Examples of nontreponemal tests? [2]
1. RPR [rapid plasma reagin
| 2. VDRL
74
What are treponemal tests?
These detect antibodies to treponemal antigens.
| Once infected these tests remain POSITIVE.
75
Examples of treponemal tests? [5]
1. FTA-ABS [fluorescent treponemal antibody absorbed]
2. TPPA [Treponema Pallidum Particle Agglutination]
3. MHA-TP [microhemagglutination assay for Treponema pallidum antibodies]
4. CIA [chemiluminescence immunoassays]
5. EIA
76
Benzathine penicillin G 2.4 million units in a single IM dose is used to treat what type of syphilis? [3]
1. Primary
2. Secondary
3. Early latent
77
Benzathine penicillin G 7.2 million units in 3 IM doses weekly is used to treat what type of syphilis? [2]
1. Late latent
| 2. Tertiary syphilis
78
What is the treatment of neurosyphilis?
Aqueous crystalline penicillin 18-25 million units per day as 3-4 million units IV every 4 hours for 10-14 days.
- This is also the treatment of ocular and otic syphilis
79
How is response to therapy in syphilis confirmed?
Repeat same nontreponemal tests used for initial diagnosis at 6 and 12 months post-treatment.
There should be a 4 fold reduction in titer.
80
Alternative treatment options for syphilis in those who are penn allergic?
Doxy, azithro, ceftriaxone, tetracycline in those with primary or secondary disease.
Otherwise needs desensitization
All pregnant women need desensitization.
81
What is the jarish-herxheimer reaction
Acute febrile reaction with HA, fever, myalgia that occurs 24 hours with treatment. More common in early disease.
- May induce labor
82
What is the prozone phenomenon?
False-negative serologic result from high antibody titers that interfere with antigen-antibody complex formation.
Effects non-treponemal tests
83
What should all patients diagnosed with primary or secondary syphilis be tested for?
HIV
84
Describe treatment of partners.
If exposure is within 90 days empiric treatment.
| If exposure was >90 days ago treat based on serologic testing.
85
What is the most common cause of genital ulcer disease worldwide?
HSV-2
86
Presentation of initial HSV infection
Multiple bilateral painful and itchy anogenital ulcers that last 10-14 days
May have adenopathy, dysuria
May cause cervicitis or urethritis
May have systemic symptoms.
87
NOTE
HSV asymptomatic reactivation with viral shedding mat occur.
| Rates are highest in first 3 months after infection.
88
HSV diagnosis
NAAT/PCR of lesion
Culture is not sensitive.
May add serologic testing to PCR to determine if lesion is acute of chronic [serologic tests are only positive in chronic infection].
89
NOTE:
In those with HIV suppressive therapy for HSV does not reduce risk of transmission of HIV or HSV to partner.
90
Treatment of resistant HSV
1. Foscarnet
2. Cidofovir
3. Imiquimod
91
Microbiology of H. ducreyi
Small fastidious gram-neg coccobacillus
| Requires enriched media, high humidity, high CO2
92
H. ducreyi presentation
- Painful purulent ulcers with ragged edge
- Self innoculated "kissing" lesions on thigh.
- Bleeds easily
- May have inguinal lymphadenopathy which can develop into painful buboes
93
Treatment of buboes
Aspiration, NOT I and D.
| - May rupture spontaneously which delays healing
94
H. ducreyi complications? [2]
1. Phimosis
| 2. Increased risk of HIV transmision
95
Diagnosis of H. ducreyi
- Gram stain shows "school of fish"
| - PCR
96
Treatment of H. ducreyi [3]
1. Azithro 1 gram once
2. Ceftriaxone 250 IM 1x
3. Cipro 500 mg BID for 3 days if HIV
- Treat all partners in past 60 days
97
What is donovanosis?
- Granuloma inguinale
| - Due to Klebsiella granulomatis which is an intracellular encapsulated gram negative
98
Who gets donovanosis?
Those living in tropical India, Australia, New Guinea, Caribbean, South Africa
99
Donovanosis presentation
- Chronic progressive painless ulceration
- Ulcers have rolled edges and easily bleeds
- Ulcers may coalesce or spread subcutaneously and form pseudobuboes
100
Complications of donovanosis?
- Scarring may lead to lymphedema of the external genitalia
101
What is a lipschutz ulcer?
- Nonsexually acquired genital ulceration
| - Due to immune response to distant infection [EBV, CMV]
102
Presentation of lipschutz ulcer?
Single or multiple bilateral painful vulvar ulcers in young women and adolescent girls
May have prodrome of fever, malaise, lymphadenopathy, tonsillitis, hepatitis
Intense pain and dysuria
Heals in 6 weeks
103
What is the most common STI in the US?
HPV
104
How does HPV cause cancer?
Early genes E6 and E7 manipulate cell cycle regulators, induce chromosomal abnormalities and block apoptosis
105
What types of HPV cause cancer?
16 and 18
106
What types cause Condylomatat acuminata?
6 and 11
107
Treatment of anogenital warts
1. Imiquimod
2. Podofilox
3. Sinecatechins 15% ointment
108
NOTE:
Both treponemal and nontreponemal tests are almost always NEGATIVE in primary syphilis
Both treponemal and nontreponemal tests are almost always POSITIVE in secondary and EARLY LATENT syphilis
109
Describe the meningovascular form of late neurosyphilis
1. Endarteritis of small blood vessels of the brain and spinal cord
2. Leads to strokes [typical MCA] and seizures
110
Describe the parenchymatous form of late neurosyphilis
Due to destruction of nerve cells
- Tabes dorsalis
- General paresis
111
What is otic syphilis?
Presents with hearing loss or tinnitis
112
When might treponemal tests become non-reactive?
If primary syphilis is treated early they may become non-reactive 5-10 years after treatment.
113
What causes false positive non-treponemal tests? [4]
1. Old age
2. Viral infections
3. APS
4. Endemic trepanematoses
114
What causes false positive treponemal tests? [4]
1. Yaws
2. Pinta
3. Bejel
4. Lyme disease
5. Bad gingivitis
115
Possible interpretations of EIA+/RPR-/FTA+ [Both treponemal tests positive, non-treponemal negative]?
1. Early primary syphilis where treponemal test became positive first [rare]
2. Prozone reaction in secondary syphilis
3. Old treated infection
4. Old untreated infection
116
Best diagnostic modality for primary syphilis?
Dark field microscopy
117
Describe syphilis screening in pregnancy
1. All during first visit
2. Twice if high risk in 3rd trimester [28-32 weeks and at delivery]
3. Any still birth after 20 weeks gestation
118
Describe the role of screening an symptomatic patient for HSV who currently has no lesions
There are glycoprotein G-based type specific assays, they have a high right of false positive but have good specificity if there is a high pre-test probability
119
Interprete + gG2 test in HSV
1. Genital herpes
| 2. False positive
120
Interprete + gG1 test in HSV
1. Genital herpes
2. Oral herpes
3. False positive
121
Donovanosis diagnosis
- Tissue biopsy and culture
| - Wright and Giemsa stain shows organisms in macrophages called Donovan bodies
122
Donovanosis treatment
1. Doxy 100 mg PO BID for 3 weeks
2. Azithro 1 gram weekly for 3 weeks
- Must see resolution of lesions before stopping therapy.
123
Treatment of urogenital vs rectal chlamydia
1. Urogenital Azithro = doxy
| 2. Rectal Doxy > azithro
124
Treatment of gonococcal conjunctivitis
1 gram ceftriaxone IM + 1 gram of azithromycin
125
Presentation of rectal gonoccal disease
>90 have no symptoms
126
Work up if DGI is suspected?
- -> May not have symptoms at sites therefore screen ALL AREAS
1. Rectum
2. Throat
3. Urethra/Vag
127
Treatment of DGI?
1. 5-7 days of ceftriaxone [may switch to cefixime if susceptible + 1 gram azithro 1x
2. Alt step down therapy is doxycycline
128
Common etiologies of non-gonoccal urethritis?
1. Chlamydia 25%
2. Mycoplasma genitalium 30%
3. Trichomonas 10-25% [in men who have sex with women, rare in women and MSM].
4. HSV
129
Treatment of NGU [empiric]
1. Doxy 100 mg BID for 7 days
| 2. Azithro 1 gram 1x
130
Why might NGU fail to respond to empiric therapy? [4]
1. Mycoplasma genitalium with resistance
2. Trichomonas [needs metronidazole]
3. HSV is etiology
4. Reinfection
131
Treatment strat for resistant trichomonas
1. Increase dose and length of tinidazole treatment
| 2. In about 1% there is still resistance, in this cause use topical paromomycin
132
What is a draw back to using paromomycin
Can cause topical reaction and ulceration
--> Try on small area of vagina first for 24 hours before using.
133
Strat to suppress recurrent BV?
Flagyl gel for 6 months to 1 year
134
BV complications with pregnancy [3]
1. PROM
2. Pre-term labor
3. Post partum endometritis
135
Diagnosis of PID?
One of the following...
1. Cervical motion tenderness
2. Uterine tenderness
3. Adenxal tenderness
136
Who needs hospitalization with PID? [4]
1. Cannot tolerate PO abx
2. Abscess
3. Pregnant
4. Cannot exclude appendicitis
137
Oral therapy for PID?
Ceftriaxone 250 IM x1 + Doxy 100 mg BID for 2 wk +/- Flagyl 500 mg BID for 2 week
138
IV therapy for PID?
Ceftotetan OR cefoxitin + doxy
139
In what STIs should all partners in past 60 days be treated?
1. Gonorrhea
2. Trichomonas
3. Chlamydia
4. Mycoplasma genitalium
5. PID
--> TREAT WHILE WAITING FOR TEST RESULTS
140
Etiology of epididymitis in young men? [2]
30% gonorrhea
| 70% chlamydia
141
Treatment of epididymitis in STI non-MSM
Ceftriaxone 250mg IM X1 + Doxycycline 100mg PO BID X10 days
142
Treatment of epididymitis in STI in MSM
Ceftriaxone IM X1 + levofloxacin X 10 days [concern for pseudmonas]
143
Treatment of epididymitis in older men
Levofloxacin 500mg PO X10 days
144
Common etiologies of proctitis/proctocolitis?
1. Gonorrhea
2. Chlamydia [D-K, LGV]
3. Syphilis
4. HSV
145
Uncommon etiologies of proctitis/proctocolitis?
1. Campy
2. Shigella
3. Entamoeba
4. CMV
146
Treatment of proctitis
Ceftriaxone IM 250 1x + Doxy for 7-21 days [depending on severity of symptoms]
- -> 7 for D-K
- -> 14 for syphilis
- -> 21 for LGV
147
What mimics IBD on biopsy with proctitis? [2}
1. Early syphilis
| 2. Chlamydia
148
What is Maculae ceruleae?
Blue gray macules that occur at shaft of pubic hair
149
Treatment of crabs?
```
Permethrin 1% cream OR Pyrethrins with
piperonyl butoxide (topical)
```
--> Treat all sexual partners in last 30 days.
150
Treatment of resistant crabs?
malathion 0.5% lotion or Ivermectin
151
How do scabies present?
Severe pruritus; especially at night or after bathing; burrows
152
Treatment of scabies? [2]
– Permethrin cream 5% (wash off after 8 hours)
| – Ivermectin 200 mcg/kg PO day 1 and 14
153
Treatment of Norwegian scabies?
Ivermectin 250mcg/kg on days 1, 15, and 29
