SH Revision 2 Flashcards
Which strand of HSV is the most common cause of genital herpes?
HSV-1
HSV-2
HSV-3
HSV-8
HSV-16
Which strand of HSV is the most common cause of genital herpes?
HSV-1
HSV-2
HSV-3
HSV-8
HSV-16
Describe the initial presentation of HSV-1 infection [7]
Genital lesions - initial infection:
- Grouped painful blisters which burst after 2-3 days, resulting in crusted erosions and ulcers on the external genitalia.
- Lesions can also occur on the thigh, buttocks, cervix and rectum.
- These can be extremely painful, making urinating and even sitting down painful (especially in women).
- Febrile illness (prodrome) lasting 5–7 days
* Dysuria, urinary frequency
* Painful inguinal lymphadenopathy
* Primary episodes can last up to 20 days.
Describe the presentation of recurrent HSV-1 infection [3]
Prodrome:
- Tingling and burning sensation in the genitals.
- May precede the appearance of lesions by up to 48 hours.
Genital lesions:
- Usually recur in the same area but lesions less severe than in the initial episode.
Duration:
- Lesions crust and heal within 10 days.
Complications usually occur with the first episode and the risk is reduced if given antiviral
therapy. They include: [3]
- Acute urinary retention (occurs predominantly in women)
- Constipation (may be a risk with first episode peri-anal disease)
- Aseptic meningitis
Describe how you dx genital HSV [3]
Polymerase chain reaction (PCR):
- Nucleic acid amplification tests (NAAT) are a type of PCR.
- A negative test does not exclude herpes (may be taken too late in an attack).
Viral culture:
- If NAAT unavail
Serology:
- BASHH 2014 guidelines state virus typing should be done via serology in all patients with a new diagnosis of genital herpes (in addition to NAAT or culture).
- To test for HSV type-specific antibodies (IgG).
DDx of genital HSV?
Primary syphilis
- Differences: singular, usually painless ulcer.
Chancroid (Haemophilus ducreyi bacterium)
- Differences: single, deep ulcer.
Lymphogranuloma venereum
- Differences: lymphadenopathy is unilateral, lack of vesicles, single or few ulcers.
Bechets:
- Differences: absence of vesicles, coexistence of oral, eye, skin or neurological involvement.
Specialist management is important during pregnancy to reduce the risk of transmission to the baby.
What is this?
NB: depends on when the infection is during the pregnancy
Management:
If the first episode is BEFORE week 28 of the pregnancy, offer the mother antiviral therapy at that time, and then again from 36 weeks until the birth.
If the first episode is at or AFTER week 28 of the pregnancy, advise the mother to take antiviral treatment from then until the birth.
Specialist delivery is important during pregnancy to reduce the risk of transmission to the baby.
What is this?
If the first episode is within 6 weeks of the due date, offer an elective caesarean section to reduce the risk of neonatal herpes.
If the first episode is earlier in the pregnancy, normal vaginal birth is advised as the risk of transmission is very low.
Which strand of HSV is the most common cause of recurrent genital herpes?
HSV-1
HSV-2
HSV-3
HSV-8
HSV-16
Which strand of HSV is the most common cause of recurrent genital herpes?
HSV-1
HSV-2
HSV-3
HSV-8
HSV-16
After the initial infection, HSV is able to enter a dormant latent phase within []
There are typical locations of HSV in both oro-labial and anogenital herpes:
Oro-labial herpes: [] ganglia
Anogenital herpes: [] ganglia
After the initial infection, HSV is able to enter a dormant latent phase within nerve cell ganglia.
There are typical locations of HSV in both oro-labial and anogenital herpes:
Oro-labial herpes: trigeminal ganglia
Anogenital herpes: sacral nerve root ganglia
What is the managment for
- simple external warts [2]
- cervical warts [1]
- oral warts [1]
Simple external warts
o Podophyllotoxin cream or solution (avoid in pregnancy)
o Imiquimod cream 5%,
o Weekly cryotherapy, if available or Electrocautery, Excision
Cervical warts
o Colposcopy
Oral warts
o Cryotherapy
The majority of anogenital warts are caused by the HPV genotypes [] and [].
HPV genotypes [] and [] are predominantly responsible for development of anogenital malignancies (e.g. cervical cancer).
The majority of anogenital warts are caused by the HPV genotypes 6 and 11.
Genotypes 16 and 18 are predominantly responsible for development of anogenital malignancies (e.g. cervical cancer).
Describe how choose between podophyllotoxin, imiquimod and TCA to treat genital warts [3]
NB: depends on the type of warts
Podophyllotoxin (e.g. Warticon):
- Good against soft lesions and can be self-applied at home.
- Disrupts cellular division. Clearance rate 43-70% and recurrence rate 6-55%.
Imiquimod:
- Good against both hard and soft lesions.
- Can be self-applied at home. Stimulates a local immune response by activating macrophages. Clearance rate 35-68% and recurrence rate 6-26%.
TCA (80-90% solution):
- Good against both hard and soft lesions.
- Applied in specialist setting. Essentially corrodes skin leading to necrosis. Clearance rate 56-81% and recurrence rate 36%.
Describe the basic pathophysiology of primary, secondary and tertiary syphilis [3]
Primary:
- The primary ulcer contains the Treponema pallidum bacterium in a
chancre
- Infiltration appears to coincide with the resolution of the primary chancre which occurs over 3-6 weeks
Secondary syphilis
- haematogenous spread of the bacterium resulting in endarteritis obliterans.
- Mucocutaneous lesions in secondary syphilis also contain treponemes
Approximately 15-40% of patients with untreated secondary syphilis progress to late syphilis involving:
- Neurosyphilis
- Gummatous syphilis
- Cardiovascular syphilis
Describe the clinical presentationf of primary, secondary, latent and tertiary syphilis [3]
Primary:
* Chancre
* A single ano-genital ulceration
* It is painless and indurated with a clean base, non-purulent
* Can be multiple, painful, and purulent (usually extra-genital)
* Resolve over 3-8 weeks
Secondary syphilis - signs are multisystemic:
* Symmetrical maculopapular rash , typically on the trunk, face, palms or soles
* Fever, malaise, myalgia, fatigue, and arthralgia (25%)
* Lymphadenopathy
* Neurological complications
* Glomerulonephritis
* Splenomegaly
Latent disease:
* Secondary syphilis will resolve spontaneously in 3–12 weeks and the disease enters an
asymptomatic latent stage. Approximately 25% of patients will develop a recurrence of
secondary disease during the early latent stage
Late (tertiary) disease
- In the late stage, the disease may damage the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints
Which neurological complications can occur from secondary syphilis infection? [5]
Neurological complications
o Acute meningitis
o Cranial nerve palsies
o Uveitis
o Optic neuropathy
o Interstitial keratitis and retinal involvement
Describe how you investigate for syphilis
PCR swab for HSV and syphilis
Treponemal tests: - Detects antibodies that react to specific treponemal antigens
- Examples include T. pallidum particle agglutination assay (TPPA) and enzyme immunoassay (EIA)
- A positive result suggests exposure to the bacteria but does not distinguish between current or past infection.
Non-treponemal tests: - This refers to two different tests:
* Rapid plasma reagin (RPR)
* Venereal Disease Research Laboratory (VDRL)
- measure the response to cellular damage caused by the infection rather than directly detecting the bacterium
- correlate with disease activity.
Dark ground microscopy
- primary syphilis if there is a visible lesion such as a chancre. A sample from the lesion can be examined under dark-field microscopy to look for Treponema pallidum.
CSF examination if ? neurosyphilis
Describe the difference in timing between primary, secondary and tertiary syphilis
Primary syphilis is characterised by generalised lymphadenopathy and a chancre
Secondary syphilis occur 3-12 weeks after appearance of the initial chancre and is characterised by systemic features, skin lesions, alopecia, and mucous patches
Early latent syphilis is serological confirmation of infection in the absence of clinical features
Tertiary or late syphilis occurs after 2 years of infection (typically 15-40 years)
- Tertiary syphilis may present with gummatous syphilis, cardiovascular syphilis or neurosyphilis
- Tertiary latent syphilis is serological confirmation of infection in the absence of clinical features
Describe what this presentation of secondary syphilis is called [1]
Condylomata lata (appear like genital warts)
Describe what this presentation of secondary syphilis is called [1]
Snail track ulcer
NB: very specific to syphilus
Linear scars at the angle of the mouth is most associated with:
Primary syphilis
Secondary syphilis
Tertiary syphilis
Congenital syphilis
Linear scars at the angle of the mouth is most associated with:
Primary syphilis
Secondary syphilis
Tertiary syphilis
Congenital syphilis
Name this sign [1]
Which is it most associated with?
Primary syphilis
Secondary syphilis
Tertiary syphilis
Congenital syphilis
Argyll Robertson Pupil
- do not constrict when exposed to bright light, but do constrict when focused on nearby object
Tertiary syphilis
Describe the risk of untreated gonoccoal infection
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
- Various non-specific skin lesions
- Polyarthralgia (joint aches and pains)
- Migratory polyarthritis (arthritis that moves between joints)
- Tenosynovitis
- Systemic symptoms such as fever and fatigue
Describe what is meant by reactive arthritis
Typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
‘Can’t see, pee or climb a tree’
- arthritis is typically an asymmetrical oligoarthritis of lower limbs
- urethritis
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
What is the name for this manisfestation of reactive arthritis? [1]
Keratoderma blennorrhagica
Describe the clinical features that help determine someone is suffering from granuloma inguinale [1]
Granuloma inguinale is characterised by one or more nodules that transform into painless ulcers.
Patients usually develop a painless papule(s) or nodule(s) that has a ‘beefy red’ appearance due to the high vascularity.
Ulcers;
- They typically ulcerate from the middle and have friable, raised and rolled margin
