SH Revision 5 Flashcards
PID is a major complication of chlamydia. Up to 16% of patients with untreated infections are at risk. The risk of tubal infertility is 1-20% following PID.
Describe the features of PID:
Signs [3]
Symptoms [4]
Long [3] and short [2] term complications
Systemic upset:
fever
malaise
anorexia
Symptoms:
- low abdominal pain
- abnormal vaginal bleeding
- vaginal discharge or cervical discharge
Signs
- marked abdominal pain
- cervical excitation
- mucopurulent discharge
Long-term complications:
- infertility
- ectopic pregnancy
- chronic pelvic pain
Short-term complications:
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis syndrome
NB: see PID notes
Describe how you investigate for chlamydia in men [1] and women [1]
Women:
- NAAT vulvovaginal swab
Men:
- urine test (first catch)
Tx for:
- uncomplicated urogenital chlamydia? [2]
- rectal infections [1]
A seven day course of doxycycline
OR
Aziothromycin due to potentially poor compliance with a 7 day course of doxycycline
Lymphogranuloma venereum (LGV) is caused by which specific organisms? [1]
Chlamydia trachomatis serovars L1, L2 and L3.
Describe the clinical stages of LGV infection [3]
Typically infection comprises of three stages:
* stage 1: small painless pustule which later forms an ulcer
* stage 2: painful inguinal lymphadenopathy
* stage 3: proctocolitis - leading to anal pain; tenesmus and discharge
Which patient populations do you offer a repeat Chlaymdia test in and why? [1]
Patients < 25 years old who are diagnosed with chlamydia should be offered a repeat chlamydia test in 3-6 months.
This is because there is a higher risk of reinfection (2-6x higher), which also increases the risk of PID and infertility.
Describe some complications of Chlamydia infection
PID:
- can result in tubo-ovarian abscesses and peritonitis
Epididymitis
Fertility issues:
- due to tubal damage from PID in women
- secondary to epididymitis in men
LGV
FItz-Hugh-Curtis syndrome:
- inflammation of the liver capsule and RUQ pain
Ocular complications:
- conjunctivitis that can progress to corneal scarring and blindness if not treated promptly.
Reactive arthritis
- urethritis, conjunctivitis, and arthritis
Describe the diagnostic criteria that needs to be met for BV dx
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:
* thin, white homogenous discharge
* clue cells on microscopy: stippled vaginal epithelial cells
* vaginal pH > 4.5
* positive whiff test (addition of potassium hydroxide results in fishy odour)
How do you differentiate between BV & trichomonas
Trichomonas:
- Frothy, yellow / green discharge
- Vulvovaginitis
- Strawberry cervix
- Wet mount: motile trophozoites
BV:
- Microscopy: clue cells
- thin, white discharge
NB: both have pH > 4.5; treat with metronidazole
How do you treat BV in:
- asymptomatic women [1]
- symptomatic [1]
- pregnant [2]
asymptomatic women:
- treatment not required (unless undergoing pregnancy termination)
symptomatic:
- oral metronidazole for 5-7 days
- a single oral dose of metronidazole 2g may be used if adherence may be an issue
pregnant
- oral metronidazole is used throughout pregnancy if symptomatic
- If asymptomatic: may be considered for treatment, but should discuss with obstetrician.
Describe the clinical presntation of chancroid [4]
Painful papules:
- early lesion that deteriorates into pustule then ulcer. May be one or more lesions
Multiple, deep ulcers
Lymphadenopathy:
- usually inguinal region
Buboe:
- infected, painful lymphadenitis that ulcerates and becomes suppurative. Can cause chronic draining sinuses.
NB: note it is rarely seen in the UK
Describe how you investigate for chancroid [2]
Chancroid is usually a clinical diagnosis. There are no laboratory tests currently available for the immediate diagnosis of chancroid.
The main investigative techniques are:
Culture and sensitivity
PCR (most sensitive)
Microscopy
Serology
Which tests should you perform if you suspect chancroid to rule out DDx? [4]
Herpes culture
Syphilis serology
HIV test
LGV
State three management options for chancroid [3]
A single IM dose (250 mg) of ceftriaxone
or
a single IM dose (1gram) of azithromycin
or an oral (500 mg) of erythromycin four times a day for seven days.
Which factors predispose patients to vaginal candidiasis? [5]
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV, iatrogenic
- Local irritatants
- Sexual activity
- Oestrogen exposure (incidence rises post menarche, but decreases post-menopause)
Treatment for uncomplicated thrush? [2]
Local tx:
- clotrimazole 500mg PV stat
Oral:
* itraconazole 200mg PO bd for 1 day or
* fluconazole 150mg PO stat
Treatment for recurrent thrush? [2]
> 4 episodes a year
induction:
- oral fluconazole every 3 days for 3 doses
maintenance:
- oral fluconazole weekly for 6 months
Treatment for thrush in pregnant patients? [2]
avoid oral anti-fungal treatments
- use intravaginal anti-fungal cream or pessary (e.g. clotrimazole 10% cream as single dose or clotrimazole pessary for 2 nights), OR
Clinical presentation of trichomoniasis?
- Frothy green-yellow discharge
- Vulval itching
- Dysuria
- Urethral irritation
- Urethral discharge
- Vulval inflammation
- Cervical inflammation (often described as ‘strawberry cervix’)
- pH > 4.5
Investigations for trichomoniasis?
Swabs taken from lateral walls of vagina: pH > 4.5
and high vaginal swab: staining, microscopy and culture.
microscopy of a wet mount shows motile trophozoites
NAAT testing - gold standard
A 15-year-old presents with a mouth ulceration and fever. On examination he has severe gingivostomatitis is a stereotypical history for infection by:
HSV - primary infection
Gardnerella vaginalis
Tx for LGV? [1]
Doxycycline 100mg twice daily for 21 days is the first-line
treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.
TOM TIP: Remember that [] cells on microscopy mean bacterial vaginosis. This is a common association tested in MCQ exams.
TOM TIP: Remember that clue cells on microscopy mean bacterial vaginosis. This is a common association tested in MCQ exams.
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
