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Micro Exam 2 > Sobel: Clinical Aspects of STDs > Flashcards

Sobel: Clinical Aspects of STDs Flashcards

1
Q

EPIDEMIOLOGY OF STD’S (USA)

How many new infections every year?

Syphilis, Chlamydia, and African American population

A

19 million new infections each year (1/2 among 15-24 y)

Syphilis rates increased in 2007 driven by gay and bisexual males (65%) especially in HIV men

Chlamydia record numbers

Highest rates for chlamydia in black women age 15-19

Gonorrhea remains high~ 70% in AA

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2
Q

TRANSMISSION OF STI’S

What is enhanced transmission of HIV associated with?

HSV-2 responsible for what % of incident cases of HIV?

STI effect M vs F:

A

Enhanced transmission of HIV associated with:

  • ulcerative genital lesions [+ + + +]
  • inflammatory genital lesions (vaginitis) [+ +]
  • altered vaginal flora (?) [+]

HSV-2 responsible for ~25% incident cases of HIV

STI effect > in transmission from male to female
Reduced by condoms!!

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3
Q

(ADULT) MALE CIRCUMCISION

How much does it reduce HIV acquisition among heterosexual men?

Where is it recommended?

Benefit:

A

RCT –Circumcision ↓ risk of HIV acquisition among heterosexual men by 51-76%

WHO recommends where prevalence of HIV is high

Benefit –Dense concentration of CD4 + T-cells, macrophages, and Langerhans cells –dense concentrations in nonkeratinized inner mucosal cells of foreskin

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4
Q

(ADULT) MALE CIRCUMCISION

Effect on HSV-2 and HPV:
syphilis and trichomonas:
N. gonorrhoeae, C. Trachomatis:

Benefits for females:

A

Circumcision significantly ↓ incidence of HSV-2 infection and ↓ prevalence of HPV
↓ risk of syphilis, ↓ trichomonas
No Benefit –N. gonorrhoeae, C. Trachomatis in males
Benefits for females -↓ HSV, ↓BV, ↓ trichomonas

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5
Q

Why is there a dramatic decrease in STIs worldwide? (4)

A

Risk reduction related to HIV

AIDS therapy HAART

Syndromic treatment of STI’s in developing countries

Programs in sex workers

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6
Q

URETHRITIS

Types of inflammation:
Symptoms: (3)
Types of urethral discharge:

A

Urethral inflammation

  • infectious
  • non-infectious

Symptoms:

  • Asymptomatic
  • Urethral discharge (Purulent/Mucopurulent)
  • Dysuria/burning/pain, pruritus
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7
Q

URETHRITIS

Infectious causes:
commonest non-gonoccal:

A

Infectious causes:
-N. gonorrhoeae

Non-gonoccal

  • Chlamydia (commonest non-gonoccal)
  • Mycoplasma genitalium
  • Etc

Note: Pathogens frequently co-exist

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8
Q

GONORRHEA
EPIDEMIOLOGY

Industrialized world:
US:
Races:
Homo vs heterosexual:
I.P.:
A

Industrialized world ↓ 90% 240/100,000 .45/100,000

In US, 400,000 new cases annually

Incidence higher in Black, Hispanic ↓

Homosexual = Heterosexual

I.P. –1-14 days, (5-10 days cervical)
:-males within 5d
:-females within 10d

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9
Q

RISK FACTORS FOR GONOCOCCAL INFECTION

just read the list

A 
Adolescence/urban
Multiple sexual partners
Nonbarrier contraception
Incorrect use of condoms
Low socioeconomic status
Concomitant use of IV drugs/crack cocaine
Previous history of gonorrhea
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10
Q

Gonorrhea symptomatic in males?

A

Infection usually symptomatic in males

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11
Q

Gonorrhea symptoms (7)

% after a single exposure:

A

Urethritis -Urethral discharge, dysuria, epididymitis, orchitis
Mucopurulent cervicitis –vaginal discharge, dysuria
Pelvic Inflammatory Diseases (10-20%)
Disseminated gonococcal infection (DGI) -Septic Arthritis
Proctitis
Pharyngitis
Conjunctivitis -Adult/Neonatal

20% after a single exposure

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12
Q

Gonorrhea

How high is the transmission rate to females?

A

Transmission rate to females is high at 50%

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13
Q

Diagnosis of Gonorrhea
Culture

Media type:
Sensitivity:
When is culture preferred?

A

Modified Thayer-Martin Media

Sensitivity 80-95%

Culture preferred for pharynx and rectum

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14
Q

Diagnosis of Gonorrhea
Culture

Women:
Men:

A

Women:

  • Cervical culture 80-90%
  • Anal culture 35-50%
  • Post-hysterectomy-urethra
  • Pharynx 5-20%

Men:Urethral exudate

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15
Q

Diagnosis of Gonorrhea

Gram Stain

A

Gram negative diplococci within or associated with PMN’s

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16
Q

Gonorrhea

Natural course

A

Resolves over several weeks. 95% asymptomatic within six months. (Infertility in females)

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17
Q

Gonorrhea

Progression as a superbug

A

sulphonamides –> PCN,TCN –> Quinolones, Macrolides –> Cephalosporins

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18
Q

Gonorrhea Treatment

2010
2013

A 
2010
Ceftriaxone 250 mg IM 
or
Cefixime 400 mg (SD orally)
or
Cefpodoxime 400 mg (SD orally)

2013
Azithromycin 1g orally (You know there will be compliance)
or
Doxycyclin 7 days

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19
Q

Gonorrhea Screening

Who is screened?
Who is at the highest risk?

A

Because GC infection among women frequently asymptomatic, screen all sexually active women if at higher risk.
No screening for M+F at low risk

Highest risk: < 25 years

  • previous GC infection
  • other STD’s
  • new or multiple sexual partners
  • inconsistent condom use
  • drug use
  • commercial sex work
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20
Q

Chlamydia Epidemiology

%Teenagers
Increased prevalence where? What population?
Average prevalence:
Asymptomatic among:

A

~4-5% of teenagers acquire chlamydia/yeast

Increased prevalence inner city. African-Americans/Latino population lacking healthcare

Average prevalence 5% (1 in 20)

Asymptomatic infection common among men and women

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21
Q

Chlamydia Risk Factors for Infection in Women:

A 
Age <20 yrs.
Recent partner change
Non-white race
Multiple partner change
Single
Inconsistent use of a barrier contraceptive
Oral contraceptives
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22
Q

Chlamydia

What do most women with positive cervical culture have?

Positive immunity:

Second infection severity? %?

A

Most females with positive cervical cultures already have UNRECOGNIZED UPPER TRACT DISEASE!

No protective immunity

A second infection (reinfection) may be more severe

> 20% became reinfected

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23
Q

Chlamydia Infection Screening

Young women:
Older women:

A

Selecting for sexual behavior risk is NO LONGER RECOMMENDED in young women (<25 y)…TEST ALL ANNUALLY

Test older women with risk factors

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24
Q

Chlamydia Infection Screening

Where is the yield highest?
Screening of males:
Non-amplification tests pick-up what %?

A

Yield highest in youngest sexually active.

Routine screening of males -NO

Non-amplification tests pick-up 60-70% of cases

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25
Q

Chlamydia

Clinical aspects: (6)

A 
Urethritis (NGU)
Cervicitis
Epididymitis, orchitis
P.I.D./Infertility
Conjunctivitis
Asymptomatic infection common
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26
Q

Chlamydia
Cervicitis

Cervical abnormalities:
Typically:
Cultures:

A

Cervical abnormalities:
Normal exam-20-70%
Hypertrophic cervicitis-19-32%
Mucopurulent or purulent-30%

Typically asymptomatic with 33% noting vaginal discharge

Endocervical cultures/PCR/DNA

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27
Q

Chlamydia
Diagnosis

Women:
Men:

A

Women: Urine or swab from endocervix or vagina

Men: Urine or urethral swab, Rectal swab for receptive anal intercourse

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28
Q

Chlamydia
Diagnosis

Culture

A

Direct immunofluorescence
EIA
Nucleic acid hybridization
NAATS

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29
Q

Chlamydia
Therapy

Rescreen when?

A

Azithromycin 1 g single dose
or
Doxycycline (100 mg bid x 7d)

Rescreening/retesting to detect reinfection at 3 months –(GC + Chlamydia)

30
Q

Chlamydia

Alternative Therapy

A

Levofloxacin 500 mg daily x 7d
Ofloxacin 300 mg bid x 7 d
Erythromycin base 500 qid x 7d
Pregnancy –amoxicillin

31
Q

NON-GONOCOCCAL URETHRITIS (NGU)
Etiology

(long list)

A

Mycoplasma genitalium (10-25%)
Chlamydia trachomatis
Ureaplasma urealyticum -pathogenicity controversial
Mycoplasma hominis -pathogenicity controversial
T. vaginalis
H. simplex
Adenovirus
Enteric organisms
Commensals -Hemophilus, N. meningitidis, Branhamella
No identifiable pathogen

32
Q

What is Mycoplasma Genitalium associated with?

A
  • Non-gonococcal urethritis (NGU)
  • Endometritis
  • Cervicitis (mucopurulent)
  • PID
  • HIV shedding
33
Q

Treatment of NGU

What may happen with Doxycycline?

A

Azithromycin 1 g (single dose)
or
Doxycycline 100 mg bid for 7 d

Unfortunately –M. genitalium often fails with doxycycline and ↑ resistance to Azithromycin

34
Q

Treatment of NGU

Alternatives

A

Erythromycin base 500 mg qid for 7 d
Ofloxacin 300 mg bid for 7 d
Levofloxacin 500 mg once daily for 7d

35
Q

PID

How many women treated annually?
Hospitalized?
Surgical procedures?

A

~1 million women are treated annually for PID in the USA
250-300,000 women hospitalized each year for PID
150,000 surgical procedures are performed each year for its complications

36
Q

Chancroid

Caused by:
Closely linked to:
Asymptomatic carrier state:
IP:

A

Hemophilus ducreyi

Closely linked to drugs/prostitution (core group)

Absence of asymptomatic carrier state
~4-5,000 cases annually (U.S.)

IP 2-10 days

37
Q

Chancroid

Ulceration:
Systemic Sx:
Inguinal adenopathy:

A

Painful ulceration, no systemic Sx.
Ulcers deep, tender, friable, edges ragged, purulent base
Painful tender inguinal adenopathy (50-65%)
Usually unilateral (chancroid bubo)

38
Q

Syphilis

Incubation period:

A

Long incubation period (12-40 d)

39
Q

Syphilis
Primary

Development and disappearance:
Ulcer:
Purulence:

A

Slow development and disappearance
Primary painless ulcer (chancre)
Lack of purulence

40
Q

Syphilis
Primary

Lymphadenopathy:
Bilateral?
VDRL:

A

Painless inguinal lymphadenopathy (80%)
Bilateral in 70%
VDRL -30% negative

41
Q

STAGES OF SYPHILITIC INFECTION
Acquired

Primary
Secondary
Latent
Tertiary

A

Acquired
Primary 10-90 (21 d) Chancre, regional lymphadenopathy
Secondary 6 wks -6 mos. Multiple mucocutaneous, fever, alopecia, lymph-adenopathy, meningitis

Latent
Early 1 year Asymptomatic

Tertiary (Late) Months/years CNS, CVS, Gummatous

42
Q

Diagnosis of syphilis

Identification of T. pallidum:
Serology:

A

Identification of T. pallidum
Dark field microscopy
Fluorescent Mab/Histology

Serology

a. Nontreponemal……VDRL/RPR/WR
i. Screening
ii. Assessment of disease activity
b. Treponemal
- Confirmatory only: FTA-ABS, MHA-TP

43
Q

Syphilis

Time between inoculation and primary syphilis:
Time between primary and secondary syphilis:
Time between secondary and latent syphilis:
Time between latent and tertiary syphilis:

A

14-21 Days

3-8 Weeks

Lesions disappear spontaneously after 3-8 wks

2-20 years

44
Q

Syphilis

% relapse in first year:

A

Up to 25%

45
Q

Treatment of syphilis

Early syphilis:

A

Benzathine PCN 2.4 m.u. IM

46
Q

Treatment of syphilis

Latent syphilis:

A

Benzathine PCN 2.4 m.u. IM weekly x 3

47
Q

Treatment of syphilis

Asymptomatic neurosyphilis:

A

Benzathine PCN 2.4 m.u. IM weekly x 3

48
Q

Treatment of syphilis

Neurosyphilis:

A

IV Benzyl PCN x 10d (IV Ceftriaxone)

49
Q

SEROLOGICAL CRITERIA FOR TREATMENT RESPONSE

Early vs latent/late syphilis:
Follow up for:

A

4 fold titer ↓ in 6 months in early syphilis, in 24 months in latent/late syphilis

Close follow up for HIV positive

50
Q

HPV

What is likely to replace cervical cytology (PAP) as primary cervical cancer screening tool?

A

HPV –DNA testing likely to replace cervical cytology (PAP) as primary cervical cancer screening tool

51
Q

HPV Vaccine

A

Routine in UK in girls (10-12)

52
Q

Genital Herpes

HSV establishes a latent state followed by:

A

HSV establishes a latent state followed by viral reactivation and recurrent local disease

53
Q

Genital Herpes

HSV types:
% HSV2:
IP:
Population:
1 vs 2 Recurrence:
A 
HSV-1 and 2 (HSV-1 increasing)
50-90% caused by HSV-2
IP 2-10 days (up to 21 days)
High prevalence all populations
Recurrence and subclinical shedding much less frequent for genital HSV-1

Many patients lack typical high-risk STD profile
History of exposure (often absent)/new partner

54
Q

Genital Herpes

% Sexually active young:
% in STD clinics:
Estimated office visits a year:
# in US

A

20-30% of sexually active young adults in U.S. (Serology) infected with HSV-2
50% in STD Clinics positive for HSV-2 (serology)
10% in STD Clinics present with clinical genital herpes
Estimated 4-500,000 office visits/year.
Commonest cause of genital ulceration in U.S.A. 50,000,000

55
Q

Genital Herpes

Symptoms:

A

Multiple painful, shallow, tender genital ulcers

Constitutional signs (first episode, F > M)

Tender lymphadenopathy

Cervicitis

Urethritis

56
Q

Genital Herpes
Diagnosis

Clinical diagnosis:

A

Clinical diagnosis –Insensitive + non-specific

Since prognosis varies HSV-1 or 2, clinical diagnosis should be confirmed by laboratory testing

57
Q

Genital Herpes
LABORATORY DIAGNOSIS

DFA:
Culture:

A

DFA…Useful

Culture–highly specific, not SENSITIVE (especially recurrent HSV) + healing lesions

58
Q

Genital Herpes

PCR:
Lack of HSV detection :

A

PCR–highly sensitive, now commercially available

Lack of HSV detection (culture/PCR) does not exclude HSV as viral shedding is intermittent

59
Q

Genital Herpes

What is type-specific HSV IgG serology based upon?

Kits:

Specificity:

A

Type-specific HSV IgG serology based upon HSV-specific glycoprotein
-Both HerpeSelect-1TM and HerpeSelect-21TM:
ELISA or Immublot by Focus Tech
-Several Kits: BIOKIT HSV-2, SureVue HSV-2

Specificity >96%

60
Q

Genital Herpes

TYPE-SPECIFIC HSV SEROLOGICAL ASSAYS is useful when? (4)

A

TYPE-SPECIFIC HSV SEROLOGICAL ASSAYS -USEFUL

Recurrent genital symptoms + negative HSV culture
or
Atypical symptoms + negative HSV culture

A clinical diagnosis of genital herpes with no laboratory confirmation

Partner with genital herpes

61
Q

Genital Herpes

Treatment of first episode

A

Treat most (if not all) patients for 7-10 days
Acyclovir 400 mg tid (200 mg 5 x/d)
Famciclovir 250 mg tid
Valacyclovir 1.0 g bid (500 mg bid probably adequate)

62
Q

Genital Herpes
Treatment of Recurrent Herpes
Most effective when?

A 
Acyclovir 400 mg tid
Acyclovir 800 mg bid
Famciclovir 125 mg bid
Valacyclovir 500 mg bid for 3 days
Valacyclovir 1.0 g once daily for 5 days

Effective if initiated at prodrome or within 24 hrs of onset.

63
Q

SUPPRESSIVE THERAPY FOR RECURRENT GENITAL HERPES

Goal:
Treatment: (4)
Efficacy:

A

Goal -↓ frequency of symptomatic recurrence

Acyclovir 400 mg bid
Famciclovir 250 mg bid
Valacyclovir 500 mg qd
Valacyclovir 1.0 g qd

Efficacy:75-80% reduction Indications: Variable!
>6 outbreaks
>Severe
Psychological

64
Q

GENITAL HSV IN PREGNANCY

What increases with recurrent HSV?
When is suppression of recurrent HSV recommended?
If active lesions at birth:
What can perinatal transmission of HSV can lead to?

A

No ↑ in congenital abnormalities with recurrent HSV

Suppression of recurrent GH near term recommended?

C-section if active lesions present

Perinatal transmission of HSV can lead to significant neonatal morbidity and mortality

65
Q

Perinatal Herpes Infection

What do most mothers of infants with neonatal herpes lack?

Risk of transmission to neonate is highest when?

A

Most mothers of infants with neonatal herpes lack history of clinically evident genital herpes.

Risk of transmission to neonate

a) Extremely low (<3%) in women with recurrent HSV
b) Highest in women with first episode genital herpes

Note: Viral cultures during pregnancy do not predict viral shedding at time of delivery and not indicated.

66
Q

Common Genital Ulcers: (3)

A

Common (Often clinically indistinguishable)

  • T. pallidum
  • Hemophilus ducreyi
  • HSV (Types 1&2)
67
Q

Uncommon Genital Ulcers: (3)

A
  • C. trachomatis(LGV)
  • Calymmatobacterium granulomatis
  • NB-multiple etiology cases (multiplex PCR)
68
Q

VAGINAL TRICHOMONIASIS

Prevalence:
Clinics in Africa:
% Asymptomatic:
Symptoms:
Males:
A

High prevalence worldwide
Prenatal clinics in Africa (20-50%)
50% asymptomatic -exclusively sexually acquired
Symptoms-malodorous vaginal discharge, dyspareunia
-Males -asymptomatic reservoir, uncommon cause of NGU

69
Q

VAGINAL TRICHOMONIASIS

Complications: (3)

A
  • prematurity
  • ↑ PID
  • ↑ transmission of HIV
70
Q

VAGINAL TRICHOMONIASIS
Diagnosis

pH:
PMNs
Motile Trichomonads:
Culture:
Tests
A 
↑ pH (> 4.5)
↑ PMNs
Motile Trichomonads (50% sensitivity)
Culture (Diamond’s, In-Pouch)
OSM-antigen detection test
PCR
71
Q

VAGINAL TRICHOMONIASIS
Treatment

Drugs:
Partner:
How common is re-infection and resistance?

A

Nitroimidazole, e.g., metronidazole (Flagyl®), tinidazole (Tindamax)
Concurrent treatment of partner
Re-infection common
Resistance uncommon

Micro Exam 2 (18 decks)

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