STD Flashcards
Herpes Virus- pathophysiology
Most common infectious etiology of genital ulceration - 32-50% of adults infected
Often transmitted unknowingly – asymptomatic viral shedding
- Have the virus w/out any symptoms and still pass it
- Majority of cases undiagnosed
Herpes Virus- cause
HSV1/HSV2
Herpes Virus- S/S & PE
Multiple painful vesicles on erythematous base, persist - 7-10 days
- red halo
Primary – fever, bilateral adenopathy
- flu like symptoms
Recurrent – no fever
Prodrome – tingling or burning 18-36 hours prior lesion
Herpes Virus- labs & imaging
Serological testing high rate of false negative
Viral studies – TOC
- PCR - CSF
- Culture
Tzank smear – gold standard
- Pos = presence of multinucleated giant cells
- scrape base of wet lesion
Herpes Virus- treatment
First episode - 7-10 days
- Acyclovir – 400mg TID OR
- Acyclovir – 200mg 5x daily OR
- Famciclovir 250mg TID OR
- Valacyclovir 1000mg BID
Episodic therapy –
- Acyclovir – 400mg BID x 5days
- Acyclovir 800mg BID x 5 days
- Acyclovir 800mg TID x 2 days
- Famciclovir 125mg BID x 5 days
- Famciclovir 1000mg BID x 1day
- Valacyclovir 500mg BID x 3days
- Valacyclovir 1gm PO QD x 5days
Suppression – Daily
- Acyclovir – 400mg BID
- Famciclovir – 250mg BID
- Valacyclovir – 500-1000mg QD
- > > For those w/ >6outbreaks a year - Reduces frequency by 70-80%
Pregnancy
- No indicated risk that treatment will hurt fetus
- Acyclovir – used w/ 1st episode or severe recurrent disease
- Risk of transmission – 30-50% among women who acquire HSV near delivery
Herpes Virus- prognosis
Chronic, lifelong infection
Lesions will spontaneously heal and then reoccur
Herpes Virus- counseling
- Natural hx or infection, recurrence, asymptomatic shedding, transmission risk
- Use of episodic vs suppressive therapy
- Abstain from sexual activity when lesions or prodromal symptoms start
- Inform partners
Risk of neonatal infection - women w/out symptoms can deliver vaginally
- Ulcer present – c section
Syphilis- pathophysiology
Incidence inc - HIV + men and MSM, IV drug usage
- 71% inc
- Test for if HIV +
Syphilis- cause
Treponema pallidum - spirochete
Syphilis- S/S & PE
Primary: Incubation - 10-90d Chancre - early - macule/papule -> erodes - Late - clean based, painless, indurated ulcer w/ smooth firm borders - unnoticed in 15-30% of pts - Resolves in 1-5w - HIGHLY INFECTIOUS Secondary: - Hematogenous dissemination of spirochetes - Usually 2-8w after chancre appears - Rash - whole body - palms/soles - Mucous patches - condylomata lata - wart like presentation - HIGHLY Infection - Constitutional symptoms - Resolve in 2-10w Tertiary: - Gumma - soft, tumor like growth tissues - CV - neuro - eye - uveitis, optic neuritis
Syphilis- diagnosis
Early latent – reactive testing w/in 1 year of infection
- no symptoms
Late latent – reactive testing >1 year after onset of infection or timing can’t be determined
- No symptoms
Syphilis- labs & imaging
Darkfield examination of exudate/tissue – gold standard
Serologic testing:
Nontreponemal – RPR, VDRL
- Reactivity fades over time – can treat them down
Treponemal – fluorescent treponemal ab (FTA-ab)
- Once positive – stays positive -> can’t treat it down
Syphilis- treatment
Primary, secondary, early latent:
1st line – Benzathine Penicillin G 2.4mill units IM one dose
Allergy
- Doxy 100mg BID x 14days
- Ceftriaxone 1gm IM/IV QD x 8-10days
- Azithromycin 2gm single dose
Tertiary – Pen G 2.4mill units IM Qweek x 3 weeks – Bicillin LA
Pregnancy
- Screen at 1st prenatal visit – repeat 3rd trimester
- Treat for appropriate stage
- Additional? – benzathine penicillin 2.4mu IM after initial dose for prim, sec, early latent
- U/S 2nd half – eval congenital syphilis
—> Congenital syphilis – 40% die or stillborn
—–> Nerve damage – vision and hearing
Syphilis- prognosis
Jarish-Herxheimerr
- occurs w/in 24hr of treatment
- acture febrile rxn - HA, myalgia, fever
- antipyretics
Syphilis- management of sex partners
Management of sex partners:
- Exposure to primary, secondary, early latent w/in 90days – treat presumptively - PenG
- Exposure to primary, secondary, early latent >90days – treat presumptively if serology not available – Pen G
- Exposure to latent w/ high nontreponemal titers >1:32 – treat presumptively for early
Chancroid- pathophysiology
Declining
Risk for transmitting HIV
Chancroid- cause
Hemophilus ducreyi
Chancroid- S/S & PE
vesicle, papule, pustule, ulcer
– soft, not indurated, very painful
Classic - painful ulcer w/ tender inguinal adenopathy
Chancroid- diagnosis
Diff to diagnose – hard to culture
Chancroid- labs & imaging
Culture
Chancroid- treatment
Azithromycin 1gm PO
Ceftriaxone 250mg IM single dose
Ciprofloxacin 500mg BID x 3days – contra in Prego
Erythromycin base 500mg TID x 7days
Sex partners
- Exam and treat symptomatic or not if <10 to contact from onset
Chancroid- prognosis
Manage
- Reexam in 3-7days post treatment
- Time for healing – related to ulcer size
- Lack of improvement – incorrect diagnosis, coinfection, noncompliance, antimicrobial resistance
- Lymphadenopathy -> drainage
Lymphogranuloma Venereum- cause
Chlamydia trachomatis
Lymphogranuloma Venereum- S/S & PE
5–21-day incubation
painless papule, vesicle, ulcer
Tender regional lymphadenopathy – unilateral
Lymphogranuloma Venereum- treatment
1st line – Doxy 100mg BID x 21days
2nd – Erythromycin
Granuloma inguinale- pathophysiology
Rare in US
Granuloma inguinale0 cause
Klebsiella granulomatis
- Calymmatobacterium
Granuloma inguinale- S/S & PE
9–50-day incubation
Painless papule -> ulcerations
No regional lymph nodes
Donovanosis
Granuloma inguinale- labs & imaging
Culture - donovan bodies
Granuloma inguinale- treatment
1st line - Doxy 100mg QD x 3w
Azithromycin 1gm once w x 3w
Cipro 750mg BID x 3w
Trimethoprim-sulfa - 800mg/160mg BID
Gonorrhea- pathophysiology
2nd most common reported infection yearly
Gonorrhea- cause
Neisseia gonorrhea
Gonorrhea- S/S & PE
Urethritis - Male
- urethral inflammation
- incubation - 1-14days
- S/S - dysuria, urethral discharge
Urogenital infection - female
- Endocervical canal - primary site
- urethra also - 70-90%
- Incubation - unclear, 10d?
- S/S - asymptomatic, vaingal discharge, dysuria, urination, labial pain/swelling, abd pain
- Bartholin’s abscess - masupilation -> I&D and sew it back up
Skin lesion, arthritis - disseminate gonorrhea
PID
Gonorrhea- labs & imaging
NAAT - urine - TOC
Gram stain - Gold
- gram negative diplococi intracellular
Culture
Gonorrhea- treatment
Cervix, urethra, rectum, pharynx:
Ceftriaxone 250mg IM single dose + Azithromycin 1g PO single dose
Disseminated Gonococcal
- 1st line - Ceftriaxone 1gm IM or IV Q 24hr
- 2nd - Cefotaxime orr Ceftizoxime 1gm IV Q8hr
Gonorrhea- prognosis
Resistance
- penicillin and tetracycline - geographic
- non to ceftriaxone
- Fluoroquinolone worldwide
- Surveillance crucial for therapy
Nongonococcal Urethritis- cause
C. Trachomatis - 20-40% Genital mycoplasmas - 20-30% - Ureaplasma urealyticum - Mycoplasma genitalium Trichomonas vaginalis HSV Unkown - 50%
Nongonococcal Urethritis- S/S & PE
Mild dysuria
Mucoid discharge
Nongonococcal Urethritis- diagnosis
Urethral smear - >5PMN
Urine microscopic - >10PMN
Pos Leukocyte esterase
Nongonococcal Urethritis- labs & imaging
Urethral smear
Urine
Nongonococcal Urethritis- treatment
Azithromycin 1gm single dose
OR
Doxy 100mg BID x 7days
Chlamydia trachomatis- pathophysiology
Most reported STD in US
Screen women <25yo
Chlamydia trachomatis- cause
Chlamydia trachomatis
Chlamydia trachomatis- epidemiology
<24yo
Chlamydia trachomatis- S/S & PE
Asymptomatic
Complications:
- cervicitis, uretisis, proctiis
- lymphogranuloma venereum
- PID - more likely than GC
Cervix - mucopurluant discharge, red base
Chlamydia trachomatis- labs & imaging
NAAT - urine Cervical/urethral swab Enzyme Immunassay - EIA - Chlamydiazyme - 85% sense - 97% - spec - high volume screening - false positives Nucleic Acid Hybridization - NA probe - Gen-Probe Pace-2 - 75-100% sensitive - 95% spec - Detects RNA - can detect GC and CT
DAN amplification assays - urine
- PCR - 95% sen
- LCR - 85% sen
Chlamydia trachomatis- treatment
Azithromycin 1gm PO single dose
OR
Doxy 100mg BID x 7days
Pregnant
- Azithromycin 1gm PO OR
- Amoxicillin 50mmg TID x 7days
Chlamydia trachomatis- prognosis
Can transmit during delivery
- conjuncitivis, PNA
Screening:
- sexually active + <25yr - yearly
- sexually active + >25yr w/ risk - yearly
- Rescren 3-4m post treatment -> high prevalence of repeat infection
Pelvic Inflammatory Disease (PID)- pathophysiology
10-20% w/ GC progress to PID
Higher in CT
Inflammatory disorder of upper genital tract
Pelvic Inflammatory Disease (PID)- epidemiology
<25 Previous PID Untreated STI Multiple sex partners Douche IUD
Pelvic Inflammatory Disease (PID)- S/S & PE
CDC criteria
- Uterine Adnexal tenderness
- Cervical motion tenderness
S/S - endocervical discharge, fever, lower abdominal pain, dysuria, pain/bleeding w/ intercourse, irregular vaginal bleeding
Complications
- infertility - 15-24% w/ 1 episode sec to GC or CT
- 7x risk of ectopic pregnancy w/ 1 episode
- Chronic pelvic pain -18%
Pelvic Inflammatory Disease (PID)- diagnosis
Minimal
- Uterine/adnexal tenderness OR
- Cervical motion tenderness
Additional
- Temp >101F
- Inc ESR
- Inc CRP
- Cervical CT or GC
- WBC/saline microscopy
- Cx discharge
Pelvic Inflammatory Disease (PID)- labs & imaging
Wet prep - white cells
CBC
ESR/CRP
Swabs/urine - GC/CT
Transvaginal US or MRI - thickening or fluid filled tubes
Laparoscopy - diagnostic
All tests can be normal
Pelvic Inflammatory Disease (PID)- treatment
No data on PO vs IV - should cover anaerobic
Parenteral regimen A
- Cefotetan 2g IV Q12hr OR
- Cefoxitin 2g IV Q 6hr And
- Doxycyline 100mg PO/IV Q12hr
Parrenteral Regimen B
- Clindamycin 900mg IV Q8hr + Gentamicin loading dose IV/IM 2mg/kg -> maintance dose 1.5mg/kg Q8hr
PO Regimen
- Ceftriaxone 250mg IM single dose + Doxycycline 100mg BID x 14days
w/ or w/out -> Metronidazole 500mg BID x 14days
Sex partner
- Male partners of women w/ PID - examined and treated w/in 60days
- Treated empirically for CT and GC
Pelvic Inflammatory Disease (PID)- prognosis
Hospitalization
- surgica emergencies
- pregnancy
- Clinical fialure of PO anitmicrobials
- Inablity to follow/tolerate PO regimen
- Severe illness, nausea/vomiting, high fever
- Tubo-ovarian abscess
Epididymitis- pathophysiology
Sexually active men - GC or CT
otherwise eColi
Epididymitis- S/S & PE
Pain, swelling, inflammation of epididymis <6wees
Chronic - >3m
unilateral testicular pain
Epididymitis- treatment
GC/CT
- Ceftriaxone 250mg IM single dose + Doxy 100mg BID x 10days
Enteric - eColi
- Levofloxacin 500mg PO QD x 10days
Bacterial Vaginosis- pathophysiology
Not an STD?
Alteration in vaginal flora
- Lactobacillus - decrease
Bacterial Vaginosis- cause
Gardnerella vaginosis
Bacterial Vaginosis- epidemiology
New sex partner Douching Dec nl flora No barrier methods IUDs
Bacterial Vaginosis- S/S & PE
Thin gray -white-yellow discharge - fishy odor
- mildly adherent to vaginal wall
Mild vulvar irritation
Bacterial Vaginosis- diagnosis
Diagnosis - Amsel Criteria - 3 or 4:
- Abnormal gray discharge
- pH >4.5
- whiff test - pos
- Wet prep - clue cells
Bacterial Vaginosis- labs & imaging
Wet Prep
- clue cells - epithelial cells eaten away
whiff test
Bacterial Vaginosis- treatment
Metronidazole - 500mg BID x 7day
Metronidazole gel 0.75% 5g intravainally QD x 5days
Clindamycin cream 5% 5g intravaginally Qhr x 7day
Prego - Symptomatic - treat due to AE - don’t use topical - screen and treat asymp if high risk for preterm delivery - at first prenatal visit Metronidazole 500mg PO BID x 7days Metronidazole 250mg TID x 7days Clindamycin 300mg BID x 7days
Sex partners
- response to therapy and relapse not related to tx of sex partner
Vulvovaginal Candidiasis- pathophysiology
Recurrent - >4 symptomatic episodes/year
Don’t usually coexist w/ STD
Vulvovaginal Candidiasis- cause
Candida albicans - 90%
Vulvovaginal Candidiasis- epidemiology
Pregnant DM Obese Immun Meds - corticosteroids, OCPs, abx Tight clothing Panty liners
Vulvovaginal Candidiasis- S/S & PE
Itching White vaginal discharge - thick, curd like Vulvar erythema Asymptomatic Burning w/ urination
PE:
Vulva/vaginal tissue bright red
Excoriated external vaginal tissue
Vulvovaginal Candidiasis- labs & imaging
Vaginal culture - gold standard pH - >4.5 Whiff test - neg, odorless KOH - spores - spaghetti/meatballs Wet prep - Hyphae
Vulvovaginal Candidiasis- treatment
Topical therapy - 7-14day
Fluconazole - 150mg PO x 1 dose
Maintenance
- clotrimazole, ketoconazole, fluconazole, itraconazole
Non-albicans - longer duration of therapy w/ non-azole regimen
Sex partner
- tx not recommended
- doesn’t reduce freq of partner
- Male w/ balanitis - treat
Pregnancy
- ONLY topical intravaginal regimens recommended
- 7days
Keep vaginal area dry
Trichomonas- pathophysiology
2x risk of HIV
Most common non-vaginal STD
Flagellate protozoan - vagina, skene ducts, male/female urethra
Coexists w/ other STDs
Trichomonas- cause
Trichomonas vaginalis
Trichomonas- S/S & PE
Vulvar itching, burning, erythema
Thin, ““frothy”” yellow/green discharge - foul smelling
Dysuria
Dyspareunia
Strawberry cervix - petechiae
Trichomonas- labs & imaging
Wet prep - gold - polymorpho-nuclear cells - motile flagellates pH - >5 NAATT - more sensitive and recommended
Trichomonas- treatment
Metronidazole - 2g PO single dose
Tindiazole - 2g PO single dose
Treatment failure
- retreat - metronnidazole 500mg BID x 7days
- Repeat failure - mettronidazole 2mg x 7days
- metronidazole susceptibility testing via CDC
Sex Partners
- should be tx
- avoid intercourse until therapy is completed and both are asymptomatic
Trichomonas- prognosis
Metro SE - N/V w/ alcohol
Trichomonas- prenatal complications
preterm birth
Human Papillomavirus (HPV)- pathophysiology
100 diff strains - 40 infect genital area
Routine pap - early detection
Human Papillomavirus (HPV)- cause
Type 16 & 18 - high risk - oncogenic
Type 6 &11 - low risk
Human Papillomavirus (HPV)- S/S & PE
associated w/ cervical cancer - probs other cancer too
- 99% of cervical cancer w/ HPV DNA
Anogenital Warts
- HPV type 6 or 11
- Asymptomatic - if large can cause obstructive issues
- Large - have a risk of causing cancer
Condyloma acuminata
Human Papillomavirus (HPV)- diagnosis
HPV DNA
Human Papillomavirus (HPV)- treatment
Removal of symptomatic warts - obstructive issues
Difficult to determine if treatment reduces transmission
No evidence any regimen is superior
Patient applied
- Podofilox - 0.5% solution or gel
- Imiquimod - 5% cream
- Sinecathechins - 15% ointment
Provider administered
- Cryotherapy
- Tricholoroacetic or Bichloroacetic acid - 80-90%
- Surgical removal
Pregnancy - DO NOT use topical
- imiquimod, podophyllin, podofilox, sinecatechins - DO NOT USE
- support removal due to proliferation and friability
- Types 6 & 11 cause resp papillomatosis in infants and children
- C section?
Human Papillomavirus (HPV)- prognosis
Vaccines
- 9-26yo - now approve for 45, don’t do it though
- Gardisil quadravalent - 6, 11, 16, 18
- Gardisil 9 valent - 6, 11, 16, 18, 31, 33, 45, 52, 58
Cervical Cancer Screening
- STD hx inc risk
- HPV testing for SCUS pap testing
Scabies- pathophysiology
Parasitic skin infection
Scabies- cause
Sarcoptes scabiei
Scabies- S/S & PE
Intense itching
Contagious
Look for tracking
Scabies- treatment
Permethrin 5% cream - all areas of body
- leave it on overnight and shower off
Ivermectin 200ug/kg PO - repeat in 2w
Persistent Symptoms
- Rash and pruritis lasts >2w
- > tx failure, resistance, reinfection, druge aller gy, cross reactivity w/ Houshold mites
- pay attention to fingernails
- Treat close contacts empirically
- Wash - linens, bedding, clothing
Scabies- prognosis
Norwegain Scabies
- aggressive infestation in immunodeficient, debilitated or malnourished
- greater transmissibility
- Substantial treatment failure w/topical scabicide or oral ivermectin
- Treat - combo topical scabicie w/ ivermectin OR repeat treatments w/ ivermectin
Pediculosis Pubis- pathophysiology
In pubic hair
Spread via sexual contact or shared infected bedding/clothes
Eggs laid at base of hair shafter
- hatch in 7-9d
Pediculosis Pubis- cause
Crab louse - Phthirus pubis
Pruritus
Lice
Nits
Pediculosis Pubis- S/S & PE
Itching - pubic and anogenital
Pale brown insects or ova seen on hair shafts
Pediculosis Pubis- treatment
Wash bedding/clothing
Permethrin 1%
Lindance 1% shampoo
Pyrethrins w/ piperonly butoxide
Retreat - if sx persist
Sex partners - tx if w/in last month
Molluscum Contagiosum- pathophysiology
Benign epithelial
Molluscum Contagiosum- cause
Poxvirus
Molluscum Contagiosum- epidemiology
Young children
Adults - sexually transmitted
Molluscum Contagiosum- S/S & PE
Pearly dome shaped papules w/ umbilicus genital Lower abdomen Butt Inner thigh
Molluscum Contagiosum- diagnosis
Skin scraping or biopsy
-> Microscope - numerous inclusion bodies in cytoplasm
Molluscum Contagiosum- treatment
Self-limiting
Cryotherapy
Curettage
Topical therapy - imiquimod
