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PR3124 PT3 > STD, HSV & VSV > Flashcards

STD, HSV & VSV Flashcards

1
Q

Name three bacterial STIs & their corresponding causative bacteria.

A

Syphilis: Treponema pallidum
Gonorrhoea: Neiserria gonorrhoeae
Non-gonococcal urethritis: Chlamydia trachomatis

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2
Q

Name two viral STIs & their corresponding causative virus.

A

Ano-genital herpes: Herpes simplex virus (HSV)

HIV/AIDS infection: Human immunodeficiency virus type 1 & 2 (HIV)

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3
Q

Name a fungal STI & its corresponding causative fungus.

A

Vaginal candidiasis: Candida albicans

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4
Q

Describe the mode of transmission for STIs.

A

Primarily by sexual contact w/ infected individual
Direct contact of broken skin w/ open sores, blood or genital discharge
Receiving contaminated blood from infected individuals
Vertical transmission from infected mother to child during:
- Pregnancy: syphilis, HIV
- Childbirth: chlamydia, gonorrhoea, HSV
- Breastfeeding: HIV

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5
Q

STIs can be contracted through dry kissing. True or false?

A

False.

However, some STIs can be transmitted through deep, wet kissing. Syphilis, gonorrhoea, chlamydia and herpes may be present in the mouth/throat of infected persons.

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6
Q

A person can be infected by more than one STI. True or false?

A

True.

Possible and not uncommon; always important to be tested for other STIs if an individual has already been diagnosed with one.

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7
Q

STIs are inheritable from parents to children. True or false?

A

False.

STIs are acquired infections; they are not inherited. However, mothers with STIs can pass on their infection to the baby during pregnancy, delivery or breastfeeding.

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8
Q

What are some risk factors associated with STIs?

A

1) Unprotected sexual intercourse
2) Number of sexual partners:
- Increased no. of sexual partners increases risk of acquiring & transmitting STIs
- Sexual contact with an individual who has multiple sexual partners are at risk as well
3) MSM (man-to-man sexual intercourse)
4) Prostitution / Commercial sex workers
5) Illicit drug use

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9
Q

What are some individual prevention methods one can adopt to minimise the risk of acquiring STDs?

A

1) Abstinence of sexual intercourse
2) Be faithful to an uninfected partner w/ long-term monogamous relationship
- i.e. Reduce number of sexual partners
3) Condom / Barrier contraceptive methods
- Note oral contraceptives are NOT able to prevent STDs!!
4) Avoid drug abuse & sharing of needles
5) Pre-exposure vaccinations (HPV, Hep B & Hep A)
6) Pre- & post-exposure prophylaxis (HIV)

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10
Q

Why is the management & prevention of STDs important?

A

1) To reduce related morbidity, progression to complicated disease (HIV/AIDS)
- some STDs are lifelong diseases & can impact QOL!
2) To prevent HIV infection
- Increased risk of HIV transmission / acquisition in pt. w/ genital herpes, gonococcal or syphilis infections
3) To prevent serious complications in women
- STDs are main preventable causes to infertility
- Prevention of HPV reduces risk of cervical cancer
4) To protect babies
- Untreated STIs are associated w/ congenital & perinatal infections in neonates, premature deliveries & neonatal deaths / stillbirth.

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11
Q

How is gonorrhoea diagnosed?

A

Intracellular gram-negative stain of diplococci in genital discharge or cultures or NAAT (e.g PCR)

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12
Q

Describe the clinical presentation of pt w/ gonorrhoea / chlamydia STIs.

A

Infected individuals may be asymptomatic.
Symptoms of uncomplicated urogenital gonorrhoea include:
M: purulent urethral discharge, dysuria, urinary frequency
F: mucopurulent vaginal discharge, dysuria, urinary frequency

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13
Q

What are some complications of untreated gonorrhea / chlamydia STIs?

A

M: urethral stricture, epididymitis, prostatitis, disseminated disease
F: pelvic inflammatory disease, ectopic pregnancy, infertility, disseminated disease
Disseminated (both): skin lesions, tenosynovitis (joint infections), monoarticular arthritis

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14
Q

What is the first-line Tx recommendation for a patient w/ uncomplicated urogenital gonorrhoea?

A

< 150kg: Ceftriaxone 500mg IM single dose
>= 150kg: Ceftriaxone 1g IM single dose

If chlamydia infection is NOT excluded:
Add doxycycline 100mg PO BD x 7 days

Alternative if ceftriaxone is not available:
Gentamicin 240mg IM single dose AND Azithromycin 2g PO single dose
- Due to significant gonorrhoea resistance against azithromycin

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15
Q

Test of cure from gonorrhoea is required. True or false?

A

False! Test of cure is NOT required unless symptoms persist (i.e. re-infection NOT Tx failure)

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16
Q

What are some counselling points pertaining to the management of sexual partners during Abx Tx of gonorrhoea?

A

1) Sexual partners in the last 60 days should be evaluated & treated. If last sexual exposure > 60 days, the most recent partner is to be treated.
2) To minimise disease transmission, pt. should abstain from sexual activity for 7 days after ceftriaxone Tx (w/ symptoms resolution).
- If pt is on doxycycline for chlamydia infection, abstain from sexual activity during 7 days of Tx (w/ symptoms resolution).
3) To minimise risk of reinfection, pt should abstain from sexual intercourse until ALL partners have been treated.

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17
Q

What is the first-line Tx recommendation for a patient w/ chlamydia STIs?

A

Doxycycline 100mg PO BD x 7 days

Alternative if doxycycline is not available:
Azithromycin 1g PO single dose
- if adherence is a concern
OR Levofloxacin 500mg PO OD x 7 days

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18
Q

Test of cure from chlamydia STIs is not required unless symptoms persist. True or false?

A

True.

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19
Q

What are some counselling points pertaining to the management of sexual partners during Abx Tx of STIs?

A

1) Sexual partners in the last 60 days should be evaluated & treated. If last sexual exposure > 60 days, the most recent partner is to be treated.
2) To minimise disease transmission, pt. should abstain from sexual activity for 7 days after single-dose therapy (w/ symptoms resolution) or until completion of a 7-day regimen w/ symptoms resolution if present.
3) To minimise risk of reinfection, pt should abstain from sexual intercourse until ALL partners have been treated.

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20
Q

How is chlamydia STI diagnosed?

A

Nucleic acid amplification tests (NAAT) or antigen detection

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21
Q

Which two types of serological tests must be used, in conjunction with darkfield microscopy of lesion exudates, to diagnose whether an individual has a syphilis infection?

A

Diagnosis requires darkfield microscopy of exudates from lesions & both of the following tests:

1) Treponemal test (confirmatory):
- uses treponemal Ag to detect treponemal Ab
- e.g. T. pallidum haemagglutination test (TPHA), T. pallidum passive particle agglutination assay (TPPA)
- more sensitive & specific than non-treponemal tests
- pt. may remain reactive for life, thus NOT used for monitoring for response to Tx

2) Non-treponemal test (response monitoring & screening tool):
- uses non-treponemal Ag (cardiolipin) to detect treponemal Ab
- e.g. of non-interchangable tests: Veneral Disease Research Laboratory (VDRL) slide test, rapid plasma reagin (RPR) card test
- +ve quantitative results indicate presence of ANY stage of syphilis; i.e. most dilute serum concentration w/ +ve reaction (1:16 positive -> 1:32 no reaction seen)
- Ab titres correlate to disease activity, thus used as Tx response monitoring tool BUT must use SAME test throughout!!
- Non-treponemal test titres usually decline after Tx & become non-reactive w/ time
- Less specific, thus can be used as screening tool; MUST be confirmed by treponemal test

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22
Q

Describe the clinical presentation of primary stage syphilis.

A

Single painless ulcer / chancre at site of infection but can also present w/ multiple, atypical or painful lesions

  • Site of infection: external genitalia, perianal region, mouth, throat
  • Heals spontaneously in 1-8 weeks
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23
Q

Describe the clinical presentation of secondary stage syphilis.

A

Skin rash, mucocutaneous lesions & lymphadenopathy

  • Multisystem involvement due to haematogenous & lymphatic spread
  • Develops 2-8 weeks after initial infection in untreated / inadequately treated individual
  • Disappears in 4-10 weeks if untreated
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24
Q

Describe the clinical presentation of latent stage syphilis.

A

Early latent = < 1 year from initial infection
Late latent = > 1 year from initial infection

Asymptomatic but picked up by serological testing

  • Possible multisystem involvement as internal organs continue to be affected by infection
  • Develop 4-10 weeks after secondary stage in untreated / inadequately treated individual
25
Q

Describe the clinical presentation of tertiary stage syphilis.

A

Can present with gummatous lesions in joints leading to impaired movement; cardiac involvement leading to heart, aortic insufficiency

  • Possible multisystem involvement of heart, eyes, bones & joints
  • Develop in approx. 30% of untreated / inadequately treated individual 10-30 years after initial infection
26
Q

Describe the clinical presentation of neurosyphilis.

A

Cognitive dysfunction, motor or sensory deficits, ophthalmic or auditory symptoms, signs & symptoms of meningitis, stroke etc.
- CNS involvement can occur at any stage of syphilis

27
Q

A positive VDRL test is sufficient to diagnose a patient with syphilis. True or false?

A

False!

Indicates presence of T. pallidum BUT must be confirmed with treponemal test (TPHA or TPPA)

28
Q

What is the recommended Tx for a patient presenting signs & symptoms of primary syphilis?

A

For primary, secondary & early latent syphilis:
IM benzathine penicillin G 2.4 MU single dose

If penicillin allergy: PO doxycycline 100mg BD x 14 days

29
Q

What is the recommended Tx for a patient presenting signs & symptoms of tertiary syphilis?

A

For unknown, late latent & tertiary syphilis:
IM benzathine penicillin G 2.4 MU once a week x 3 doses

If penicillin allergy: PO doxycycline 100mg BD x 28 days

30
Q

What is the recommended Tx for a patient presenting signs & symptoms of neurosyphilis?

A

1) IV crystalline penicillin G 3-4 MU q4h OR 18-24 MU OD as continuous infusion x 10-14 days OR
2) IM procaine penicillin G 2.4 MU OD + PO probenecid 500mg QDS x 10-14 days

If penicillin allergy: IV/IM ceftriaxone 2g q24h x 10-14 days
- Skin test to confirm penicillin allergy; desensitise if necessary

31
Q

What are some monitoring parameters to look out for in the pharmacological management of syphilis pt.?

A

Safety: Jarisch-Herxheimer reaction

  • acute febrile reaction frequently accompanied by HA, migraine & other symptoms w/in 24h of Tx
  • Antipyretics will help BUT not prevent

Efficacy: using quantitative VDRL / RPR titre
Primary & Secondary: 6 & 12 months from Tx initiation
Latent & Tertiary: 6, 12 & 24 months from Tx initiation
Neurosyphilis: CSF examination q 6 month until normal CSF

32
Q

What is considered as treatment success or failure when using VDRL or RPR tests to monitor Tx response of syphilis pt.?

A

Success:
Decrease in VDRL or RPR titre by at least fourfold (e.g. 1:64 to 1:16)

Failure:

  • shows signs & symptoms of disease
  • failure to decrease in VDRL or RPR titre by at least fourfold OR increase (e.g. 1:16 to 1:64)
  • retreat & re-evaluate for unrecognised neurosyphilis
33
Q

Varicella-zoster virus and herpes simplex virus 3 are nonsynonymous with each other. True or false?

A

False.

Common name of HSV type 3 is VSV

34
Q

Which type of herpes zoster virus often causes cold sores?

A

HSV1

35
Q

Which type of herpes zoster virus often causes genital herpes?

A

Generally HSV2, but may involve HSV1

36
Q

Which type of herpes zoster virus often causes chickenpox?

A

VSV or HSV3

37
Q

Describe the clinical presentation of a patient experiencing chickenpox.

A

Benign self-limiting illness resulting in diffuse vesicular rash across scalp, face, limbs & trunk (palms & soles are spared)
- can be severe in immunocompromised individuals
- groups of new lesions appear over 4-7 days
Fever starts in 1-2 days before rash appears & last for 4-5 days
- usually abates once rash has completely appear

38
Q

Describe the mode of transmission for chickenpox.

A

Inhalation of infected droplets; respiratory transmission

39
Q

Describe the mode of transmission for shingles.

A

Contact transmission

40
Q

What are some major risk factors for herpes zoster / shingles?

A

Immunocompromised & increasing age

41
Q

Describe the clinical presentation of a patient experiencing shingles.

A

Rash begins as papules -> vesicles -> pustules over 3-5 days & usually dries w/ crusting in 7-10 days.
Rash often preceded by tingling, itching or pain (or combination) for 2-3 days & may be continuous or episodic.
Post-herpetic neuralgia (10-50%) is a pain persisting after rash resolved for many months or even years.

42
Q

What is the recommended antiviral treatment for chickenpox / shingles?

A

Start antiviral Tx w/in 24-48h of rash onset to reduce duration & severity of symptoms.

Either PO acyclovir 800mg five times daily x 7 days
Or PO valacyclovir 1g TDS x 7 days

43
Q

Describe the mode of transmission of genital herpes.

A

Transfer of body fluids or intimate skin-to-skin contact

44
Q

Briefly describe the pathogenesis of HSV infection.

A

Primary mucocutaneous infection -> infection of nerve ganglia -> establishment of latency -> reactivation -> recurrent outbreaks / flairs

45
Q

Genital herpes cannot be transmitted if the patient remains asymptomatic. True or false?

A

False!

Shedding & transmission can still occur while being asymptomatic!

46
Q

Describe the clinical presentation of a pt w/ genital herpes.

A

1) Classical painful multiple vesicular or ulcerative lesions
- vesicles develop over 7-10 days & heal in 2-4 weeks
2) Localised itching, pain, tender inguinal lymphadenopathy
3) Flu-like symptoms (e.g. fever, HA, malaise) during first few days of lesions appearance
4) Prodromal syndrome include burning, stinging & itching
5) Symptoms are less severe in recurrent disease

47
Q

What are some diagnostic tests available to determine if pt. has genital herpes?

A

1) Virologic tests: viral culture tests, NAAT (e.g. PCR) for HSV DNA from genital lesions
2) Type-specific serologic tests:
- more useful for recurrent infection
- presence of HSV2 Ab implies anogenital infection

48
Q

What are the therapeutic goals of Tx for genital herpes?

A

Reduce tranmission
Relieve symptoms
Shorten clinical course
Prevent complications & recurrences

49
Q

What are some supportive care pt can adopt during Tx for genital herpes?

A

Warm saline bath relieves discomfort
Good genital hygiene to prevent superinfections
Counselling regarding natural history & lifelong risk

50
Q

What are the benefits & limitations of antiviral Tx for genital herpes?

A

Benefits:

1) PO acyclovir & valacyclovir has proven to reduce viral shedding by 7 days, duration of symptoms by 2 days & time to heal for 1st episode by 4 days
2) Comparable efficacy between acyclovir & valacyclovir; choice dependent on cost and pt adherence
3) Max benefits when initiated at earliest stage (w/in 72h)

Limitations:

1) Does NOT prevent latency or affect frequency & severity of recurrent disease after discontinuation of drug
2) Topical antiviral offers minimal clinical benefits; used only for cold sores

51
Q

What is the recommended antiviral treatment for 1st episode of genital herpes?

A

Either PO acyclovir 400mg TDS x 7-10 days
Or PO valacyclovir 1g BD x 7-10 days

If severe / hospitalised: IV acyclovir 5-10mg/kg q8h x 2-7 days & complete with PO for a total of 10 days

Extend Tx duration if healing is incomplete.

52
Q

What is the mechanism of action for acyclovir & valacyclovir?

A

Valacyclovir is a L-valine ester of acyclovir.

Both inhibit the viral DNA polymerase & thus inhibit DNA synthesis & replication.

53
Q

What are some counselling points to provide for patients on acyclovir / valacyclovir?

A

Take w/o regards to food, after food if GI upset.
For IV therapy: Maintain adequate hydration to prevent crystalluria

SE for acyclovir: Malaise, headache, N/V/D
SE for valacyclovir: Headache

54
Q

What are the recommended antiviral treatments for recurrent genital herpes?

A

1) Chronic Suppressive Therapy (either/or):
- Acyclovir PO 400mg BD
- Valacyclovir PO 1g OD
- Valacyclovir PO 500mg OD (< 10 episodes/year ONLY)

2) Episodic Therapy (either/or):
- Acyclovir PO 800mg BD x 5 days
- Acyclovir PO 800mg TDS x 2 days
- Valacyclovir PO 500mg BD x 3 days
- Valacyclovir PO 1g OD x 5 days

55
Q

What are the benefits & limitations of chronic suppressive antiviral therapy for recurrent genital herpes?

A

Benefits:

1) Reduce frequency of recurrences by 70-80% in pt w/ > 6 recurrences/year
2) No symptomatic outbreaks -> improved QOL
3) Established long-term safety & efficacy
4) Decrease transmission risk w/ consistent condom use & abstinence during recurrences

Limitations:

1) Cost
2) Compliance

56
Q

What are the benefits & limitations of episodic antiviral therapy for recurrent genital herpes?

A

Benefits:

1) Shorten duration & severity of symptoms
2) Less costly vs chronic suppression
3) Increased compliance

Limitations:

1) Requires initiation w/in 1 day of lesion outbreak or during prodrome
2) Does not reduce transmission risk

57
Q

What are some non-pharmacological counselling points with pt with HSV infection?

A
  • Educate natural Hx of disease
  • Encourage to inform current & future sexual partners
  • Sexual transmission of HSV can occur during asymptomatic periods
  • Should abstain from sexual activity w/ uninfected partners when lesions or prodromal symptoms are present
  • Risk of HSV sexual transmission is reduced w/ daily use of valacyclovir or acyclovir by infected pt.
  • Latex condoms, when used consistently & correctly, may reduce risk of genital herpes transmission
  • Neonatal HSV infection risk
  • Increased HIV acquisition risk
58
Q

How should the sexual partner of a patient infected with genital herpes be managed?

A

1) Symptomatic sexual partners should be evaluated & treated in the same manner as symptomatic pt w/ genital herpes.
2) Asymptomatic sexual partners of pt w/ genital herpes should be questioned concerning Hx of genital lesions & offered type-specific serological testing for HSV-2.

59
Q

The use of only one type of serologic test (nontreponemal or treponemal) is sufficient for the diagnosis of syphilis. True or false?

A

False!
Both treponemal & non-treponemal tests must be used together for the diagnosis of syphilis.
- Use of only one type of serological test can result in false-negative results among persons tested during primary syphilis and false-positive results among persons without syphilis or previously treated syphilis.

PR3124 PT3 (12 decks)

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