STD Part 1 Flashcards
How is syphilis transmitted?
Person to person by direct contact with a syphilitic sore (chancre)
These occur mainly on the external genitals, vagina, anus, or in the rectum
Could also occur on the lips and in the mouth
Also can be passed on from mother to child during delivery
Clinical presentation of syphilis?
Has been called “The Great Pretender” since it can mimic so many other diseases
They present in various stages of the disease based on treatment status
Primary, secondary, latent, tertiary (including neurosyphilis), and congenital
Describe primary syphilis. Onset? Site of infections? Signs/symptoms?
Incubation period: 10-90 days (mean 21 days)
Site of infection: Genitalia, perianal region, mouth, throat (usually present where bacteria enters)
Signs/symptoms: Single, painless chancres that erodes, ulcerates, and eventually heals. Multiple painful lesions possible but not common.
Chancre lasts 3-6 weeks regardless of therapy, but still need treatment to prevent secondary syphilis
Describe secondary syphilis. Onset? Site of infection? Signs and symptoms?
Onset is usually 2-8 weeks after the initial infection in untreated or inadequately treated individuals
Site of infection: Multisystem involvement secondary to hematogenous and lymphatic spread; it occurs somewhere besides the primary infection
Signs and symptoms: Pruritic or nonpruritic rash, mucocutaneous lesions, flulike symptoms, lymphadenopathy
Describe latent symphilis. Onset? Site of infection? Signs and symptoms?
Occurs 4-10 weeks after secondary stage in untreated or inadequately treated individuals
Classified as a positive serologic test with no other evidence of the disease (ie no symptoms)
Early and late latent syphilis:
Early - considered infectious (less than 1 year)
Late - most have no further sequelae (more than 1 year)
Site of infection: Dormant, multisystem involvement
Asymptomatic!
Describe tertiary syphilis. Onset? Site of infection? Signs and symptoms?
Develops in 30% of untreated or inadequately treated individuals 10-30 years after initial infection
Site: CNS, heart, eyes, bones, joints
Signs and symptoms:
CV syphilis: Aortitis or aortic insufficiency
Neurosyphilis: Meniningitis, dementia, deafness, blindness
Gummatous lesions involving any organ or tissue
Describe congenital syphilis
Syphilis caused by t pallidum because it can cross the placenta at any time
Can result in fetal death, prematurity, or congenital syphilis.
Early: First months of life, resembles secondary disease
Late: later in childhood and adolescence, resembles tertiary stage
When are babies most at risk for congenital syphilis?
When pregnant woman is in the primary or secondary stage of syphilis
How do you diagnose syphilis?
Visualising the spirochete via darkfield microscopy
Or more commonly, blood tests
How can you monitor a patient’s response to treatment?
Non-treponemal tests (VDRL and RPR)
Nonspecific so not good for diagnosing initially
Presented as a ratio ie 1:32
want number to go down
ie 1:32 to 1:8 after therapy
What blood tests are used for syphilis? Which is better?
No-treponemal test (VDRL and RPR) Treponemal tests (FTA-ABS, TP-PA, various EIA's)
Treponemal tests specific for the syphilis antibodies so good for diagnosis but not measuring response bc antibodies stay around
Non-treponemal tests used to measure response
Must use BOTH types to confirm diagnosis
Treatment for primary, secondary, and early latent (less than 1 year) syphilis?
First line: Benzathine penicillin G 2.4 million units IM x 1 dose (one and done)
Penicillin allergic pts: Doxycycline 100 mg PO 2 times daily for 14 days
Pregnant and allergic to penicillin: Do penicillin desensitization protocol and use penicillin
Follow up with quant tests:
primary and secondary: 6 and 12 mos
latent: 6, 12, 24 mos
Treatment for late latent syphilis (over 1 year) or latent syphilis of unknown duration?
Benzathine penicillin G 2.4 million units IM once weekly for 3 successive weeks
Pregnant patients allergic to penicillin: Penicillin desensitization and follow first line
Penicillin-allergic: Doxycycline 100 mg PO twice daily for 28 days
Follow up with quantitative tests at 6, 12, and 24 months
Treatment for Neurosyphilis?
Aqueous CRYSTALLINE penicillin G 18-24 million units IV/day, for 10-14 days
or
Aqueous PROCAINE penicillin IM daily PLUS probenacid four times daily for 10-14 days
Follow up: CSF exam every 6 months until cell count is normal
Retreat if it has not decreased at 6 months or is not normal at 2 years
How do we approach penicillin allergic pregnant patients?
Get skin tested to see if it’s a true allergy (positive skin test indicates IgE mediated reaction)
Conduct desensitization IN A HOSPITAL by slowly introducing the antigen, complete over 4-12 hours. Oral or IV desensitization possible.
Patient must then be maintained on penicillin through the course of therapy
See gram negative diplococci on stain - what disease is it?
Gonorrhea
See spirochete on stain - what disease is it?
Syphilis
How does gonorrhea infect pts?
Infects the mucous membranes of the reproductive tract (cervix, uterus, fallopian tubes), urethra (women and men), and mouth/throat/eyes/anus
How is gonorrhea spread?
Transmitted via sexual contact with penis, vagina, mouth, or anus
Or spread from mother to baby during childbirth
Risk factors for gonorrhea?
Multiple or new sex partners or inconsistent condom use
Urban residence (in areas with disease prevalence)
Adolescents (females in particular)
Lower socio-economic status
Use of drugs
Exchange of sex for drugs or money
African American
Signs and symptoms of gonorrhea?
Many men and most women are asymptomatic
Urethral symptoms include discharge 1-14 days after infection, unusual bleeding between periods
Can have scrotal pain
Rectal symptoms include itching, soreness, bleeding
Can also have sore throat, but usually throat is asymptomatic
Complications of gonorrhea?
Women: PID, infertility, ectopic pregnancy
Men: Epididymitis and/or infertility
All patients: Disseminated gonococcal infection (enters the blood) - characterized by arthritis, tenosynovitis, and/or dermatitis
How to diagnose gonorrhea?
Gram stain of urethral specimen: looking for PMN leukoctes with gram negative diplococcus. Gram stain of asymptomatic patients or endocervical, pharyngeal, or rectal specimens is not recommended
More specific testing is recommended:
Culture, nucleic acid hybridization tests, nucleic acid amplification tests (NAAT) are common. NAAT’s have better sensitivity, no susceptibility though
How to treat uncomplicated gonorrhea?
ceftriaxone 250 mg in single intramuscular dose
PLUS
azithromycin 1 g single dose OR doxycycline 100 mg BID for 7 days
Do we contact previous sex partners in infected gonorrhea patients?
All sex partners from preceding 60 days should be evaluated and treated
Which is preferred as the 2nd agent added to gonorrhea treatment: Azithromycin or doxycycline?
Azithromycin - compliance advantages with single-dose therapy, and higher prevalence of gonococcal resistance to tetracycline than to azithromycin
How to treat uncomplicated gonorrhea in someone with a severe cephalosporin allergy?
Gemifloxacin 320 mg PO plus azithromycin 2 g PO as single doses
(requires a test of cure visit 1 week after therapy)
Follow-up of gonorrhea treatment?
Clinicians should advise patients to be retested 3 months after treatment to make sure they haven’t been re-infected
Test of cure required for alternative therapies
